Chesapeake Section AIHA/ASSE PDC
Impact of Opioids on
Workers
Marianne Cloeren, MD, MPH, FACOEM
Senior Medical Director, Managed Care Advisors
Thursday, April 21, 2016
Objectives
Explain opioids and their legitimate role in workers’ comp.
Identify factors that support status quo of opioid abuse and
misuse.
Discuss impact of opioids on medical costs, lost work days
and RTW planning.
Brainstorm ideas for helping employees make better
informed decisions.
.
Key Messages
Take These Home
Most opioid prescriptions in workers’ compensation injuries
are NOT clinically appropriate.
Opioid prescriptions increase both medical and disability day
related costs.
Most doctors prescribing opioids are NOT following treatment
guidelines.
Most patients who wind up on long-term opioids were not
educated about choices, risks, benefits.
2/3 of those on opioids for 90 days will still be on them 5 years
later.
3
What Are Opioids?
Opium/Opiates/Opioids
Drugs derived from (or synthesized to mimic) chemicals from
the opium poppy.
History: morphine, opium, heroin -> synthetics.
Nerve receptors: pain, euphoria (high).
Long term use causes physical dependence.
Addiction risk -> 1/3 with long-term use.
4
Knowledge Check
Poppies
Pop Quiz!
Why do all
presentations
about opioids
include a
picture of a
poppy?
Terminology
What is the
difference
between an
“opiate” and
an “opioid”?
Short-Acting Opioids
Types:
Combined with acetaminophen (oxycodone, hydromorphone,
codeine)
Injection – usually for acute pain, in ER or hospital setting – e.g.
morphine, meperidine.
Examples?
High potency – hydromorphone.
Limited to Acute, or Intermittent Use:
Intermittent withdrawal if used on a chronic daily basis
Increased potential for addiction
6
Long-Acting Opioids
Gradual Release
Deliver the
drug in a
more steady
way, keeping
it more even
in the bloodstream.
Dangers
Should only be
prescribed
to patients
already on
opioids.
Overdose risk if
opioid naïve.
Formulations
Formulations
include pills,
liquids and
skin patches.
Examples?
7
Clinical Appropriateness
Usually Appropriate
Significant acute
injuries like
broken bones
CDC guidelines
suggest 3 day
limit when
needed
Usually Inappropriate
NOT appropriate for
acute sprains
and strains.
NOT appropriate for
almost all
chronic noncancer pain.
Do not improve
outcomes for
acute disc injury.
Gray Areas
Waiting for surgery
authorization
Post-surgery – how
long?
Acute Prescription
Time-Limited
3 days to one
week
New CDC
guides on
chronic
opioid Rx
Screening
Risk vs. benefit
Risk of
addiction,
side effects,
interactions
Adjustment
Highest risk
for side
effects on
thinking,
alertness,
reflexes
Formulation
Only shortacting
opioids
should be
used
acutely
Acute Opioid Risk Considerations
Safety
Work/home/driving safety
(children at home?)
Habits
Use of other substances
(e.g. alcohol).
Risk of Addiciton
Interactions
Interactions with other
medications.
Past addiction.
Current alcohol misuse.
Childhood trauma.
Mental illness.
Cognitive Impact
Acute Rx
Impacts:
Alertness
Thinking
Reflexes
Judgment
Particular Fitness for Duty Issues
Public Safety
Transportation
Health Care
Police
Commercial drivers
Doctors
Fire Fighters
Pilots
Nurses
Military
Ship captains
Paramedics
Rescue
Air traffic
Equipment operators
Other examples?
Essential Job Duties Common to Public Safety Positions
Job Considerations
Erratic, prolonged, varied shifts
Rescue
Austere, varying environment
Vision, hearing, smell, touch
Drive long and/or fast
Effective spoken communication
Pilot planes, ships
Read and write effectively
Pursue, apprehend, restrain
Evaluate rapidly changing situations
Stand/walk long hours
Maintain alertness and focus
Opioids
Effects
Drowsiness, trouble thinking, etc.
more common with acute use –
once a patient is on them for
several months, such side
effects are less common
Sometimes cause side effect of
increased pain sensitivity –
mistakenly treated with
increased doses of narcotics
Constipation, sexual dysfunction,
sleep disorder, depression
Withdrawal
Agitation, Insomnia, Runny nose, Hot and
cold sweats, Yawning, Muscle aches,
Abdominal cramping, Nausea, Diarrhea
Dependence/Tolerance/Addiction
Needed to feel normal
Increasing dose needed
Used improperly; drug seeking behavior
Subacute Period
Second Prescription through 90 Days
Ongoing use after the inflammation from the acute injury has
subsided (second prescription through 90 days of use).
Risks start to outweigh benefits.
Tolerance and physical dependence start.
Best opportunity for education and triggering active decision
making – before prescriptions drift into chronic.
Chronic Opioid Use
90 Days Onward
At 90 days, opioid use is considered chronic.
Chronic opioid guideline use is supposed to kick in at this
point – but no system trigger for this.
Most doctors DO NOT implement chronic opioid guidelines
at this recommended point (or ever.)
Subacute to Chronic Risk
2011 study of 30,000 patients
prescribed opioids > 90 days
over 6 months.
5 year follow-up after 90+
day prescription
Still on
opioids
Off opioids
66% of those followed for 5
years were still on
opioids.
Citation
Martin BC, et al. Long-Term Chronic
Opioid Therapy Discontinuation
Rates from the TROUP Study. J Gen
Intern Med. 2011.26(12): 1450–
1457.
http://www.ncbi.nlm.nih.gov/pmc
/articles/PMC3235603/
Chronic Opioids and Lost Work Days
Odds of chronic work loss were 6X > for
claimants with schedule II
Odds of chronic work loss were 11-14X if any
opioid > 90 days
Cost at 3 years $20,000 more for schedule II vs.
none
Opioid therapy for nonspecific low back pain and the outcome of chronic work loss
18
Volinn E, et al. Opioid therapy for nonspecific low back pain and the outcome of chronic work loss.
Pain. 2009 Apr;142(3):194-201.
Chronic Opioids
Are Doctors Using Chronic Opioid Guidelines?
In a study of practices in 17 states:
– Psychological evaluations - 4%
– Drug screening –7%
Wang, Workers’ Compensation Research Institute, 2011:
ttp://www.oregon.gov/oha/pharmacy/DocumentsArticlesPublications/Long
er-Term%20Use%20of%20Opioids%20%E2%80%93%20WCRI.pdf
Which of the following do you routinely do in cases in which you prescribe
opioids – for non-cancer pain – for 90+ days?
This was a poll used in
an educational
presentation for doctors
at QuantiaMD; results
were from > 10,000
doctors.
20
Chronic Opioids Impact on Function
Do Opioids Improve Function?
Study of 1843 workers’ compensation claimants - 111 (6%)
received opioids for 1 year
Daily opioid dose increased significantly over the year
Majority did not have improvements in pain or function!
– 26% reported pain improved by ≥30%
– 16% reported function improved by ≥30
Franklin et al, Natural History of Chronic Opioid Use Among Injured Workers w
Low Back Pain, Clin J Pain, Dec, 2009
Opioids in Workers’ Compensation – Research Summary
Appropriate?
Most early
opioid Rx
in WC
are not
clinically
indicated
Impact?
Opioid
prescription
– More lost
time
– Higher
overall
claim costs
Duration?
Guidelines?
90 days of
use is the
trigger for
chronic
opioid
guidelines
Most doctors
are not
following
guidelines
Why Is This Happening?
No requirement to follow guidelines.
Physician dispensing (repackaging companies).
Lack of incentives for better outcomes.
Much pressure on physicians to prescribe opioids for any
pain.
The system makes it easier to do things wrong than do
things right.
Can you think of any other reasons?
23
Indications for Discontinuation
When to Stop Opioids
Failure of initial trial to result in
objective functional improvement
Medication no longer needed
Intolerable adverse effects
Non-compliance
24
Examples of Functional Improvement
How can we measure function?
Physical output or performance (with focus on job specific
activities)
Increased active range of motion, strength or aerobic
capacity
Increased social engagement accompanied by decreased
emotional distress
25
The ACPA Quality of Life Scale
26
www.theacpa.org
The ACPA Quality of Life Scale, cont’d
27
Important Information for Workers
Acute Prescription
Opioids don’t work any better than non-opioids for
musculoskeletal injuries like low back strains
Lots of side effects
Worse long-term outcomes
They should be stopped if not helping function
Some people have trouble getting off them once started
(some studies -> 1/3 become addicted)
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Important Information for Workers
Decision-Making
Timely…
Informed…
2/3 of those on
opioids for
90 days are
still on them
5 years later
At 30-90 days,
there should
be an
informed
decisionmaking
process about
continuing
opioids
Assessment of
clinical value vs.
alternatives
Assessment of the
risk of
dependence,
addiction and
side effects
Discussion about
what long-term
opioid use will
mean
Subacute to Chronic: Opioid Management Plan
If decision is made to continue at 90 days, there should be:
Written materials.
A signed agreement.
A plan for discontinuation if there is not improvement in
function and symptoms.
A plan for monitoring compliance: urine, PDMP, pill counts
A plan for using other approaches too – psychological,
exercise, behavioral.
Chronic Opioid Use
Anticipate problems:
Dependence is the norm; addiction is common.
Very difficult to impact course unless the employee
recognizes the benefit of stopping.
Addictions expertise needed to stop in many cases;
sometimes rehab programs.
Usually many other medications are also needed to treat
the side effects.
Chronic Opioid Side Effects
Insomnia
Changes in hormonal systems, leading to decreased sex drive
Constipation
Depression, anxiety
Decreased immunity to illnesses
Hyperalgesia (increased pain)
What about RTW?
Sedation is more of a problem early in use…
In the early time period of opioid use (first few weeks),
sedation and impairment are common.
Later in opioid use, tolerance develops and many people
are not noticeably impaired. (But may be if
polypharmacy use, especially other sedatives.)
Those who do not want to RTW will often claim sedation.
Case 1
Scenario
Employee is released to return to
work on limited duty after one
week off due to acute lumbar
strain. He reports that he is
taking Naproxen and Percocet
as needed for pain.
Needed Info
What else do you need to know?
Case 1
Medication Use
He needed the Percocet 4 times a
day the first week. Now he just
needs it to sleep, and
sometimes once during the day.
He is only taking the Naproxen
once a day, even though the
prescription says he can take it
3 times a day.
Advice
How could he adjust the regimen?
What else should be discussed?
CDC Guidelines
New Guidelines!
http://www.cdc.gov/
mmwr/volumes/6
5/rr/rr6501e1.ht
m
Three days of
treatment or less
will often be
sufficient; more
than 7 days will
rarely be
required.
Case 1 Actions
Percocet Use
Use Percocet
before bed,
and after
work shift if
needed
(This is consistent
with the
prescription.)
Alternatives
Use Naproxen 3
times a day
with food –
this will help
reduce pain
and
inflammation
(This is consistent
with the
prescription.)
Treatment Plan
Give employee
info about
the CDC
guidelines
and
recommend
discussion
about plan
Role of PBM,
medical
support
team
Work Impact
When first
adjusting to
opioids, they
can have large
impact on
concentration,
reflexes,
thinking,
safety.
Changing regimen
to after work
should
mitigate this
risk.
Case 1 Discussion
Discussion
Other ideas?
Questions?
Concerns?
Summary - General Principles
Few never or always situations – each case must be addressed individually
Impact on essential job duties is the most important factor – what are these?
Expected duration of the condition needs to be considered
Employee motivations need to be identified and considered
Overlapping rules, regulations and benefits programs: ADA, FMLA, OWCP, OPM
Clinical review and support can be really helpful, with reference to guidelines
Contact Information
Marianne Cloeren, MD, MPH, FACOEM
1-443-466-0033
[email protected]