It may be obvious, but it is important to keep in mind: Pain hurts. That simple fact can make it difficult for employers, employees and providers to see beyond the quick fix mentality of using opioids as a first line of defense to mitigate pain.

It’s an important issue as the level, extent and duration of pain is critical to the management and return-to-work (RTW) strategies of Workers’ Compensation programs. Is the first line of treatment opioids? They do relieve pain and patients prefer them for obvious reasons. Or should the initial treatment consist of physical therapy (PT) combined with less addictive analgesics?

It’s not an easy issue to tackle. There are workers so severely injured and in such legitimate pain, that PT is not an option, at least initially. But what about all those other injuries? Those where opioids are not clinically indicated?

What can be done to change the current opioid utilization paradigm?

Back to Work

One thing is certain, the debate over opioid use is one of the hottest in the work comp industry today. There are so many questions and issues to address. Yes, opioids reduce pain, but will the injured worker become dependent? Will RTW be delayed because of a lack of conditioning, flexibility and/or strength?

Employers and providers also worry that they could be found to be dismissive of true and potentially debilitating pain if they minimize medication-based pain management. They fear that employees in severe pain could spiral into depression or other conditions that could lengthen their disability.

However, some fundamental facts can’t be ignored. The Centers for Disease Control and Prevention (CDC) has noted that overdoses from prescription painkillers kill more people than heroin and cocaine combined. And yet, the Workers Compensation Research Institute (WCRI) reports that between 65% 85% of injured workers who receive pain medications get narcotics.

Opioids Prevail in Comp

Why are we still relying on opioids? Here are some often cited contributors to its misuse:

Busy physicians want to make patients feel better, and narcotics do that. Some doctors see a pain target and think the only weapons they have are a needle for an injection and a pen to write a prescription.
The majority of comp injuries involve back, shoulder or other musculoskeletal injuries, and narcotics are the most common prescription for such pain.
Direct dispensing by physicians may play a role in the growth of narcotic prescriptions. Dispensing medications is a primary revenue generator for many physicians today.
Injured workers often simply pressure their MD to prescribe opioids.

Additionally, in a work comp environment, there is no financial exposure for the injured worker. Indeed, there are often benefits to be gained from being out of work, including paychecks, opportunities for retraining, and financial settlements. None of these encourage the worker to try therapies other than the prescription drugs that provide immediate relief.

The Case for PT

Both employers and insurers are concerned about cost. Twelve PT treatments over 30 days can cost $2,000, depending on market, injury and other factors. In stark contrast, a 30-day supply of an opioid costs an employer about $140.

But cost of treatment alone doesn’t begin to tell the story. A recent study of 12,000 workers’ comp claims found that those involving certain types of opioids were almost four times as likely to have an overall cost of $100,000 or more than were claims without a prescription. These workers often had delays in RTW and, more importantly, the use of medications didn’t target the underlying problem or help the worker return to job functionality.

For those reasons, increasingly, employers and some physicians are looking toward PT as an alternative. Research is showing not only that avoidance of opioids is better in terms of medical management and reducing risk of addiction, but that early intervention with PT can improve RTW rates.

What can be done?

The risk of opioid addiction, delays in RTW and other factors call for a closer look at the value of PT in conjunction with less addictive therapies such as non-steroidal anti-inflammatories as a first line of therapy.

But it’s not enough to simply send an injured worker to any PT provider. Here's how to set up a comprehensive approach to PT for workplace injuries:

Your workers’ compensation provider offers programs to educate physicians on the dangers and alternatives for opioids. Despite increasing research on the perils of opioids, utilization remains high. Often just a few providers in a network, prescribing for hundreds of injured workers a year, can skew utilization rates. Identifying, educating, and—if they don’t change their prescribing patterns—removing them from networks is important.
Incorporate experienced independent (so their commitment is to your goals and patient outcomes) physical therapists in your network. In addition to in-depth knowledge of regulatory requirements, these therapists must understand the industry they will cover, the job responsibilities of workers and the ultimate RTW goals of an employer.
Ensure that the care team understands the employees’ job requirements (not just the basics, but the actual tasks to be done every day).
Explain to workers their role in pain management and help them understand how to accurately gage pain.
Acknowledge that reliance on opioids comes with limitations on work—including driving to/from and operating heavy machinery.
Explore alternatives that can support PT. Cognitive behavioral therapies have shown their value, as has simply encouraging the worker to engage in pleasant and enjoyable activities recommended by therapists to support PT and get workers back on the job.

Additionally, make sure your PT program starts with a thorough musculoskeletal evaluation—something busy physicians often can’t do. This will help the therapist to better understand any limitations the patient may have and make it possible to develop goals and a specific treatment program in order to return employee back to work and decrease the chance for further injury.

Say no to dependence

It’s been said that opioids lead to dependence, whereas physical therapy leads to independence. It’s an important point to consider. PT is not habit forming; there is no risk of overuse. Plus, physical therapists will also be in tune with how to educate, motivate and create a culture of wellness.

In short, employers, and the brokers and agents who help them identify and build successful programs, must recognize that opioids do not address the cause of the pain; they only cover it up for a period of time. PT offers so much more then palliative modalities to help the injured worker. PT also helps to address poor habits in posture and movement, correcting muscle strength, range of motion and deconditioning problems, and it provides education and training in how to accomplish necessary activities in a safe and less painful manner.

For these and other reasons, now is the time for employers to take a stand against the use of opioids as a reflexive first line of therapy for injured workers. The results will be faster return to work, lower cost and a healthier workforce.

Michael Weinper, PT, DPT, MPH, cofounded Physical Therapy Provider Network (PTPN). Weinper is a physical therapist with more than 40 years of experience in clinical practice, management consulting, administration, and program development. Established in 1985, PTPN has built a track record for delivering comprehensive, cost-effective and high quality outpatient rehabilitation services. For more information visit www.ptpn.com.

Special Reports /

Don't always turn to opioids: Physical therapy may be preferable for injured workers, employers

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