Articles | Cases

What employers can do to stop narcotic abuse

Aptly described by Gary Franklin MD, Washington State fund's Medical Director as a "hair on fire" issue, the widespread use of narcotic painkillers to treat injured workers has states, regulators, and insurers all struggling to reverse the trend. While a long-term solution to the misuses and abuse of narcotic painkillers in Workers' Comp will require a concerted effort by these stakeholders, employers can not afford to wait.

The eye opening facts are:

Here are four steps employers can take to stem this troubling issue:

1. Encourage working through pain by returning injured workers to work

The epidemic use of opioids to treat injured workers is relatively new and grew from the virtuous goal of helping to reduce pain and transition workers back to work as quickly as medically possible. Until about 15 years ago, the drugs were used for end-stage cancer or other end-of-life care. With success in those areas, pain experts felt the medications could be used to treat other kinds of long-term pain with little risk of addiction.

Today, narcotic drugs are widely prescribed to treat common problems such as back pain, even though there is little evidence that they provide long-term benefits for musculoskeletal injuries. During the last decade, insurers readily reimbursed doctors for prescribing painkillers while eliminating payments for treatments that did not rely on drugs, such as therapy. In effect, opioids were viewed as a silver bullet - an inexpensive, quick cure. Researchers, however, have found use often leads to delayed recovery; in fact, Danish researchers have published a study indicating the chronic pain patients getting non drug treatment recover at a rate four times higher than those on opioids.

Claimants develop tolerance to the drugs and need greater amounts to get the same effect, so doctors routinely increase the dosage, believing it is safe to increase dosages as long as patients are improving. Yet, many do not improve but suffer from lethargy and continuous pain. Worse, opioids can lead to addiction and have other serious side effects, including fatal overdoses. A commonplace injury slowly morphs into a crippling one as the worker increases tolerance for the drugs, 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.

Managing pain is critical to help injured workers return to work and remain productive; yet, finding ways to effectively deal with it is often illusive. While the pain is real, there are also psychosocial factors that can lead to increased intensity. Preoccupied with the pain and lacking confidence in the ability to return to work, an injured worker can believe so strongly in the severity of the injury that it becomes a chronic disability.

The key is to engage the worker before the attitude can develop. 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.

A new study has shown distraction reduces pain-and it's not purely psychological. The study, published in the June issue of Current Biology, found that distraction might actually stop pain from reaching the central nervous system by setting off the release of opioid-based chemicals in the body.

The researchers asked study participants to complete either a difficult or easy memory task while a painful level of heat was applied to their arms. They found that participants who completed the harder memory task experienced less pain and using high-resolution spinal fMRI (functional magnetic resonance imaging) discovered that the pain signals were blocked from reaching the spinal cord.

According to the researchers, the pain-relieving effects involve endogenous opioids, which are naturally produced by the brain and play a vital role in the alleviation of pain.

The study participants were then required to complete the task again, but this time they were given either a drug called naloxone, which blocks the effects of opioids, or a simple saline infusion. The researchers found that distraction was significantly less effective (40%) when participants received naloxone.

The researchers said their findings lend support to the use of cognitive behavioral methods in treating pain. These approaches also have the potential to prevent pain from becoming chronic by altering the underlying neurological signals in the spinal cord.

2. Identify physicians who understand the issue

While data suggests that a small percentage of doctors who treat injured workers prescribe the vast majority of narcotic drugs (in California, it's just 3%), knowing and avoiding these offenders is not enough.

Patient education is essential to reign in the use and abuse of opioids and physicians need to step up. 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.

3. 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. The typical case is one when the claimant is on OxyContin, or another narcotic drug for several years, the doses continue to escalate, and the treating doctor has no long term plan other than 'more'. There's little accountability: The treating provider does not follow standards; the claims examiner does not review the treatment plan for appropriateness; and the injured worker is not required to actively participate in recovery.

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 claimants comply with prescribed narcotic regiments and don't abuse their medications. But even here the employer needs to be cautious. A recent article in Business Insurance, "Comp drug testing raises costs, questions" examines the surging utilization and costs of drug testing and casts a shadow on strategies used to attract business. While drug testing can be a best practice, it behooves the employer to learn about the lab's Workers' Compensation expertise, its service quality, technological capabilities and scientific approaches.

4. 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.

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. Doctor shopping - seeking care from multiple doctors and obtaining multiple prescriptions for the same type of drug
  3. Refilling prescriptions early or reporting lost prescriptions
  4. Frequent trips to the emergency room for prescriptions
  5. Having a great knowledge of drugs and trying to dictate their treatment even though they do not have a medical background

Today, most experts agree that there is far too much usage of opioids in Workers' Comp. It's a slippery slope that leads to bad outcomes for all concerned. While the task of dealing with those who have been caught in the cycle is daunting, recognizing and advocating alternative methods for treating pain is a critical step to break the cycle.