By John Stahl, Esq.
LexisNexis Online Subscribers: Citations below link to Lexis Advance. Bracketed citations link to lexis.com.
The numerous ills associated with workers’ compensation claimants (claimants) abusing prescribed opioids is a perfect example of medical care professionals acting in haste in a manner that results in claimants and workers’ compensation insurers repenting at leisure. High drug costs are a near certainty; addiction and a fatal overdose are additional significant risks.
Medical care providers commonly prescribe opioids, also known as pain-relief medications, when a claimant sustains pain associated with compensable harm. This can relate either to the immediate harm, such as a hurt back or a broken wrist, from the compensable injury or from surgery or other “reasonable and necessary” medical care related to any compensable harm. For example, Occupational Injuries and Illnesses Ch. 10, § 10.05 [Ch. 10, § 10.05] (LexisNexis) states that “patients who have undergone hand surgery typically require relatively potent narcotic medication to control pain in the immediate postoperative period.”
Key phrases in the above quote are “potent narcotic medication” and “immediate postoperative period.” Prescribing an appropriate dosage of this literally strong medicine for the “immediate postoperative period” is reasonable and proper.
One element of the widespread problem relates to the practice of medical care providers prescribing unduly high dosages of opioids and/or keeping claimants on those drugs well beyond the “immediate postoperative period.”
Occupational Illnesses and Injuries Ch. 15, § 15.08 [Ch. 15, § 15.08] (LexisNexis) summarizes the problems associated with long-term opioid use in the context of claimants with chronic low-back pain. That provision observes that “patients with chronic low back pain often manifest depression, anxiety and sometimes addiction to pain medication … This dysfunction may exacerbate and perpetuate the pain, which may then increase the level of disability.”
This section on chronic low-back pain provides an excellent framework for better understanding issues related to opioid abuse and applies equally well regarding a wide variety of compensable harm that prompts prescribing opioids.
Like most workers’ compensation issues, the road to opioid abuse begins with a compensable incident. This leads to the “reasonable and necessary” services that a medical care provider offers a claimant including an opioid prescription to ease the pain associated with the compensable harm. The trouble starts when the compensable harm, or subsequent treatment for that harm, creates chronic pain that prompts prescribing a long-term regimen of opioids.
The long-term use of opioids often coincides with depression and anxiety that the extended period of pain or other concerns related to the workers’ compensation claim triggers. Causes of those psychological problems range from anxiety regarding lost income, to frustration regarding a slow recovery from original and/or subsequent injuries, to the strain that the other sources of angst places on marriages and other personal relationships.
A commonly (and extraordinarily short-sighted) utilized quick fix involves extending the time that a claimant is prescribed an opioid. Increasing the morphine-equivalent dosage of that drug often simultaneously occurs. Giving medical providers the benefit of the doubt, the logic behind this practice is that more aggressively combatting the pain will improve the claimant’s comfort level to an extent that will alleviate the accompanying depression and/or anxiety.
The first problem is that, at best, opioids merely eliminate the pain without addressing the underlying problem that is causing that discomfort. This can be thought of as a car owner dampening the sound associated with a faulty muffler that still spews exhaust from the rear of his or her vehicle.
This masking of symptoms will likely result in the related condition continuing to cause pain, which will simply be eased if a medical care provider merely continues prescribing opioids. Additionally, related depression and anxiety will probably continue until the pain is either actually eliminated or at least addressed in a better manner than figuratively pouring pills down the claimant’s throat.
Further, giving a depressed person easy access to a potentially lethal amount of drugs defies common sense. A person in great physical pain accidentally overdosing on drugs that alleviate that pain is a comparable risk.
The good news is that good practices exist for properly managing opioid use and appropriately responding when that use becomes abuse.
Effective Drug Monitoring Problems
Four experts who recently discussed methods to address actual and potential abuse of those substances at Workers’ Compensation Research Institute’s (WCRI) 2013 annual conference included Peter Kreiner, Ph.D., of Brandeis University in Waltham, Mass., Dean Hashimoto, MD, of Partners Healthcare System in Boston, Mass., James Hudak of Paradigm Outcomes in Walnut Creek, Calif., and Harry Leider, MD, of Ameritox, Inc., in Baltimore, Maryland.
The primary message that Kreiner communicated was that an ounce of prevention was worth several pounds of cure. The prevention regarding the risk of opioid abuse related to state-operated prescription drug monitoring programs (PDMPs). Only Missouri has not utilized this type of program.
Kreiner described an effective PDMP as one in which physicians and pharmacies that dispensed claimants opioids comprehensively reported that activity to the relevant state agency. The PDMP then was equally comprehensive in distributing that information to physicians, pharmacies, and law enforcement agencies. This monitoring’s scope encompassed Schedule II, III, and IV drugs in virtually every state.
One reason for widely distributing that data was to help ensure that a treating physician was fully aware of all the opioids that that physician and other medical service providers prescribed a claimant. A related reason was to hinder physician shopping by claimants who saw multiple doctors as an effort to obtain redundant opioid prescriptions.
Including law-enforcement agencies in the distribution list helped identify physicians and pharmacies that dispensed an unduly large amount of opioids.
Elements that helped enhance a PDMP’s effectiveness included:
Kreiner noted that inter-state data sharing helped fill in a claimant’s prescription history. He additionally described the unsolicited reports as a PDMP proactively analyzing data and raising appropriate red flags as needed.
More specific monitoring practices that Kreiner advocated included:
These guidelines boil down to the basic principle that being aware of the degree to which a claimant has access to opioids helps prevent use of such substances becoming abuse.
Hashimoto succinctly described the recommended treatment guidelines with claimants who presented an enhanced risk of abusing opioids as “what we’d like doctors to be doing.” He added that enforcing “meaningful change” regarding those treatments was difficult.
His presentation also addressed the importance of consensus regarding “what is a reasonable clinical approach” to treating opioid abuse. The identified components of those guidelines were evidence-based medicine and the practical experience of medical care providers who treated opioid-addicted patients. Hashimoto added that those guidelines were mostly informational, rather than prescriptive, and that they played a large role in conducting utilization reviews.
Related to the concerns described in the “Background Information” section of this article, above, the general treatment guidelines for treating claimants with acute pain called for:
The recommended general treatment guidelines for claimants with chronic pain addressed comparable issues and expressed enhanced concerns regarding psychological aspects of an extended period of physical pain.
Hudak placed the indisputably serious opioid abuse problem in perspective by noting both that it has been a concern for roughly one hundred years and that relapses commonly occurred regarding numerous health problems in addition to that abuse. These examples of reoccurrences of problems after obtaining treatment included hypertension and asthma.
A more positive observation regarding claimants who became addicted to opioids was that “there’s more of a commitment to change” compared to the general population. This related to an injured worker’s desire to return to his or her job.
Additional important elements to treating opioid-addicted claimants included:
Hudak further recommended the holistic approach that reflected the biological, psychological, and social aspects of addiction. This included:
The success regarding this approach to opioid addiction was summarized as “a decrease in costs, a decrease in morphine equivalents, and a high level to return to work.”
Leider cited the statistics that poisoning was the leading cause of death from injury in the United States, that drugs caused roughly 90 percent of poisoning deaths, and that opioid analgesics were a factor in more than 40 percent of those drug-poisoning-deaths.
The presentation also expressed the related objectives of improving the care and reducing “medical costs for complex/high risk injured workers on chronic opioid therapy.”
Specific alternatives to treating chronic pain that lacked risks associated with long-term opioid use that were discussed included:
Leider noted as well that both the American Pain Society and the American Academy of Pain Medicine recommended regular urine drug testing for claimants who either were addicted to opioids or were at risk for that addiction. One recommendation regarding that testing was that it be administered regardless of whether the claimant had displayed any aberrant behavior that indicated the existence of that problem. This reflected a statistic that roughly 25 percent of claimants who did not display behavior that raised a red flag still had high levels of opioids in their urine.
A further recommendation was that the frequency of the testing reflect the perceived risk of addiction based on every relevant factor. The recommend minimum frequency was roughly three times each year.
The decreases in the number of medical professionals and the simultaneous growth in need for their services for reasons that include the aging of the American population is increasing the demand on these caregivers’ time. This phenomenon increases the probability that doctors will utilize the quick fix of prescribing opioids, rather than take the time to understand and properly address a claimant’s pain. This makes a corresponding increase in the use of the effective monitoring and treatment guidelines that the WCRI panels advocated critical.
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