Preventing opioid abuse. Medical professionals are finding there are many opportunities to prevent workers’ comp cases from going down the path to opioid abuse. (Photo: Shutterstock)

When employees injure themselves at work, a potentially lethal risk may ensue — they may be prescribed and become addicted to an opioid painkiller. As we know, the United States is currently experiencing an opioid epidemic — with 130 people dying every day from opioid overdoses. And in many cases, the addiction began with a work-related injury.

As a licensed therapist, I previously worked with patients who suffered from opioid addictions both in inpatient and outpatient settings. It was heartbreaking to see people struggle to cope with these dependencies, and over the years, it was the small successes that kept me going.

Today, my clinical experience in the drug rehab setting has been useful in the case management of workers’ compensation claims, as there are many opportunities to prevent cases from going down a path to opioid use, abuse and addiction. Here are key best practices claims professionals should strive to foster among all workers’ comp stakeholders.

Creating a positive workers’ comp experience

  1. Shift the health care mindset from “pain-free” to “managed pain.”

In the United States, pain treatment has too often been interpreted as the need to achieve an immediate pain-free status. This mindset has been a major contributing factor to the opioid epidemic. Trying to change this way of thinking continues to be a huge challenge. Though new prescribing guidelines have and are being put into place, many patients are still being prescribed opioids as a first option in managing pain when more conventional strategies should be tried first.

It’s a hard reality to face, but with workers’ comp injuries, some pain is unavoidable. Injuries hurt, as do the aftereffects of surgery and other medical procedures. And while managing pain to a tolerable level is a reasonable goal, eliminating it altogether is not. After all, pain is a normal part of the healing process and, in most situations, injured employees can expect their pain to improve over time.

There are ways to manage pain without opioid prescriptions. Patients must be active in their recovery, adhering to their treatment plans. They may be directed to use over-the-counter medications first such as ibuprofen, Aleve or Tylenol. On the other hand, they may be instructed to use hot and cold therapy, apply compresses and engage in physical therapy. Such therapies should be attempted before opioids are considered. There is a proper place for opiates in treating chronic pain, but it should be monitored carefully and follow appropriate acute pain and CDC guidelines.

  1. Educate workers about the potential adverse effects associated with taking prescription pain medications.

When injured employees are provided an opioid prescription, they should be educated on the potential adverse effects (see sidebar). Research shows that after a month of use, there’s an increased risk of addiction, as well as other side effects. Patients may exhibit adverse effects soon after usage, but prolonged use significantly increases the risk. If users start to experience an adverse effect, they should immediately notify their nurse case manager or treating physician.

Injured employees should also be educated on how overdose deaths occur. Opioids relax the breathing muscles in the body, which, in high doses, could lead to respiratory depression and death. Family members should also be informed of this risk. Some physicians prescribe naloxone (often the nasal spray Narcan), along with an opioid, which reverses the effect of an opioid overdose, but someone must be present to administer it if the user stops breathing. In some states, this type of co-prescribing is required.

If patients are informed and aware of these risks, they may decide against using opioids in favor of alternative pain-management techniques. All clinical stakeholders, including treating physicians, nurse case managers and pharmacists, should facilitate patient education.

  1. Avoid and minimize unnecessary opioid prescriptions in the first place.

The workers’ comp industry must work with treating physicians to avoid unnecessary opioid prescriptions. If injured employees are not prescribed opioids, they’re more likely not to become reliant or develop an addiction in the first place.

Carriers and payers must remind treating physicians of treatment guidelines. For acute musculoskeletal injuries, most guidelines recommend treatment start with NSAIDs (nonsteroidal anti-inflammatory) drugs such as Advil or Tylenol.

Today, if an employee experiences a severe injury, there’s usually sufficient time for the adjuster to refer the patient for nurse case management. In addition, when the initial evaluation is scheduled, it’s highly likely the nurse case manager would attend. In this situation, the nurse can listen to the physician’s recommendations to ensure opioid guidelines are addressed. Another way to proactively work with treating physicians is through the payer’s managed provider network (MPN), which also communicates opioid guidelines to treating physicians.

  1. Ensure opioid-prescribing guidelines are followed.

Many states have developed opioid-prescribing guidelines and mandatory drug formularies, including Oklahoma, Washington, Ohio, Tennessee, California, Arizona, and Texas. National guidelines have also been developed through the CDC, American College of Occupational and Environmental Medicine (ACOEM), and Official Disability Guidelines (ODG). A drug formulary helps guide treating physicians to medications considered safe according to evidence-based research. Adhering to formularies also helps control pharmacy costs.

However, guidelines and formularies are relatively new practices. Treating physicians may not be familiar with all protocols, prescribe an opioid and later realize it wasn’t approved. With formularies in place, they can go back and prescribe a different medication in accordance with the guidelines.

Some insurance companies are also using acknowledgment forms specifically targeted at opioid prescribing. By signing these forms, treating physicians in the MPN acknowledge they are aware of the guidelines and agree to follow them. As physicians become more accustomed to these new requirements, we’re starting to see more successful control of opioid use as has been demonstrated in Texas as well as California, where for the first time in years, NSAIDs are being prescribed more often to injured employees than opioids.

Other services, such as utilization and peer-to-peer reviews, provide another set of eyes to ensure opioids are prescribed and used appropriately. These reviews often facilitate an overall case assessment to see if polypharmacy is occurring or if more than one physician is prescribing an opioid to the same patient — for example, if an injured employee is receiving separate opioid prescriptions from his treating orthopedic surgeon and pain management specialist.

  1. Screen injured workers for use of all drugs.

When treating physicians write and continue to fill opioid prescriptions, a common best practice is to perform a drug screening to ensure injured employees aren’t using other drugs such as heroin, which could contribute to opioid dependency and addiction.

It’s also important to realize there are special considerations around screening for opioids due to how quickly they move through a person’s system. For example, with a saliva test, heroin can be detected for only up to five hours after the drug’s use; with a urine test, up to seven days after use; and with a hair sample test, up to 90 days, although it can take a few days for the drug to initially appear in the hair.

In addition, screenings should be sophisticated enough to detect the level – not just presence – of drugs. For example, a screening might detect a patient is taking a higher opioid dose than necessary.

  1. Consider implementing drug-free workplace policies.

In a RAND study, “The Effects of Substance Use on Workplace Injuries,” the presence of alcohol or drugs was detected in up to 15 to 20% of occupational fatalities. According to the National Council on Alcohol and Drugs (NCAD), nearly 77% of illegal drugs users are employed. When the effects of alcohol abuse are added, there’s a significant risk for substance impairment in the workplace. Drug-free workplace policies can help to provide a safer workplace; discourage alcohol and drug abuse; and encourage treatment, recovery and return to work for employees with abuse problems.

NCAD recommends a drug-free workplace should include a written policy, access to assistance, supervisor training and regular drug testing, particularly for safety-sensitive positions. For example, a heavy industrial company might test more frequently than an accounting firm.

  1. Know and identify signs of substance use and abuse.

Another key concern is many employers don’t offer training to identify signs and symptoms of substance abuse. However, managers and co-workers can be the first ones to spot potential substance abuse in the workplace. [See the sidebar for some of the common signs.] If an injured employee is out from work, a nurse case manager or treating physician can help watch for signs of substance abuse.

  1. Utilize weaning, if and when necessary.

While opioid withdrawal is rarely lethal, the user will feel horrible if he tries to quit cold turkey. One of the reasons is an opiate doesn’t treat but only masks the pain. As such, a person’s receptors will be highly sensitive. This is why users often require increasingly higher doses. Side effects also include vomiting and diarrhea. It is a very painful and miserable experience, which is why those who try to quit cold turkey often break down and resume use.

It’s much easier and more effective to utilize an established medication weaning protocol to safely transition patients off opioids and eventually discontinue inappropriate medications that are doing more harm than good. There are even tapering protocols to wean patients off complex polypharmacy regimens, but it’s important to work with an expert in these practices.

Marianna Kritsberg, MSW, LCSW, RN, ([email protected]) is a branch manager at Genex Services.

Partial List of Opioids’ Potential Adverse Effects

  • Osteoporosis
  • Emotional imbalances
  • Sleep disruption
  • Metabolic changes
  • Cardio stress
  • Sexual dysfunction
  • Depression
  • Loss of muscle mass
  • Anemia
  • Weight gain
  • Hot flashes

Common Signs and Symptoms of Drug Use and Abuse

  • Chronic lateness or absence from work
  • Frequently leaving work early
  • Appearing to be busy but not getting anything done
  • Smell of alcohol or marijuana
  • Bloodshot eyes
  • Red nose and cheeks
  • Sudden weight loss
  • Frequently upset stomach
  • Trembling hands
  • Irritability
  • Mood swings
  • Headaches
  • Insomnia
  • Memory loss
  • Polypharmacy
  • Doctor and/or pharmacy shopping