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Proof that “a higher use of opioids [among patients with occupational diseases] may … lead to addiction, increased disability or work loss, and even death” prompted the Workers’ Compensation Research Institute to conduct a study entitled “Longer-Term Use of Opioids.” Dongchun Wang was the lead researcher.
The study’s goals included helping “public officials identify means to strengthen the design or implementation of public policies related to narcotics use and help payors target efforts to better manage the use of narcotics while providing appropriate care to injured workers and reducing unnecessary risks to patients and unnecessary costs to employers.”
Three primary topics of interest were:
1. How guidelines such as state prescription drug monitoring programs and pain policies related to both prescribing narcotics and workers’ compensation policies for pharmaceuticals and narcotics explained “substantial variations across the states in the use of narcotics.”
2. “To what extent a relatively small number of heavy prescribers and heavy users influence the overall use of narcotics.”
3. The relationship between other medical services, such as surgery and active physical therapy.
The following overview of the study touches on points related to these topics. The full 65-page study is available through the above-provided link.
Study Definitions and Parameters
The researchers interchangeably used the terms “opioids” and “narcotics” to refer to “prescription opioids for pain relief.” The definition of “longer-term users of narcotics” was “those who had narcotics within the first three months after the injury and had three or more visits to fill narcotics prescriptions between the seventh and twelfth months after the injury.”
The scope of the research for the 21 states in the study was limited to nonsurgical workers’ compensation claims “with more than seven days of lost time that had narcotics over the specified period.” These states included California, Massachusetts, Texas, Iowa, and Louisiana.
The timeframe of the approximately 300,000 workers’ compensation claims that met the criteria described above was that the injuries occurred between October 2006 and September 2009.
General Findings Regarding Opioid Use
The research showed that “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.” Identified adverse effects of this practice included overdoses and addictions that required costly, but avoidable, treatment. Related data showed that “over the study period, several states saw a noticeable increase in the prevalence of longer-term narcotic use.”
It was observed as well that little proof existed that opioids effectively treated either non-acute pain or chronic non-cancer pain. There was evidence that “opioids may be indicated for acute non-traumatic pain when there is significant objective evidence of injury and other pain medications ... [having] failed to control pain in the short term.” Short-term was defined as up to three weeks after an acute injury.
Opioids have also been found to be reasonable “options for pain relief during two to four weeks of initial treatment [for traumatic injuries and post-operative pain].”
State-specific findings included that the New York and Louisiana workers’ compensation systems had particularly high levels of longer-term use of opioids. The statistics showed that at least one in six injured workers in the 2009-2011 study period who were prescribed narcotics in those two states had longer-term use of those substances.
The rate in Texas was also high, but a pharmacy closed formulary that became effective in that state in September 2011 dramatically reduced the number of prescriptions for opioids and other “not-recommended drugs.” Aspects of this system included mandatory pre-approval of all prescriptions within its scope.
New York’s Internet System for Tracking Over-Prescribing Act now conditions prescribing opioids on checking a prescription drug monitoring program database. Other states require training of physicians who prescribe opioids and/or consolidation of prescriptions for those drugs.
Best Practices for Managing Opioid Use
Medical treatment guidelines in study states recommended monitoring and management techniques that extend beyond the practices described above. These best practices included “careful screening of patients prior to the use of chronic opioid therapy and close monitoring and management through [periodic] drug testing and psychological evaluation and testing.” A recommendation related to screening patients was beginning opioid use with a short-term trial of the prescribed drug.
Another general guideline related to recommending using narcotics “as part of comprehensive care, including active physical therapy and exercise to promote timely recovery.”
The research revealed both that following the recommendations netted positive results and that many states did not adhere to those guidelines. Specific findings included that 18-30 percent of the injured workers in most states in the study received drug testing; the median percentage of testing in these states was 24 percent. The better news was that the statistics showed that the percentage of injured workers who received at least one drug test during the study period increased significantly.
Other statistics showed that less than 10-percent of the injured workers in many of the states in the study received psychological evaluation and treatment. The data revealed as well that “even in the state with highest use of these services, only 1 in 4 injured workers with longer-term narcotic use had psychological evaluation and 1 in 6 received psychological treatment.”
Unduly prescribing opioids is a relatively inexpensive short-term solution with unduly expensive long-term effects.
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