Opioid abuse in the workers' compensation arena is greatly influenced by physician discretion, says the Workers' Compensation Research Institute (WCRI), a factor that played an important role in the Massachusetts W.C. system's fall and rise from painkiller dependence.

The WCRI recently published its findings in a report, “Longer-Term Use of Opioids.”

“Massachusetts is a good case study, because when the WCRI looked at 2007-2010 workers' comp. data in a 2011 study, the state was a high user of opioids,” says Dean Hashimoto, MD, chief of occupational and environmental medicine at Partners HealthCare Systems and member of the Massachusetts Department of Industrial Accidents (DIA) Health Care Services Board. “This is surprising because Massachusetts has experienced the lowest medical costs in the country, and was an early adopter of a drug prescription monitoring program in 1991.”

The number of opioid-related poisoning deaths in Massachusetts shot from 94 in 1990 to 637 in 2007. Meanwhile, 42 percent of workers in the state were receiving schedule II narcotics such as codeine and morphine, the highest rate in terms of dosage and treatment length among 17 states monitored by the WCRI.

One seed for this trend may have been planted when Massachusetts became one of the first states to adopt regulations, built upon hospital-developed statutess, requiring doctors to rate pain. Although the intention may have been good, Hashimoto says that the focus on pain medication as part of primary-injury treatment “led to the growth of pain specialty programs in W.C. in particular.”

Additionally, there was a parallel erosion of primary-care physician access to workers' compensation patients, causing injured workers to visit hospital emergency rooms for care, where they were more likely to be treated with pain medications.

A push by state regulators, physicians and insurers has helped to reverse reliance on long-term pain medication.

Now in Mass., physicians are legally obligated to take a continuing-education course on pain physiology and the effects of opioids before they obtaining or renewing medication licenses.

Further statewide W.C. chronic pain guidelines emphasize a return to improved function, including the psychosocial impact of pain management on mental, emotional and social wellbeing, as opposed to simple pain relief. They also ask for a written agreement between patient and doctor, random drug screenings for concentration of painkillers in the body, and a second opinion when total opioid doses exceed 120 mg per day of morphine equivalents.

Recently, the Mass. BC/BS, the largest group health insurer in the state, has required that new opioid prescriptions written for more than 30 days must be accompanied by a medical authorization before coverage is approved. Short-acting opioids have to be obtained from a single prescriber or group, and purchased from one pharmacy or chain, to avoid patients trying to dodge the watchful eye of their doctor.

“The revised Mass. chronic pain guidelines were published in March 2012, but were circulated with the relevant medical societies during the prior two years,” says Hashimoto. “The BC/BS restrictions were first implemented in 2010 and made stricter this year because of perceived success.”

The adopted rules align with the American College of Occupational and Environmental Medicine's (ACOEM) nationally-recognized pain management standard, which focuses on medical, behavioral therapy, physical conditioning and education to help workers become self-sufficiently functional shortly after injury. It includes using NSAIDS, standard over-the-counter painkillers, to treat most types of pain, and limit needed opioids to about a week's worth of use.

As a result, opioid prescriptions and opioid-poisoning deaths have leveled from 2008 to 2010, and the WCRI found that while most of the country has experienced an increase of long-term narcotics use from 2007 to 2011, Mass. saw a four percent decrease in usage- the only decline in the 23-state survey.

This case study may be an important guiding light to healing an increasingly drug-addicted nation: a 2012 Journal of Pain article pointed out that the annual cost of pain was $635 billion in 2010 while heart disease and cancer cost $309 billion and $243 billion, respectively. Opioid poisoning is also one of the three leading causes of injury death in the U.S., alongside motor vehicle traffic and firearms.

Special Reports /

How the Mass. Workers' Comp System Kicked Its Own Drug Habit

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