Workers and opioids
What employers and employees need to know about treatment choices
- Before committing to using opioids long-term, workers and their doctors should discuss alternatives, some experts suggest.
- A plan for stopping the use of opioids is one of the most important and overlooked parts of the treatment process, according to one expert.
- Employers should train supervisors to recognize behavior that may indicate drug impairment.
When you get injured, you just want the pain to go away.
But in the case of opioid painkillers – which are increasingly being used to treat chronic pain – experts contend the medications may cause further harm, such as addiction or unintentional overdose, when prescribed unnecessarily or misused.
The issue has particular relevance for employers. Approximately 32 percent of workers’ compensation patients take opioids, according to a 2012 study from Ohio State University. The strong pain medicine could have an effect on injured workers’ personal health and ability to function and work safely.
Marianne Cloeren, medical director of Bethesda, MD-based Managed Care Advisors, recommends that employers become well-informed and provide workers with appropriate information and policies related to opioid use.
“I think that employers have very little control over treatment choices,” Cloeren said, “and so it’s imperative to make sure that the people who do have control over the choices are making good choices, or at least have enough information to be able to make a good choice.”
Does the injury warrant opioids?
Somewhere between the appropriate use of opioids and addiction is misuse, which Michael Coupland, president of West Palm Beach, FL-based Integrated Medical Case Solutions, described as using the drug for reasons other than pain relief – such as the euphoric feeling it can cause.
Coupland oversees a national panel of psychologists that helps patients cope with pain and trauma, often work-related. He stressed that most people take opioids at the prescribed dose, but many times the drugs are not warranted, and the pain could have been effectively handled with other methods, such as cognitive behavioral therapy.
Cloeren agreed. “Not every acute injury needs to be managed with opioids, and in fact the musculoskeletal ones usually should not be,” she said.
Strong non-steroidal anti-inflammatory medication may be adequate for an acute injury. If ongoing pain is being experienced, Cloeren suggested alternatives such as physical therapy and learning techniques to take the worker’s mind off the pain through use of music, laughter or meditation.
The problem, she pointed out, is painkillers often are prescribed without a conversation about alternatives. Injured workers need to ask their health care provider, “Is this a severe enough injury that opioids are warranted?” she said.
“And for many acute injuries, they are,” she added. “But I think even in an acute injury, it would be important for someone who has a personal history of substance abuse to understand that there are alternatives and that they’re at increased risk for difficulty getting off them.”
Avoid going from ‘use’ to ‘dependence’
Workers should be aware that they can become addicted to these types of drugs and may be at higher risk based on their personal or family health history, Cloeren said.
Another factor to consider is side effects, which may include difficulty concentrating, sleepiness and lack of coordination. Even after the body adjusts to the medication, long-term use could result in other issues, such as problems with the immune system, depression and sleep disorders, Cloeren noted. She recommends making opioid use short-term, with the patient and doctor developing a plan for revisiting the issue and stopping medication use.
“A plan for stopping is, I think, one of the critical things that are missed when you first start opioids,” Cloeren said. “In the acute prescription period, I think there should be an explicit discussion of how long opioids are going to be used and a plan for stopping them, and that actually could be a way that an employer could get involved to help educate an injured worker.”
She explained that the employer could ask the worker about a plan for stopping use of the medication. This, Cloeren said, should trigger the worker to think about it if he or she has not already.
In Cloeren’s opinion, 30 days after beginning use of opioids is a good time for the patient and doctor to discuss whether to continue use. Many treatment guidelines suggest 90 days, but Cloeren insisted earlier is better.
“A lot of people just drift down that path of chronic opioid use and dependence,” she said. “The patient and doctor need to have conscious decision-making and discussion about whether this condition warrants long-term opioids and how we’re going to manage it long-term.”
One of the most important questions to ask is whether the worker has had a significant improvement in function. In its treatment guidelines, the Washington State Department of Labor and Industries states that opioid use should be discontinued if the worker is not functioning better or has adverse effects related to the drug.
However, Cloeren advised against simply taking the worker’s opinion as evidence of improvement. Instead, she recommends using a standardized questionnaire for measuring and comparing function over time.
To help employees make wise decisions regarding opioids, employers can make pamphlets or other informational materials available in the workplace. In states in which the employer selects a panel of providers for their workers to choose from, Cloeren said employers should evaluate the doctors’ treatment and education philosophy for opioids as part of the criteria.
At work, employers also should be alert for signs that drugs may be impairing behavior. As Cloeren explained, “The employer is not going to be the person that has the expertise for judging whether the treatment plan is appropriate, but they certainly should be able to monitor how the person is doing. Is the person alert? Are they following orders? Are they getting to work on time? Are they performing well?”
Coupland emphasized the importance of occupational health surveillance, which can include having employees annually declare any medications they are taking that may have an impact on their ability to safely perform job duties.
In the 1970s, employers were watching for signs that an employee was intoxicated or hungover, Coupland said. Now, the big issue is opioids, and supervisors should be trained to identify behavior that indicates prescription drug misuse. An example of a yellow flag would be an employee who is excessively drowsy and falling asleep at his or her workstation. A red flag would be a driver who gets lost on a regular route.
Employers have to be careful with what they say and focus on work performance rather than speculate about the worker’s drug use, Coupland said. Let the worker know falling asleep is not acceptable and ask if he or she needs to speak with a health care professional about a health concern. For red flags, Coupland suggested the employer have the worker evaluated for fitness of duty.
Both Coupland and Cloeren said employers should recognize that many workers take opioids in accordance with the prescription and do not experience adverse problems in the workplace.
“I think that employers … have to know that people who are on appropriate doses of opioids can perform safely,” Coupland said. “It’s a very individual thing. People metabolize these drugs differently, so you really have to know as an employer if this particular person is able to perform their cognitive job demands on opioids.”