Narcotic misuse and abuse still plagues Workers' Comp system

It seems not a day goes by without some media headline calling attention to the rising number of Americans addicted to prescription painkillers. Spurred by a medical community that is quick to offer narcotics as a solution to pain, the problem has become a public health crisis. In fact, prescription drug overdoses are now the leading cause of injury-related death, surpassing auto accidents.

The longer an injured workers uses pain medications containing narcotics, the more likely there will be serious health consequences and the less likely the worker will return to work. Despite efforts to curb the use and cost of opioids in the Workers' Comp system, the use of these drugs remains frighteningly high, according to new studies. One study, Interstate Variations in Use of Narcotics 2nd Edition, by the Workers' Compensation Research Institute (WCRI) examined interstate variations and trends in the use of narcotics and prescribing patterns of pain medications in the workers' compensation system across 25 states. It concluded that while there was a "sizable increase" in the use of drug testing of longer-term opioid users over the study period (between 2008/2010 and 2010/2012), the percentage of claims with opioids that continued with opioids on a longer-term basis changed very little (within two percentage points) during the study period.

The study confirmed that narcotics use persists in the workers' compensation system. In 2010/2012, about 65 to 85 percent of injured workers with pain medications received narcotics for pain relief in most states. Louisiana had the highest number of longer-term users, one in six injured workers. New York, Pennsylvania and Texas followed closely, with one in eight. ("Longer-term users" was defined as those that had opioids within the first three months after the injury and had three or more visits to fill opioid prescriptions between the seventh and 12th months after the injury.)

According to the study, "the average injured worker in New York and Louisiana received over 3,600 milligrams of morphine equivalent narcotics per claim (double the number in the typical state). To illustrate, this amount is equivalent to an injured worker taking a 5-milligram Vicodin® tablet every four hours for four months continuously, or a 120-milligram morphine equivalent daily dose for an entire month."

Michigan had the highest amount of narcotics per claim among the Midwest states. It is worth noting that this is an increase as Michigan was among the states with lower use of narcotics per claim compared with the typical state in 2008/2010. Longer-term opioid use by injured workers was much less prevalent in Indiana, Missouri, New Jersey and Wisconsin, with fewer than one in 20.

Similarly, findings from new research by the California Workers' Compensation Institute (CWCI) shows the use of narcotic drugs has remained at record levels since 2010; virtually the same 3% of high-volume Schedule II opioid prescribing doctors continue to write more than half of the prescriptions, and that nearly half of the prescriptions are for minor injuries where medical evidence does not clearly support Schedule II opioid use.

While an effective, long-term solution to this multi-facet problem remains illusive, employers can take steps to manage their claims:

Encourage working through pain by returning injured workers to work
Employees on Workers' Comp develop tolerance to the drugs and need greater amounts to get the same effect, so doctors routinely increase the dosage, which can lead to addiction. A commonplace injury slowly morphs into a crippling one as the worker takes more drugs but does not achieve improvement in increased function or reduced pain, and does not return to work, resulting in escalating medical costs, longer claim duration and greater long term risk exposure for the employer.
The psychological effects of managing chronic pain should not be ignored. A number of past studies have shown that distraction, such as keeping busy and returning to work, is highly effective in altering the experience of pain. Some studies showed that distraction interferes with pain perception while other studies show that pain increases when it is the focus of attention.
Monitor through drug testing and psychological evaluations
The WCRI study notes that medical treatment guidelines for chronic opioid management recommend the use of monitoring and management services, such as periodic drug screening and psychological evaluations. The researchers found an increase in drug testing, but continued low use of psychological services. If opioids are started, it's important to have a plan as to when to stop.
Identify physicians who understand the issue
Painkillers are often prescribed without a discussion of the alternatives or adherence to the American College of Occupational and Environmental Medicine's (ACOEM) Opioid Treatment Guidelines, which focus on the treatment of acute and chronic non-cancer pain for workers' comp cases. While it's important to know and avoid doctors that prescribe a high percentage of narcotic drugs, it's equally important to identify those physicians who proactively seek alternatives to the treatment of pain and take the time to explain the potential dangers of intensive drug regimes. Those that can effectively deal with the fear of pain, reassuring the patient that returning to an active lifestyle will be beneficial, help prevent the worker from developing the all- consuming disability mindset that spells disaster for workers' comp claims.
Address narcotic-related legacy claims
Perhaps the most difficult aspect of controlling this problem is dealing with workers now on high opioid dosages who are not benefiting from them. A critical step is to get involved and demand a plan of action and timetable to wean the claimant off of the drugs. The compassionate employer will work with injured workers to help them recognize when there is a problem, and then help them use medications appropriately or get off the medication. Drug testing is a necessary component of the treatment protocol to ensure that employees comply with prescribed narcotic regiments and don't abuse their medications.
Beware of red flags of prescription drug abuse
Part of the challenge in dealing with prescription-abusing injured workers is identifying when a worker is experiencing a problem and/or when a problem is escalating. Everyone is vulnerable since anyone can become addicted; yet, many deny addiction or are adept at hiding it.
While employers have to be careful with what they say and focus on work performance rather than speculate about the worker's drug use, some of the signs of abuse are:
1. Changes in behavior, failure to maintain eye contact, slurred speech, ready excuses for problem behaviors, and/or an anxious or jittery manner
2. Drowsiness or falling to sleep at workstation; unusual slips in performance or alertness
3. Doctor shopping - seeking care from multiple doctors and obtaining multiple prescriptions for the same type of drug
4. Refilling prescriptions early or reporting lost prescriptions
5. Having a great knowledge of drugs and trying to dictate their treatment even though they do not have a medical background