The One-Two Punch of Benzodiazepines and Opioids on Workers’ Compensation Claim Costs

New study finds combined use of these drugs significantly increases workers’ comp costs

Thomas A. Robinson, J.D., the Feature National Columnist for the LexisNexis Workers’ Compensation eNewsletter, is a leading commentator and expert on the law of workers’ compensation.

A group of occupational medicine experts has released results of an important, soon-to-be published study indicating that the addition of benzodiazepines to an opioid treatment regimen significantly increases workers’ compensation costs [see Robert A. Lavin, MD, MS, et al., “Impact of the Combined Use of Benzodiazepines and Opioids on Workers’ Compensation Claim Cost,” Journal of Occupational and Environmental Medicine (JOEM)]. Building on earlier studies that had shown that the cost and duration of workers’ compensation claims increase as opioid dose increases, this new study is the first to examine the impact of benzodiazepines, particularly in relationship to concomitant opioid use or abuse.

Benzodiazepines and the Holy Trinity Effect

Many within the workers’ compensation context are relatively familiar with the explosive growth in opioid prescriptions in the treatment of injured workers. Particularly those of us who are not medical professionals, however, are not nearly as knowledgeable about benzodiazepines. It may be recalled that benzodiazepines generally belong to the group of medicines called central nervous system (CNS) depressants. They are often used to relieve anxiety, to treat insomnia, and to help relax muscles or relieve muscle spasm. Commonly prescribed brand names include Ativan, Dalmane, Diastat, Valium, and Librium. According to many experts, benzodiazepines and opioids comprise eight of the top ten most abused medications in the United States [see Jones CM, et al., “Pharmaceutical Overdose Deaths, United Sates, 2010.” JAMA. 2013; 309(7):657–659: http://www.mymatrixx.com/opioids-are-in-the-news-but-not-new-in-workers-comp/#sthash.6U9Rjd2n.dpuf].

Benzodiazepines may be habit-forming, especially when taken for extended periods of time or in high doses. They make up part of a popular, but dangerous drug combination of short-acting opioids, muscle relaxants and anti-anxiety drugs. The combination is sometimes called the “holy trinity” by drug abusers because the feeling of euphoria that it can produce is similar to that produced by heroin.

Study Examines 11,394 Lost Time Injury Claims

The researchers examined all 11,394 lost time injury claims filed in the Louisiana Workers’ Compensation Corporation (LWCC) Claims Payment Database (CPD) from 1999 to 2002 and followed for 7 years postinjury. A private mutual insurance company, the LWCC writes approximately 25 percent of the fully insured market in Louisiana. The CPD information included demographic data, treatment, indemnity and medical claim costs, as well as the claim closing dates.

All prescriptions for benzodiazepines and opioids were selected on the basis of their national drug codes. Pills and dose information were abstracted from each prescription. From the LWCC data, the researchers calculated the average number of claims with prescription benzodiazepines and opioids, average number of prescriptions per claim, pills per claim and the Diazepam Equivalent Dose (DED), or morphine equivalent dose (MED) per claim each year postinjury. Average duration and claim costs were examined for combinations of claims that ever had benzodiazepine and/or opioid utilization.

Finally, the researchers performed a multivariate logistic regression analysis to determine the association of benzodiazepines and opioid with the risk of having the final workers’ compensation cost at $100,000 or higher, controlling for gender, age, attorney involvement, and back and neck body part. In this cost analysis, benzodiazepines were controlled for opioids, and opioids were controlled for benzodiazepines.

Study Finds 16-18 Percent of Claimants Prescribed Benzodiazepine & Opioids

Among its findings, the study determined that:

> during the initial year of the injury, nearly half of the claimants (46.4%) were prescribed opioids, but only 4.9% received a benzodiazepine prescription during the course of treatment;


> while the tendency is for the number of open claims to decrease each subsequent year–because of return to work and settlements–the percentage of claimants receiving opioids each year remained relatively stable, at least 7 years after the injury;

> the percentage of claimants receiving benzodiazepines increased up to the third year of injury and stabilized thereafter (16.3% to 18.6%);

> the number of benzodiazepine pills per claim (498), prescriptions per claim (8), average DED per claim (3985), and the average daily milligrams DED per claim (10.9 mg/day) did not appreciably change after year three postinjury; and

> the number of opioid pills per claim (895) and prescriptions per claim (11) remained relatively stable after year 4, but the average milligram MED, and the average daily milligrams MED per day continued to increase throughout the 7-year study period.

The study noted that a major difference between opioids and benzodiazepines was reflected in the continuing opioid dose escalation in the remaining open claims, as opposed to the benzodiazepines, where dose escalation tended to stop 3 years after the injury.

The researchers stressed that more than half of all claims (6,413 claims; 56.3%) did not involve either prescription opioids or benzodiazepines and only 44 (0.7%) of these claimants were prescribed benzodiazepines without prescription opioids. Claimants prescribed opioids were divided into two mutually exclusive groups: those who were only prescribed short-acting (SA) opioids and those only prescribed long-acting (LA) opioids. Building upon the group’s prior studies with the same data, the researchers indicated that with regard to combinations of benzodiazepines and opioids:

> 15.8% of claimants only prescribed SA opioids also received at least one prescription for a benzodiazepine, but

> 59% of the 5.2% of claimants ever prescribed LA opioids were also prescribed benzodiazepines.

> Claimants prescribed with LA opioids were associated with both a higher opioid daily dose and a higher frequency of benzodiazepine use–factors associated with worse (i.e., higher cost, longer duration) claim outcomes.

Impact on Claim Costs

As to claim cost data, the researchers indicated that the presence of prescription benzodiazepines:

> more than tripled claims costs, from $10,801 to $34,613, for claimants never receiving opioids;

> more than tripled claims costs, from $43,438 to $123,311, for claimants receiving SA opioids; and

> increased by some 51% the claim costs, from $139,734 to $211,097, for claimants receiving LA opioids.

After controlling for gender, low back pain, marital status, and attorney involvement, the logistic regression analysis indicated that an odds ratio for benzodiazepines being associated with claim costs greater than $100,000 was 2.74 times higher than claims without benzodiazepines.

Some Inconvenient Truths

From their own study and others, the researchers point to an unfortunate set of conclusions:

> benzodiazepines adversely affect claim outcomes;

> benzodiazepine prescribing occurs despite the absence of evidence for the efficacy of long-term benzodiazepine;

> benzodiazepines and high-dose opioids are associated with mental health and substance misuse;

> in opioid maintenance populations, the prevalence of benzodiazepine abuse is 50% or more;

> prescription benzodiazepines in opioid maintenance patients are eight times higher than those in the age-matched population; and

> both high doses of opioids and concurrent use of opioids and benzodiazepines are associated with higher mortality.

From their own data and a review of other studies, the researchers noted a particularly harmful phenomenon: that as noted above with my mention of the “holy trinity” of drug abusers, because benzodiazepines tend to increase the intensity and duration of psychotropic reward, the use of benzodiazepines often leads to drug abuse, particularly in susceptible individuals. Again, citing the complementary work of other experts, the group also noted that in the opioid maintenance population using benzodiazepines, there is a higher incidence of psychiatric hospitalization and higher frequency of anxiety and depressive disorders. Moreover, those with pain and mental health disorders may have more somatic symptoms, reduced levels of function, and greater mental distress, which might partially explain the concomitant use of benzodiazepines and opioids.

The study does indicate that the dose equivalent per claim of benzodiazepines and opioids followed different trajectories during the course of the study. Increasing opioid dosages might reflect progression of disease or condition affecting the claimant and, if so, the remaining open claims might represent a subset of individuals with more severe medical conditions. On the other hand, these long-term open claims might represent a disproportionate number of individuals with substance abuse or mental health problems. Such factors could certainly contribute to the cost and duration of claims. Stabilization of benzodiazepine dose might also reflect differences in the psychotropic effects of benzodiazepines compared with opioids, because the latter may require increasing doses to achieve the same effect. On the other hand, dose progression might also not occur with chronic benzodiazepine use because the user is trying to avoid withdrawal symptoms, which studies indicate are more prolonged and problematic than opioid withdrawal.

Limitations of the Study

The primary limitation of the study is that it addresses the association between benzodiazepines and opioids with claim outcomes; a definitive cause-and-effect relationship cannot be shown. Nor does the study address individual physician prescribing patterns that may influence outcomes. And while the study does not establish a direct link between poor workers’ compensation outcomes and psychological and social issues, it is, nevertheless, likely that claimants with complex psychosocial issues will have costlier claims with delayed resolution. Finally, the study does not address mortality rates, which have been associated with high dose of opioids in combination with benzodiazepines in other studies.

Commentary

In a recent exchange I had with a friend and colleague, Stuart Colburn, Esq. (Board Certified in Workers’ Compensation within the State of Texas, Shareholder at Downs Stanford, P.C., and co-author of Texas Workers’ Compensation Handbook (LexisNexis)), Colburn allowed that “this important study confirms the obvious; that is, the adverse relationship between claim outcomes and prescription patterns.” Colburn noted that the authors made clear the limitations of the study (i.e., the study was not designed to address a causal relationship) and call for further scholarship.

“But many stakeholders agree the combination of benzodiazepines and opioids has no place in workers’ compensation, regardless if these prescribing patterns are statistically correlated with or the cause of the poor outcomes,” says Colburn. “If we truly care about these injured workers, regulators should work with providers and payors to eradicate the practice of chronically providing both drugs simultaneously in the workers’ compensation context.”

Colburn believes that “doctors practicing such medicine should be identified and educated about the most recent evidence” and that “if no medical efficacy can be demonstrated, chronic benzodiazepine prescribing practices should be addressed by all means necessary.”

While higher claim costs are a negative outcome for employers and payors, Colburn warns that “the effect on injured workers and their families (and the public at large) is potentially catastrophic and in fact can be deadly.”

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