This article is the first installment of NCCI’s series On Opioids. This series is aimed at exploring three viewpoints on issues surrounding opioid use and workers compensation: those of doctors, insurers, and regulators. NCCI conducted interviews with professionals from each of these areas and the articles in this series reflect their opinions on the topic.
America is in the midst of a growing opioid epidemic that is impacting families, businesses, and states across the country. The problem is greater than many people realize. In 2016, 11.5 million Americans misused prescription opioids, with 2.1 million reporting an opioid use disorder.1 Even more startling—116 Americans died every day from an opioid-related overdose.2 Numerous states have declared public health emergencies, and a nationwide public health emergency was declared in October 2017 to activate additional resources to help address the crisis.
Prescription opioids are a class of drugs used to treat moderate to severe pain, particularly chronic pain. The Centers for Disease Control and Prevention3 says that in 2016, the US prescribing rate for opioids was 61 prescriptions per 100 persons. NCCI data shows that injured workers who were prescribed at least one prescription in 2016 received three times as many opioid prescriptions as the US opioid prescribing rate. This issue is of particular concern to stakeholders in the nation’s workers compensation system because injured workers are often prescribed opioids for pain, so workers compensation is directly affected by the far-reaching societal impacts of the opioid epidemic in the United States.
In this first of a three-part series, we hear from several doctors in the workers compensation system.
Talking to Prescribing Physicians
Given the serious risks associated with opioids, including the potential for addiction and overdose, the physicians we interviewed agreed that it is the responsibility of the treating practitioner to prescribe opioids with care and to use evidence-based guidelines. These guidelines outline when to prescribe opioids, as well as recommend the appropriate drug dosage. When prescribing an opioid, the treating physician must provide the patient with an accurate diagnosis, honest communication, and clinical expertise. In recent years, however, prescribers have come under scrutiny for prescribing excessive amounts of opioid painkillers and, as a result, they are more careful in their practices.
The doctors that were interviewed also agreed that narcotics in general, and opioids specifically, became a first line of treatment for pain management. Only recently has there been careful evaluation of the potential for addiction and overdose. So, let’s take a step back.
How Did We Get Here in the First Place?
Like most epidemics, the beginning is only clear in hindsight. According to the physicians we spoke with, significant marketing efforts to promote opioids and what may be characterized by some as controversial scientific research began a cultural shift for many physicians, starting with a study4 in the mid-1980s that addressed the use of opioids for pain relief.
The physicians said four key factors led to the rise in the prescribing and consuming of opioids:
- The intent to
cure pain
- Wide acceptance that opioid painkillers were low-risk and non-addictive
- A lack of experience in opioid addiction science
- The scientific lag in determining a dosage ceiling for opioids
The physicians said that seemingly, a new culture formed around the practice of pain management. That culture was further propelled in 2001, when the Joint Commission5 released new pain management standards, including the idea that pain is a vital sign, like body temperature and heart rate. These new standards perpetuated the notion that pain must be treated—it no longer needed to be endured, one doctor recalled. Pain itself was now viewed as a disease, and opioids became the supposed low-risk cure.
Within the workers compensation system, claimants in the coal industry became some of the first to feel the effects of these deemed “miracle drugs,” according to one doctor. Doctors and industries in West Virginia and Kentucky became the target of opioid marketing efforts. Those receiving the sales pitches were assured that new formulas for the extended-release opioid products were less likely to become habit-forming or result in addiction. Additionally, certain groups cashed in on not only dispensing huge quantities of opioids and other addictive drugs, but some doctors even scheduled visits with patients from out of state.
Where Are We Now?
It has become clear now that opioid use has several serious side effects. One particularly dangerous aspect of the opioid crisis is what doctors call “polypharmacy”—the practice of doctors prescribing multiple drugs to treat one or more of a patient’s conditions, either knowingly or because a patient is seeking drugs from more than one physician. Some drugs have serious interactions with each other and can deepen the dependence on substances, taking a patient one step closer to addiction.
One doctor provided the following example. Consider an injured worker who complains of both chronic pain and anxiety. The worker may be prescribed an opioid as well as a benzodiazepine (an anti-anxiety medication, such as Xanax). However, when not taken as prescribed, the use of these drugs in combination can result in the patient’s respiratory system completely shutting down, risking death.
The potential to become addicted varies significantly from person to person. And pain, like one’s emotions, is completely subjective and immeasurable, one physician explained. Doctors now try to assess a patient’s susceptibility to addiction by asking questions about previous substance use, sexual abuse, psychological issues, and family history. Such screenings were not systematically used in the past. Additionally, doctors now use number scales to help gauge a patient’s pain. However, as one doctor noted, when a patient is intent on obtaining opioids, they can easily manipulate medical professionals by providing false responses.
Within the workers compensation system, the doctors said they may have more influence with a patient who is veering toward opioid dependence or addiction—especially if the injured worker believes they may lose their benefits if they do not adhere to the agreed-upon treatment plan. Importantly, the doctors all noted that addressing psychosocial issues and fully understanding the patient’s sources of pain are crucial to getting the injured worker on a path to recovery.
If Not Opioids, Then What?
Physicians agree that alternatives to opioids do exist, such as acetaminophen, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDS). However, these may not always be appropriate, depending on a patient’s comorbidities, such as heart conditions. Other non-drug treatments, such as massage therapy, acupuncture, cognitive behavioral therapy, and yoga, have shown some promise for patients with chronic pain. However, doctors acknowledge that all patients are unique, and the path to finding an effective treatment of choice can be long. Geographical location was also mentioned as a challenge because rural areas may lack the specialized treatment centers or physicians with training in nontraditional methods.
Acceptance of alternative treatments often depends on the motivation of the patient and how strongly they believe they need opioids, the doctors said. For example, weight loss can reduce back pain, but it can be much more of a struggle convincing a patient to eat less and exercise when they are used to simply taking a pill.
Successes
While the national narrative is heavily focused on the deaths and damage that the opioid epidemic is causing, the interviewed physicians said that there are some successes worth noting. Several states have or are instituting new workers compensation regulations to combat opioid abuse, such as prescribing guidelines and drug formularies. Prescription drug monitoring programs are also proving helpful in deterring misuse. The physicians agreed that with its observance of guidelines, strict adherence to treatment plans, and regular drug testing of injured workers, the workers compensation system is better off than the public at large in battling the opioid epidemic.
Some specialists are claiming increasing success rates for weaning people off opioids. One physician claimed that 72% of workers returned to work in six months because of his clinic’s treatment. The interdisciplinary approach is viewed as increasingly promising.
The takeaway from our physician interviews? Physicians and patients are now highly aware of the opioid crisis. Physicians are increasingly careful in prescribing opioids or other prescription pain medications, and doctors are keeping a close watch for signs of abuse, dependence, and addiction. This vigilance on the front lines of the opioid crisis may signal another coming shift in the culture of how we are treating pain in America.
Stay tuned for our next installment, On Opioids—The Claims Professionals’ Perspective, which will focus on the experience of insurance companies dealing with the opioid epidemic in workers compensation. At our
Annual Issues Symposium 2018, we’ll explore opioids and workers compensation further as we present Opioids—Killer Pain Relief.
Special thanks to the physicians who generously shared their thoughts: Dr. R. David Bauer, Dr. Scott E. Brown, Dr. Jeffrey Hazlewood, Dr. William C. Nemeth, Dr. Suzanne Novak, and Dr. David C. Randolph.
This article is provided solely as a reference tool to be used for informational purposes only. The information in this article shall not be construed or interpreted as providing legal or any other advice. Use of this article for any purpose other than as set forth herein is strictly prohibited. The articles in this series reflect the viewpoints of the experts we interviewed and do not necessarily represent the views of NCCI.
