Injured and addicted?

By Kyle W. Morrison, senior associate editor

Worksites can present many types of hazards. Although some people may believe an injury occurring from those hazards is the worst-case situation, a worker recovering from that injury could be in just as much danger – if not more.

From 1999 to 2008, the number of drug poisoning deaths involving opioid analgesics, or painkillers, more than tripled – to about 148,000 from 4,000, according to the Centers for Disease Control and Prevention. Also, for every unintentional opioid analgesics overdose death, there are nine people admitted for substance abuse treatment, 35 emergency department visits and 161 reports of drug abuse or dependence, CDC said. Although it is unclear how many involve employees who were injured on the job and are in the workers’ compensation system, experts contend that the national trend of painkiller abuse extends to recovering workers.

“Opiate abuse is a major national public health problem,” said Richard Victor, executive director at the Cambridge, MA-based Workers Compensation Research Institute. “Because the overwhelming majority of workers’ compensation drugs are for pain, opiate use is an especially important concern for workers’ compensation payers, medical providers and patient advocates.”

Growing problem

No hard data exists linking employees recovering from injuries to prescription painkiller drug abuse. But the evidence of painkiller abuse in the general public, coupled with the anecdotal evidence of painkiller abuse in workers’ comp, makes the issue a concern, according to Ishita Sengupta, director of workers’ compensation at the National Academy of Social Insurance, a Washington-based nonprofit think tank that focuses on social insurance.

“This has been an issue that has been coming up a lot,” Sengupta said, noting that the amount of abuse in the system is likely “considerable.”

Additional evidence leading experts to believe this is a growing problem includes an increase in the number of painkiller prescriptions written under workers’ comp. Prescription drugs made up 19 percent of all medical expenses in 2009, with the popular painkiller OxyContin being the No. 1 prescribed drug, according to a study from the National Council on Compensation Insurance Inc., a Boca Raton, FL-based provider of workers’ comp and employee injury data.

Also, among injured workers with more than seven days of lost time who received at least one prescription under workers’ comp, 55-85 percent were prescribed narcotics, a WCRI study found. NCCI’s workers’ comp prescription drug study also found an increase in physicians dispensing such drugs, and the increase was associated with increased drug costs per claim.

But does an increase in the number of opioid prescriptions lead to an increase of abuse? Some experts say it does. In the general public, the number of painkiller prescriptions in the United States has been growing, and more opioid overdoses occur now than from heroin or cocaine combined – increasing to what CDC in November called “epidemic levels.” This would likely be seen in workers’ comp as well, experts warn.

“Doctors don’t necessarily approach a distinction between an injury in workers’ compensation or an injury anywhere else” when prescribing painkillers, said David Deitz, M.D., the national medical director at Liberty Mutual Insurance in Boston.

Cause and effect

The WCRI study, issued last July, examined variations in the use of narcotics in workers’ comp health care across 17 states.

“Tremendous variation has been reported in the WCRI’s narcotics study,” Victor said, including in the amount and the strength of narcotics prescribed among the states.

For instance, injured workers in four states (Louisiana, Massachusetts, Pennsylvania and New York) received 80-125 percent more narcotics prescriptions per claim than the other 13 states, which suggests the possibility of overtreatment, researchers found.

In seven states, injured workers were more likely to receive narcotics on a longer-term basis than in the other states, and few of those users received appropriate recommended monitoring services to minimize the chances of abuse. Victor said a prevalence of longer-term narcotics use often is associated with a higher risk for potential misuse and abuse, and the WCRI report noted that this could lead to workers having a greater risk for further disability, work loss and even death.

“What we see in workers’ compensation is – particularly for lower-back injuries and other types of soft-tissue injuries – there’s probably some overuse of narcotic medications in situations where a number of guidelines recommend they be used cautiously or not at all,” Deitz said.

It is difficult to ascertain why doctors may veer from prescription guidelines and why there is an overall trend of overprescribing painkillers, Deitz said, because it often comes down to the motivations of a single doctor with a single patient. He speculated that part of the reason may stem from past incidents in which patients – particularly cancer patients – were undertreated for pain.
Now the pendulum has swung in the other direction, and perhaps too far, he said.

Workers who develop an abuse problem will have difficulty returning to the job, and that could bring issues for employers. “If it becomes a drug abuse issue, then employers have to incur additional costs for rehabilitation and testing,” Sengupta said.

As with many statistics on this topic, there is no solid data on the effect prescription drug abuse may have on an employee who returns to the job after an injury. Deitz speculated that the majority of injured employees who take pain medication will recover and return to work with few complications, and only a minority will develop an abuse problem. But he stressed that any potential prescription drug abuse would extend beyond the workplace.

“From our perspective, the real tragic effect of this is the functional disability that excessive narcotics create,” Deitz said. “That’s an issue not just for the workplace, but for [workers’] interactions with their families and society.”