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ACOEM tightens guidelines, cautions against the use of opioids in any safety sensitive job, not just motor vehicle driving
Much has been written lately on the increased use—both licit and illicit—of opioids. Against this backdrop, concern is mounting over the impact this usage may have in the workplace, specifically the ability of workers to safely perform their jobs. Opinions and data have varied, resulting in confusion in the field as to whether it was chronic pain or chronic opioid use that resulted in apparent cognitive impairment, and also whether such opioid usage elevated the risk of safety-related injuries. The American College of Occupational and Environmental Medicine (ACOEM), which focuses on issues relating to employee health, recently decided to update its guidelines regarding the use of opioids. The ACOEM guidelines are intended primarily for healthcare providers and comprehensively address a myriad of occupational injuries and/or disease. These guidelines are considered “evidence-based” i.e., developed by using the most reliable and current evidence to inform patient care decisions. Among these is the ACOEM Opioids Guideline [which form part of the Reed Group Ltd. Disability Guidelines], dealing with the use of opioids in treating working age adults suffering from chronic or post-op pain. Last issued in 2009, ACOEM has determined that an update to the guideline, which now recommends against prescribing chronic or acute opioid use for employees in “safety-sensitive” jobs, was appropriate. The related research, ACOEM Practice Guidelines: Opioids and Safety Sensitive Work, undertaken by Kurt T. Hegmann et al, is summarized and published in the July 2014 edition of the Journal of Occupational & Environmental Medicine.
Prudence Is Appropriate When Prescribing Opioids for Working Age Adults
ACOEM’s 2009 guideline formerly advised healthcare providers to warn patients that cognitive impairment, potentially affecting activities such as driving, may occur with opioid use. It further advised healthcare professionals to warn patients to avoid potentially dangerous situations if they were feeling in any way impaired. In other words, unless the patient exhibited adverse effects, no restrictions were considered necessary. By contrast, ACOEM’s 2014 guideline is significantly more proactive. Rather than taking a “wait and see” approach, the guideline now flatly states that “[a]cute or chronic opioid use is not recommended for patients who perform safety-sensitive jobs.” The reason for this tightening of the guideline is simple—all the large research studies reviewed by ACOEM found an association between opioid use (whether weak or strong opioids) and an increased risk of motor vehicle crashes. Risk estimates varied widely from 29% to a startling 800% increased risk. ACOEM extrapolated out these results to caution against chronic or acute opioid use in connection with any “safety-sensitive” job, not just motor vehicle driving. It identifies such occupations as operating heavy equipment, driving a forklift, working at heights, or working at tasks requiring high levels of cognitive function. ACOEM has stated its intent to update this guideline every three years, or more frequently if appropriate. Additionally, although the guideline is intended for occupational healthcare practitioners, the evidence upon which it is based suggests that it could appropriately be applied more broadly.
Examining the Evidence Supporting the Guideline
Hegmann et al. undertook significant research to amass the evidence supporting this change in the guideline. They scoured 7 databases and did both PubMed and Google Scholar searches for relevant epidemiological studies performed through October 2013. Over 21,000 article abstracts relating to evidence of harm were identified and evaluated through abstracts, critiques and the compilation of evidence-based tables. From this trove, 12 studies were selected for inclusion in the analysis. Each of these looked at whether there was an association between opioid use and motor vehicle accidents. All answered this in the affirmative.
Researchers from around the world, including researchers from Norway, Canada, U.K. and Australia, undertook the studies reviewed by ACOEM. Three Norwegian and one Canadian study were population-based studies, two of which had a study group of over 3,000,000 individuals. Each study concluded that there was an increased risk of motor vehicle accidents associated with opioid use, with two suggesting that the risk was in proportion to the opioid dosage. A 2004 Australian study, which looked at over 2,000 commercial vehicle drivers, found chronic “excessive sleepiness” and sleep-breathing problems among the drivers, and further found an association between opioid use and the risk of commercial vehicle accidents. Some studies used as their comparison low-dosage opioid use rather than zero use, a fact that ACOEM suggests may result in underreporting of the risk estimate. Encouragingly, a 2009 U.K. study concluded that the increased risk of motor vehicle accidents was reversed once the opioid usage stopped. Based on findings such as these, the ACOEM guidelines recommend that the patient wait until approximately 90% of the opioid has left his or her system before engaging in “safety-sensitive” tasks.
The obvious benefit to this updated guideline is the potential reduction of accidents and injuries, a potential strengthened by the apparent muscularity of the evidence underpinning the guideline. ACOEM acknowledges that implementation of these guidelines could potentially hinder someone from working whose work-related cognitive function is not actually impaired. However, ACOEM maintains there is no “validated method” to effectively measure an individual’s impairment level. Recommending against chronic or acute opioid use while engaged in “safety-sensitive” occupations is therefore deemed to be the wiser course of action.
Evidence-based guidelines are only as good as the evidence supporting them. Here, ACOEM took another look at the evidence supporting its 2009 Opioids Guideline and determined that the evidence not as robust as preferred. Given the rise in opioid use, clarification was considered necessary. The 2014 Opioids Guideline is unequivocal in recommending against chronic or acute opioid use for patients who work in “safety-sensitive” jobs. This refinement, backed by a significant body of research, should prove helpful to practitioners charged with the treatment of occupational injury or disease.
Stuart D. Colburn, Shareholder at Downs Stanford PC in Austin, Texas, agrees overall with the new guideline. “Use of opioids, especially long term use of such powerful new drugs in the occupational injury context, outpaced science and our experiences dealing with the hazards of these drugs,” explains Colburn. “ACOEM contributes another guideline that should be of greater use to taxpayers, physicians, and payors to determine the appropriate level and use of opioid painkillers.” Colburn believes that more and better research in the future will help all guidelines makers update their data and provide the best available evidence to the physician community. But Colburn warns that “the physician community must want to follow the best practices of medicine instead of simply prescribing for profit, and we must still deal with the issues of drug diversion and doctor shopping.” Still, Colburn believes that “these guidelines certainly represent another step towards the goal of a providing the best medical care to the injured worker.”
Robert G. Rassp, The Law Offices of Robert G. Rassp, Sherman Oaks, California is troubled by the new guideline. “These updated ACOEM guidelines are inconsistent with the current Chronic Pain Guidelines that allow for long term opioid treatment if the injured worker is on stable dosages of medications, is not abusing the medications, is functional in activities of daily living (ADLs), side effects are minimized, there is no diversion of medications, and the injured worker is working,” says Rassp. “The research from this meta-analysis of the studies simply confirm the obvious—that people who are on long term opioid (and probably short-term) opioid therapy, are lousy drivers, and should not be operating certain machinery while on these drugs.” Rassp believes that what is more important and is not in this study review is “whether long term use of opioids are permitted with the above described characteristics of effective treatment.”
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