Opiod overuse a public health emergency’
Workers’ compensation doses rise
Doctors are prescribing more and more narcotics to injured workers every year. Oxycontin, an opioid associated with prescription drug abuse, is the most commonly prescribed medication in workers’ compensation claims.1
Meanwhile, overdose deaths from prescription pain killers are rising dramatically, especially among women.2 These troubling trends underscore the importance of following guidelines on chronic pain management, occupational medicine experts say. They also urge physicians to limit or eliminate high-dose, long-term use of opioids for non-cancer pain.
"The dosing problem in workers’ compensation is huge," says Gary Franklin, MD, MPH, medical director of the Washington Department of Labor and Industries and a pioneer in addressing the risks of opioid use in chronic pain. "There are probably tens of thousands of high-dose users in every state in workers’ compensation."
Sales of opioids have grown exponentially in the past decade, and in 2010, the opioids sold could have medicated every American adult with 5 mg of hydrocodone every four hours for one month, according to the Centers for Disease Control and Prevention.2
This is driven in part by high prescribed doses, says Franklin. "If their pain and function wasn’t better on 120 (mg) than it was on 60 or 40, don’t keep moving it up," he says. "Get a consultation. Do something different."
Physicians also need to take a comprehensive approach to pain management, using different therapies and screening for depression, other medication use and abuse risk factors, says Kathryn Mueller, MD, MPH, FACOEM, an occupational medicine physician at the University of Colorado in Denver and a contributor to the American College of Occupational and Environmental Medicine (ACOEM) guideline on chronic pain management.
"We’ve been overprescribing for acute and sub-acute pain, so there are just too many pills out there in circulation," she says.
As costs rise, both in dollars and lives, opioid overuse and abuse is getting increased attention. "Now that we know what we know, why is it taking so long to make changes? That’s the frustration," says Franklin. "If these were Salmonella [food-borne] deaths, it wouldn’t have taken this long. It’s a public health emergency."
A human right to be pain-free?
The increase in opioid prescriptions began with good intent. In 2001, The Joint Commission released a pain management standard that emphasized the importance of assessing and treating pain. In 2010, the International Association for the Study of Pain organized a global summit, which issued a declaration calling access to pain management a human right. In 2011, an Institute of Medicine report called chronic pain "a national public health challenge."
Occupational medicine experts don’t dispute the need to better manage both acute and chronic pain. But simply writing a prescription for a hydrocodone — and upping the dosage if there is residual pain or discomfort — is not the answer, says Mueller.
A comprehensive pain management approach includes screening for depression, monitoring the overall use of medications, and encouraging physical activity or return to work, according to the ACOEM guidelines. In some cases, psychotherapy or periodic drug screening may be warranted, and patients should sign a treatment agreement stating that they understand how they should use the opioids, the guidelines state.
Yet a study of longer-term use of narcotics by injured workers (who had prescriptions 12 or more months after the date of injury) found that only 7% had undergone a psychological evaluation and 4% had received psychological treatment. About one in four had drug testing, which is recommended to ensure that patients are not taking multiple types of narcotics or contraindicated drugs, and that they are taking the prescribed medicine and not filling prescriptions that are used by others.3
The study, based on 300,000 worker’s compensation claims in 21 states, analyzed cases with injuries that occurred from Oct. 1, 2006 to Sept. 30, 2009 and revealed great variation among states.
"If you’re moving into that phase where you’re considering prescribing opioids for a longer period of time for pain relief, then you really need to be following all of the recommendations for monitoring patients to prevent abuse and unintentional misuse," Mueller says. "These include checking the prescription drug monitoring programs (PDMP), treating any psychological issues, performing random drug screening, and establishing doctor-patient agreements."
Prescription drug monitoring programs provide a database for physicians to check whether patients may be receiving additional drugs from another doctor or are taking other medications that would interact with opioids. Such programs are available or under development in 48 states. In addition to Washington state, other states such as Colorado and Massachusetts have adopted revised pain management guidelines for workers’ compensation.
Workers’ compensation case managers also can play a role in monitoring the narcotics’ prescriptions of employees, says Mueller.
The patterns of use among injured workers reflect the broader problem of narcotics use: A subset of injured workers takes high doses of narcotics. Based on prescription costs, the top 10% of claimants account for 80% of the narcotic use.4
"The share of claimants that are getting five or more narcotics prescription within a year of the date of injury has been growing," says John Robertson, FCAS, MAAA, director and senior actuary of the National Council on Compensation Insurance (NCCI) in Boca Raton, FL.
Overdose deaths top traffic accidents
Women are more likely to die from a drug overdose than a traffic accident. In 2010, 6,631 women died of an opioid overdose. From 2004 to 2010, emergency room visits by women from opioid misuse or abuse more than doubled.2
Turning around those trends will require adherence to guidelines and careful prescribing, says Franklin. New workers’ compensation guidelines in the state of Washington call for using assessments of function and pain to determine whether injured workers taking opioids have "clinical meaningful improvement." (http://www.lni.wa.gov/claimsins/Files/OMD/MedTreat/FINALOpioidGuideline010713.pdf)
Prescribing opioids if there is no "clinical meaningful improvement in functionis not considered proper and necessary care" by the state workers compensation insurer, according to the guidelines.
Doctors in other states also should recognize the potential for legal liability if there is an opioid overdose and they failed to properly monitor a patient’s use, Mueller says.
The initial treatment for acute low back pain should be non-steroidal anti-inflammatory drugs, according to ACOEM. Doctors should discuss the risks as well as the benefits with patients before starting them on opioids, ACOEM says.
"Our new guidelines say you should not use opioids for strains and sprains," says Franklin of the Washington state guidelines. "You should not start opioids, even a first prescription, in someone who does not have a severe injury."
Patients also need to have realistic expectations about pain management, says Mueller. Physicians may not be able to get rid of all their pain, she says. "In the end, the person is going to have to manage their life by adopting strategies they can largely do on their own such as exercise, stretching, applying heat or cold and using mind/body techniques," she says.
Recommendations for opioid use
The American College of Occupational and Environmental Medicine (ACOEM) provides these recommendations from the Evidence-based Practice Panel on Chronic Pain. The Guidelines for the Chronic Use of Opioids is available at http://ow.ly/nQV1s
- Routine use of opioids for treatment of chronic non-malignant pain conditions is not recommended, although selected patients may benefit from judicious use.
- Opioids are recommended for select patients with chronic persistent pain, neuropathic pain, or complex regional pain syndrome (CRPS).
- Screening of patients by asking about prior substance abuse with simple tools and using currently available screening tools designed for use in populations on or considering opioid therapy is recommended as there is evidence that patients with a prior history of drug or alcohol abuse or psychological problems are at increased risk of developing opioid related use/abuse problems. A psychological evaluation would also be indicated in most cases.
- The use of a treatment agreement to document patient understanding and agreement with the expectations of opioid use is recommended. There is evidence that many patients do not adhere to prescribed treatment (including with an agreement); however, these agreements are felt to be needed and coupled with a urine drug screening program. Patients should be informed about what is responsible use of opioids and how to interact with their physician and pharmacy in obtaining medication. If literacy is a problem, the physician should read the agreement to the patient and ascertain that they understand it or revise the agreement so they can read and understand its content.
- Routine use of urine drug screening for patients on chronic opioids is recommended as there is evidence that urine drug screens can identify aberrant opioid use and other substance use that otherwise is not apparent to the treating physician.
References
- Lipton B. Workers Compensation Prescription Drug Study: 2013 Update. Annual Issues Symposium 2013. Available at http://ow.ly/nQVos. Accessed on July 22, 2013.
- Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Vital Signs: Overdoses of prescription opioid pain relievers and other drugs among women — United States, 19992010. MMWR 2013;62:537-542.
- Wang D, Hashimoto D, Mueller K. Longer-term use of opioids. Workers’ Compensation Research Institute, Cambridge, MA, October 2012, WC-12-39.
- Laws C. Narcotics in workers compensation. NCCI Research Brief May 2012. Available at http://ow.ly/nQVhs. Accessed on July 22, 2013.