By Roberto Ceniceros
Jul. 29, 2011
The nation’s liberal consumption of narcotic pain relievers continues to gain recognition for its detrimental impact on injured workers—particularly those treated for chronic pain—and their employers.
Addiction, deaths and longer disability durations are among problems caused by overprescribing narcotic pain medications known as opioids to injured workers, while medical guidelines that could help alleviate the problem are rarely followed, occupational medical experts say.
Although the phenomenon drives employer costs, it is not limited to workers’ compensation cases, occupational medical experts say.
“It really needs to be appreciated as a public health and important medical treatment problem that goes well beyond workers’ compensation,” said Dr. David Deitz, national medical director at Liberty Mutual Group in Boston. “We in the United States have a narcotic problem.”
Several factors are responsible, such as the widespread marketing of prescription drugs and doctors wanting to help patients suffering from chronic pain, the medical experts said.
A report released June 29 by the Washington-based Institute of Medicine states that chronic pain affects 116 million people in the United States, or more than the total affected by heart disease, cancer and diabetes combined, costing about $635 billion annually in medical care and lost productivity.
Meanwhile, growing efforts to address prescription drug abuse include a program unveiled this spring by President Barack Obama’s administration. The program aims to educate doctors on the misuse and “misprescribing” of opioids.
Applying medical guidelines would help eliminate unnecessary narcotics consumption and the problems it drives, the occupational medical experts say.
Injured workers could benefit from insured and self-insured employers working with their insurers, pharmacy benefit managers, nurse case managers, peer review doctors and others to identify claims where narcotic pain relievers are prescribed and to address the underlying medical problem rather than merely treating pain with narcotics, the medical experts said.
Most medical guidelines, such as those produced by the American College of Occupational and Environmental Medicine, or the Official Disability Guidelines encourage that approach, they added.
But very few doctors follow medical guidelines when prescribing narcotic pain relievers to injured workers, according to research that includes a study published this month by the Cambridge, Massachusetts-based Workers Compensation Research Institute.
The guidelines call for early intervention with treatments such as cognitive therapy that aim to help patients return to their daily activities as soon as possible, said Dr. Bernice Peplowski, interim medical director for the San Francisco-based State Compensation Insurance Fund.
The SCIF recently drew complaints from the Sacramento-based California Society of Industrial Medicine & Surgery for revising its medical network contract language to require doctors treating its claimants to agree not to prescribe more than a 60-day supply of opioids without prior approval.
The drugs typically plateau in their effectiveness at 60 days and the guidelines call for limiting their use to that period, according to SCIF.
The guidelines essentially direct that “there is a place for opioids, but that place is for acute severe pain for a brief period of time or end of life [care],” Peplowski said.
“That is where opioids are appropriate … because used in a fashion other than that, they can be destructive and harmful.”
Doctors treating a unique patient needing narcotic pain relievers beyond the 60 days can request the SCIF’s approval, Peplowski said. Such a request gives SCIF’s utilization peer review doctors an opportunity to help the treating physician develop a plan of care.
But the society, which represents medical providers that treat injured workers, said in a June 20 letter to the SCIF that it is concerned the insurer is attempting to “place an improper restraint on providers’ obligations to provide care by defining medical necessity, not on the basis (of) evidence-based guidelines, but rather as a matter of contractual obligation.”
The fact that narcotics are overprescribed is undeniable, said Stephen J. Cattolica, the society’s director of government relations. But others in the medical treatment chain, such as pharmacy distributors, also are responsible for the problem, he added.
It’s not a matter of blaming doctors or patients, several occupational medical experts agreed. Other factors often influence doctor prescriptions.
A primary care provider may want to help a patient suffering from pain while not knowing all the problems associated with narcotics, Deitz said.
More doctor education is necessary, said Dr. Kathryn Mueller, a professor in the department of emergency medicine at the University of Colorado Denver’s medical campus and one of the WCRI report authors.
About 10 years ago, accrediting organizations and some state medical boards pushed doctors to make certain that any pain was treated adequately, Mueller said.
“So the push to take care of undertreated pain, which we agreed did exist, I think has unfortunately led to this situation where now they have to worry about maybe we are overprescribing,” she said.
Applying the medical guidelines when prescribing narcotics could help, Mueller said.
The guidelines call for practices such as screening patients for their susceptibility to drug addiction and other risk factors, such as co-morbid psychiatric conditions. They also call for monitoring patients provided with long-term narcotics prescriptions through practices such as periodic urine tests.
The medical experts stressed, though, that the urine tests discussed in the guidelines are not the type provided by employers, such as for pre-employment screening. They are medical exams provided by the treating doctor to assure appropriate medication compliance.
But the WCRI report titled “Interstate Variations in Use of Narcotics” said that in most of the 17 larger states studied, psychological evaluation and treatment were provided in only 3 to 4 percent of cases.
The study examined 75,000 nonsurgical claims that had 360,000 pain medication prescriptions associated with them.
“Longer-term use of narcotics has a greater potential for overuse, abuse and diversion, and also puts injured workers at higher risk of disability and work loss, and even death from prescription drug overdose,” the report concludes. “However, we found that few of those longer-term users of narcotics received the services recommended by medical guidelines for chronic opioid management, such as drug screening and psychological evaluation and treatment.”
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