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

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

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

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What can be done to change the current opioid utilizationparadigm?

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Back to Work

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

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Employers and providers also worry that they could be found tobe dismissive of true and potentially debilitating pain if theyminimize medication-based pain management. They fear that employeesin severe pain could spiral into depression or other conditionsthat could lengthen their disability.

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However, some fundamental facts can’t be ignored. The Centersfor Disease Control and Prevention (CDC) has noted that overdosesfrom prescription painkillers kill more people than heroin andcocaine combined. And yet, the Workers Compensation ResearchInstitute (WCRI) reports that between 65% 85% of injured workerswho receive pain medications get narcotics.

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Opioids Prevail in Comp

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

  • Busy physicians want to make patients feel better, andnarcotics do that. Some doctors see a pain target and think theonly weapons they have are a needle for an injection and a pen towrite a prescription.
  • The majority of comp injuries involve back, shoulder or othermusculoskeletal injuries, and narcotics are the most commonprescription for such pain.
  • Direct dispensing by physicians may play a role in the growthof narcotic prescriptions. Dispensing medications is a primaryrevenue generator for many physicians today.
  • Injured workers often simply pressure their MD to prescribeopioids.

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

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The Case for PT

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

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But cost of treatment alone doesn’t begin to tell the story. Arecent study of 12,000 workers’ comp claims found that thoseinvolving certain types of opioids were almost four times as likelyto have an overall cost of $100,000 or more than were claimswithout a prescription. These workers often had delays in RTW and,more importantly, the use of medications didn’t target theunderlying problem or help the worker return to jobfunctionality.

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For those reasons, increasingly, employers and some physiciansare looking toward PT as an alternative. Research is showing notonly that avoidance of opioids is better in terms of medicalmanagement and reducing risk of addiction, but that earlyintervention with PT can improve RTW rates.

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What can be done?

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

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

  • Your workers’ compensation provider offers programs to educatephysicians on the dangers and alternatives for opioids. Despiteincreasing research on the perils of opioids, utilization remainshigh. Often just a few providers in a network, prescribing forhundreds of injured workers a year, can skew utilization rates.Identifying, educating, and—if they don’t change their prescribingpatterns—removing them from networks is important.
  • Incorporate experienced independent (so their commitment is toyour goals and patient outcomes) physical therapists in yournetwork. In addition to in-depth knowledge of regulatoryrequirements, these therapists must understand the industry theywill cover, the job responsibilities of workers and the ultimateRTW goals of an employer.
  • Ensure that the care team understands the employees’ jobrequirements (not just the basics, but the actual tasks to be doneevery day).
  • Explain to workers their role in pain management and help themunderstand how to accurately gage pain.
  • Acknowledge that reliance on opioids comes with limitations onwork—including driving to/from and operating heavy machinery.
  • Explore alternatives that can support PT. Cognitive behavioraltherapies have shown their value, as has simply encouraging theworker to engage in pleasant and enjoyable activities recommendedby therapists to support PT and get workers back on the job.

Additionally, make sure your PT program starts with a thoroughmusculoskeletal evaluation—something busy physicians often can’tdo. This will help the therapist to better understand anylimitations the patient may have and make it possible to developgoals and a specific treatment program in order to return employeeback to work and decrease the chance for further injury.

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Say no to dependence

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It’s been said that opioids lead to dependence, whereas physicaltherapy 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.

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In short, employers, and the brokers and agents who help themidentify and build successful programs, must recognize that opioidsdo not address the cause of the pain; they only cover it up for aperiod of time. PT offers so much more then palliative modalitiesto help the injured worker. PT also helps to address poor habits inposture and movement, correcting muscle strength, range of motionand deconditioning problems, and it provides education and trainingin how to accomplish necessary activities in a safe and lesspainful manner.

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

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Michael Weinper, PT, DPT, MPH, cofounded Physical TherapyProvider Network (PTPN). Weinper is a physical therapist with morethan 40 years of experience in clinical practice, managementconsulting, administration, and program development. Established in1985, PTPN has built a track record for delivering comprehensive,cost-effective and high quality outpatient rehabilitation services.For more information visit www.ptpn.com.

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