by Kim Krisberg
Researchers studying workers’ compensation claims have found that almost one in 12 injured workers who begin using opioids were still using the prescription drugs three to six months later. It's a trend that, not surprisingly, can lead to addiction, increased disability and more work loss – but few doctors are acting to prevent it, explains a new report from the Massachusetts-based Workers Compensation Research Institute (WCRI).
Report researchers looked at longer-term opioid use in 21 states and how often doctors followed recommended treatment guidelines for monitoring injured workers' use of the prescription painkillers. In the states studied, researchers found "relatively low compliance" among physicians when it came to implementing monitoring services such as drug testing and psychological evaluations and treatments, which can help prevent opioid addiction and its often-unfortunate outcomes. The report, authored by Dongchun Wang, Dean Hashimoto and Kathryn Mueller, states:
Opioids have been widely prescribed for and filled by injured workers — about 55 –85 percent of injured workers received narcotics, despite medical recommendations to avoid routine prescription and to limit the use of opioids to more severe pain or pain which is unresponsive to other analgesics. The growing public concerns regarding overuse and abuse, which often result in emergency room visits and even overdose deaths, are shared by the workers' compensation health care community. These concerns are increasingly important public policy issues, given the limited evidence of the effectiveness of opioids in treating chronic noncancer pain.
According to the report, which is based on almost 300,000 workers’ compensation claims and 1.1 million associated prescriptions in 21 states, use of both drug testing and psychological evaluation and treatment were low. For workers’ comp claims associated with longer-term opioid use, only 18 to 30 percent were drug tested in most of the states studied. Psychological services uptake was even lower: Only 4 to 7 percent of injured workers with longer-term opioid use received such services in the average state. And even in states with the highest uptake, there's a lot of room for improvement: Only one in four such workers received a psychological evaluation in those states, and one in six received psychological treatment.
Among the states studied, the highest utilization was found in Louisiana and New York, where one in six and seven injured workers (respectively) with narcotics were categorized as longer-term users. The rate was about one in 10 in Texas, Pennsylvania, South Carolina, California and North Carolina, and one in 20 in Arizona, Wisconsin, New Jersey, Indiana and Iowa. The report states:
Narcotics were frequently received by the injured workers for pain relief...in typical states, more than 3 in 4 injured workers who had more than seven days of lost time, had no surgery but took prescription pain medications received narcotics for pain relief. ...In 10 of the 21 states, the percentage of claims with narcotics that were identified as longer-term users of narcotics increased 1–3 percentage points.
However, policy interventions can make a difference, as was seen in Massachusetts, where the percentage of longer-term narcotic users declined by about 4 percent from 2007–2009 to 2009–2011. While researchers noted that "more rigorous analysis" is needed to explain the Massachusetts decline, they did highlight policies that may have contributed, such as mandatory education for prescribers of controlled substances and better utilization of the state's Prescription Drug Monitoring Program, an online portal where authorized users can view a patient's prescription history.
Similarly, the report cited a Texas Department of Insurance finding that fewer opioids were being prescribed to injured workers after state policymakers adopted a guideline-based closed formulary for the state's workers’ compensation system — a move that reins in prescribing authority. According to recent statistics from the Texas agency, the rate of opioid prescriptions dispensed to injured workers went down by 10 percent and associated costs declined by 17 percent.
“This (WCRI) study addressed a very serious issue: how often doctors followed recommended treatment guidelines for monitoring injured workers under their care, who are longer-term users of narcotics,” said Richard Victor, WCRI’s executive director, in a news release. “This study will help public officials, employers, and other stakeholders understand as well as balance providing appropriate care to injured workers while reducing unnecessary risks to patients and costs to employers.”
Prescription painkiller abuse is a growing problem throughout U.S. communities. Consider this startling statistic: For the first time since 1980, the number of unintentional poisoning deaths in the United States exceeded deaths from motor vehicle crashes — and the overwhelming majority of those poisoning deaths were due to drugs. According to the Centers for Disease Control and Prevention, drug poisoning deaths involving opioids more than tripled from 1999 to 2008, from 4,000 to 14,800. In just one state, Ohio, unintentional drug poisoning deaths increased a whopping 350 percent from 1999 to 2008, largely driven by prescription drug overdoses — that's four deaths each day.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.
This report deals with a serious problem in American health care that goes way beyond workers comp. Thanks for tipping us off to it. I do think readers should be aware, however, that the "Workers Comp Research Institute" which put it out is composed almost entirely of big insurance companies like Travelers, Liberty Mutual and Chartis/AIG -- and big, injury-generating employers like UPS. Here's their board:
The emphasis on "abuse" by injured workers is worth taking with a grain of salt. I have seen a few really sorry examples of the member insurance companies trying to label a worker an "addict" simply because his/her claim was becoming expensive. Those who do become addicted often do so at the instigation of irresponsible physician prescribers. Pain management is big business these days.
It wouldn't surprise me if "almost" one in twelve injured people is still in real pain after three months. It wouldn't surprise me if three-quarters of people who were hurt badly enough to miss more than a week of work, and got a prescription, were in enough pain to warrant short-term use of codeine. Remember that the safety net for blue- or pink-collar workers is minimal and most families are more or less financially stretched - you don't take seven days off for a little bump or bruise. These are people who are really hurting.
Are you seriously arguing that a lack of drug testing of patients prescribed opioids is bad?
There is a severe lack of credibility, even sanity, in the current moral panic about prescription opioids. Almost without exception, every discussion mentions the rise of ER admissions for OD, and OD deaths, as if these were all patients who were prescribed opioids. But they're not -- the epidemic is in the diversion of prescription opioids into the illegal drug trade, and that's where the bulk of the rise in ODs are happening. There is little or no credible evidence that there is an "epidemic" of addiction resulting from patients prescribed opioids by their doctors.
And, in marked contrast, there is decades of solid research that shows that the majority of patients do not become addicted to opioids, even after long-term use and physical dependence. The small minority of patients who become addicted are for the most part people who are prone to addiction.
Furthermore, the US's posture with regard to opioids is demonstrably exceptional and non-scientific, given that much of the rest of the world neither almost universally adulterates them as the US does, nor controls them as tightly as the US does ... and yet, it is the US with higher rates of opioid abuse.
In short, there is an irrational, arguably puritanical bias against opioids in the US which is abundantly demonstrated in recent press. The reportage is dishonest -- eliding the distinction between the abuse of prescription opioids by patients and the abuse of diverted prescription opioids. It also frequently equivocates physical dependency with addiction.
This is first and foremost the fault of Purdue Pharma and the FDA for stupidly not imagining that the buffer in oxycontin can be easily circumvented by the highly-technical and imaginative trick of crushing the pills for the quick high which is so correlated to addiction. This single-handedly created, first, the opportunity for a new illegal market in an abused opioid; and, second, once that market was created, creating a new, vast generation of opioid addicts.
This was ironically and sadly in the context of a medicine-wide and regulatory reevaluation of the safety of opioids which led to a loosening of restrictions in the 90s. But with this new tide of opioid addiction, those opposed to these changes, and others, wrongly concluded that the new epidemic of opioid addiction was largely, even exclusively, the result of the lessening of restrictions. And so now they lead the call for draconian tightening.
And worse. With the DEA's crackdown on enforcement, newly trained doctors are now notoriously resistant to prescribing opioids at all. A large portion, perhaps the majority, of non-specialists now refuse to prescribe opioids in any case outside a hospital.
There is no other class of medications as effective at controlling pain than opioids. And they're not as dangerous as they're often alleged, as many or most OD fatalities occur in conjunction with another CNS depressant, usually alcohol. And there are a whole lot of other prescription drugs which people are OD'ing on in conjunction with alcohol which don't have the same hysteria associated with them. Vastly prescribed medications, such as Xanax or Ambien, for example. And those, especially the former, are widely abused and also involved in the diverted illegal drug trade. There is a deep inconsistency about which classes of drugs are marked for special scrutiny -- to the absurd degree of expecting drug testing of patients, no less.
I'd like to think that Krisberg, the WCRI, and those like-minded would be happy to find themselves treated like criminals, under suspicion, when they are taking *any* prescription medications, including opioids and anti-anxieties and sleeping-pills and many others, which are diverted into the illegal drug trade, frequently abused, involved in addiction, and in ODs. But I suspect not.
Keith, you make some compelling points about the US having a poorly conceived approach to opioids. It sounds like you're considering the testing recommendation to be punitive, though. I understand it not as treating patients "like criminals," but as one element of a recommended treatment approach that's designed to benefit the patient. Of course, how the recommendations are executed will determine whether patients feel punished or supported (or ignored, as is often the case in healthcare encounters these days).
I'd like to see careful monitoring of all patients -- not just pain patients, and not just injured workers -- who regularly take drugs that have the potential for severe adverse events (as well as diversion). For instance, it seems that some physicians are handing out prescriptions for psychotropic drugs far too freely, without helping their patients understand and weigh the risks and benefits. Writing repeated scripts with little or no discussion about the patients' symptoms, side effects, or alternatives (e.g., physical therapy for musculoskeletal problems, counseling for mental-health conditions) is a problem whether it's happening with opioids, psychotropic drugs, or any other medication.
Thanks for your comments. I don't think this particular report is calling for injured workers to be treated as criminals (and I certainly wouldn't argue for that either). It is examining the application of clinical risk reduction interventions that can help reduce the chance of addiction and unintentional poisoning. In my reading of it, I did not get the impression that the authors thought there should be blanket policies in regard to opioid use and injured workers --- but rather that physicians are a critical piece to making sure workers can safely heal, rehab and appropriately manage their pain.
I think addressing this issue of opioid abuse (which truly is becoming a very serious public health problem nationwide) is still in its early stages and stakeholders on all sides are still trying figure out how to stem abuse and flow of these drugs into the black market while still fairly and appropriately caring for patients and alleviating their pain. It's a very complicated issue (because as you said, the majority of those abusing painkillers weren't prescribed the drug; more on that here: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/), However, almost all prescription drugs involved in overdoses come from prescriptions --- which means, from a public health perspective, we've got to engage doctors in a comprehensive approach that allows for the effective management of pain, helps reduce opioid overdoses and stems the flow of drugs into the open market.
How all that will effectively happen remains to be seen --- I think it's far too complex a problem to be solved anytime soon. The WCRI report examined one small aspect of this issue --- and at this stage in the game, I think collecting as much as data as possible is crucial.
Keith-I'd just like to say THANK YOU! You just saved me a whole lot of typing & said it so much better than I ever could. Having been in pain management for 11yrs now, having had multiple spine surgeries (with more to come in the future) that all began with an OTJ injury as a Paramedic (assaulted by a drunk) & in the meantime 'developing' (however that happens) Fibromyalgia, I can personally attest to what it's like every single month to be treated like a common junkie-both at the PM Dr with the monthly drug tests, pill counts & the sudden 'taking away' of whatever med the DEA no longer thinks is 'safe' that month (last month my PM stopped writing Soma....just like that...because OTHER people abuse it); but also in trying to fill my Roxicodone-often having to go to 5 or more Walgreens stores before I finally find one that admits to having it in stock. It's not as if I'm new to these meds-I've been on them for 11+yrs and I've got the MRI's and surgery scars to prove why I need them (as if the cane & 'odd' gait isn't enough). I understand the need of the Dr's to protect themselves, never knowing when the DEA will show up-but I must admit (especially here in FL) it is getting pretty ridiculous just getting the medications that even my Specialists agree that I need just to be able to get out of bed every day.
I often use this phrase when describing my "life": I'm not living, I'm merely existing.
As for addiction-the way I see it if I'm "addicted" to these meds then really, who cares? As long as I don't drive or do other things while taking them that could injure myself/others, & as long as they're giving me SOME semblence of a life, then does it truly matter if my body "needs" them? Or would it be better to just leave me here in my bed 24/7/365, crying & wishing I were dead because the pain is too much to bear just because the DEA or some board of beaurocratic jerks "don't feel comfortable" about me taking pills? It's gotten to the point that we're treating everyone like common criminals &/or junkies, rather than treating the criminals & junkies individually. Whatever happened to personal responsibility/accountability anymore anyway? I know that I have to take my meds as my Dr prescribes them & that's exactly what I do. I have never, nor would I ever, sold them or given them away & I certainly wouldn't take more than prescribed because then I'd run out and would be miserable until my next appointment & refill. Is it a shame that not everyone is responsible with their meds as I am? You bet! But it's not MY fault-I'm just the one, along with millions of others who live in chronic pain, who is punished for the actions of those others.
What I wouldn't give to remember what it feels like to have pain less than a 7 on the 1-10 "pain scale".
Thanks again for saying what so many of us in CP feel!
Thanks for your comment, Tanya - you may see some of your experience reflected in Kim's more recent post, Chronic pain patients caught in the middle of growing opioid abuse problem.
You mention that some pharmacies won't admit to having certain pain meds in stock, and I've read that this is a step some pharmacies are taking in response to armed robberies by thieves seeking narcotics -- yet another example of how actions by criminals can make life much harder for chronic pain sufferers.
Liz-Thank you, I did actually just read that other post. Another good one here at SB. I've been a lurker for awhile because, admittedly, a lot of the topics covered are over my head-but with my Paramedic background as well as completing all but the last 12cr hours of my RN (up until I got hurt), I do still very much enjoy discussions of all things medicine/pharma/etc. I just know enough to keep thy mouth shut when everyone else in the room obviously has more education in their pinkies than I've had in my years in school ;-)
You're exactly right about the robberies at pharmacies as well. Not keeping the narcotics (especially oxycodone) in stock-at least where Walgreen's is concerned according to what my Pharmacist told me-is apparently a corporate decision. They are only allowed to order "just so much" at a time & are not allowed to keep any sort of quantity in stock, nor can they tell the customer when they will have it in stock, nor are they allowed to call other area Walgreen's stores to see who might have it in stock. Makes for quite the hassle for us to try and fill our Rx's every month & is especially difficult considering so many of us attempting to fill it are disabled and in pain, thus having to spend all afternoon driving to multiple other branches until we're able to find one to fill it is definitely one problem that I think somebody needs to consider & adapt store/corporate policies to accommodate. It would be one thing if it was birth control or antibiotics & able bodied people who aren't at a pain level of 8 or 9 already when they get there, ya know? It's definitely frustrating.
I am by nature a pretty understanding & reasonable person, so I'm not the one you'd typically see in this situation who yells at the Pharmacist or cops an attitude with the PM Dr....but after dealing with these "new rules" since Jan 1st I admit that I am tired of the hassle now. Luckily the last 2 months my "regular" Walgreen's store has had my Roxicodone in stock when I've gone in to have it filled, so that's been nice. Now I'm dealing with trying to find an alternative to Soma for the awful muscle spasms I constantly have. My PM said that he will no longer write it for anyone anymore because someone, somewhere has suddenly decided that carisoprodol is "bad" for us. (I think it has more to do with the fact that, just like oxycodone, oxycontin & dilaudid-Soma has become a favorite "drug of choice" on the streets, perhaps even used as a potentiator-but of course that's just my theory. PM Dr did say that the call was made by the DEA about it being "bad for you", so that pretty much told me all I needed to know.) But I was initially put on the Soma after my 2 back surgeries in Oct 2010 because nothing else even came close to touching the spasms-flexeril & zanaflex do about as much good as swallowing an M&M. I suppose there's always valium, but I don't necessarily need my whole body/mind to relax-just the knots all over my back/hips.
I do want to say that I hope my 1st post didn't come across like that I was unsympathetic to the obstacles that PM Dr's & pharmacies, etc. have to deal with regarding narcotics because I absolutely understand it & I'm perfectly willing (& actually glad) to take my monthly drug tests at the Dr and do the random pill counts, etc. It just shows in my file that I follow the rules and that I'm not your common junkie, so if the DEA or any other aspect of "Big Brother" (including SSA since I'm on disability) wants to look at my file they will see mountains of evidence from the last 11yrs and there will be no question that I'm definitely NOT "one of THOSE people". :-)
I do however wish something different could be done as far as the pharmacy end of it because it really isn't right to have to go through THIS much to get Rx's filled every single month. FL is particularly bad because the DEA has been investigating and closing down TONS of "pill mills" the last couple of years-but somebody really needs to step up and say wait a minute-we can't continue to treat legitimate chronic pain patients like this.
Perhaps I'll write a letter to the Surgeon General & Atty General Bondi. Couldn't hurt, eh? Probably won't do any good, but at least I'll know I tried I suppose.
Thanks for your comments, Tanya! And feel free to jump in whenever you have thoughts to share -- no special expertise required, although you obviously do have that.
It's especially valuable to get the perspectives of people who suffer from the diseases and conditions we're writing about, so thanks for being willing to share your experiences. And you should definitely write to some public officials (and heads of pharmacy chains, medical societies, etc) whose decisions affect your life! They need to hear from people who are experiencing what may be unintended consequences of well-intended policies.