By Karen O’Hara
The workplace has become a battleground in the national war against painkiller abuse and addiction. With such high stakes, employers are turning to occupational health professionals for guidance.
On any given day, an employee may be:
- functionally impaired by one or more substances
- taking more than a prescribed dose
- unsafely mixing a prescribed medication with other substances
- replacing a prescription opioid with an illicit drug such as heroin
- battling withdrawal symptoms In some cases, people taking painkillers also may be using medicinal or recreational marijuana or abusing alcohol.
SCOPE OF THE PROBLEM
An average of 44 people die each day in the U.S. from prescription painkiller overdoses. In 2014, the most recent reporting year, more than 47,000 drug overdose deaths occurred, largely attributed to prescription pain medications and heroin, according to the Centers for Disease Control and Prevention.
The front page of the New York Times recently featured two U.S. maps with the title: How America’s Drug Epidemic Spread, 2002 to 2014. The 2002 map is predominantly gray and light blue, representing four to eight deaths per 100,000 people from prescription painkiller or heroin overdoses. The 2014 map is largely red and orange, denoting a death rate of about 125 people a day, or an average of 15 people per 100,000. (Refer to New York Times, Jan. 20, 2016.)
Types of users have changed along with addiction patterns. A study published in The Journal of the American Medical Association found that, unlike past generations of heroin addicts, today’s users are more likely to be employed, older, white, living in affluent suburbs, and to have previously abused prescription painkillers. (Refer to JAMA, 2014; 312(2):118-119.) The National Institute on Drug Abuse estimates nearly half of people under 30 who inject heroin had initially abused prescription opioids.
A significant percentage of overdose deaths can be traced to chronic pain associated with work-related injuries and disability. For example, the New York Times cited an alarming pattern of overdose deaths among injured blue-collar workers in Appalachian states, where prescription pain medication use spiked in the mid-1990s. Heroin became the lower-cost alternative when legal and regulatory constraints were adopted to make it harder to obtain prescribed opioid medications.
The Substance Abuse and Mental Health Services Administration reports approximately three percent of workers are under the influence of an illicit drug at any given time. Between 2009 and 2013, nearly 60 percent of patients in the general population – many of whom are employed – were legally prescribed potentially dangerous mixtures of opioids and other medications, according to A Nation in Pain, a report released Dec. 9, 2014, by the pharmacy benefit management company Express Scripts. (See http:// lab.express-scripts.com/lab/insights/ drug-safety-and-abuse/americas-painpoints.) Two-thirds of these patients got their prescriptions from two or more physicians; nearly 40 percent filled them at more than one pharmacy.
A National Governors Association (NGA) monograph further describes the nation’s dilemma: “Reducing the opioid pill supply, for example, can have the unintended consequence of increasing heroin use. Laws aimed at unscrupulous providers can make ethical providers less willing to prescribe out of fear of scrutiny from law enforcement. One state’s successful efforts to reduce illicit sources of preEmployers Consult Workplace Health Experts in Response to Opioid Addiction Epidemic 7 continued on page 8 Gary Franklin, M.D. prescription drugs can shift illegal activities to neighboring states.”
OPIOID EFFECTS
Opioid drugs are derived from morphine, codeine, and other opium poppy extracts to relieve pain and anxiety. They comprise a class of medications that include oxycodone, methadone, Dilaudid, fentanyl, and hydrocodone. Heroin is synthesized from morphine, which binds to receptors in the brain.
Over time, the brain develops tolerance, so more of the drug is needed to achieve the same euphoric effect. This is accompanied by dependence or an intense craving for the drug to avoid withdrawal symptoms.
Disorders that may co-occur with painkiller addiction include depression, anxiety, bipolar disorder, schizophrenia, and alcoholism. Symptoms of prescription painkiller abuse vary among individuals based on their genetic makeup, length of addiction, and frequency of use. Physical symptoms may include nausea and vomiting, pinpoint pupils, slurred speech, flushed skin, slow breathing, and seizures. Mood swings, depression, anxiety, social isolation, lying, and stealing may be observed.
Studies show about 50 percent of patients taking opioids for at least three months are still on opioids five years later, and that there is no substantial evidence to support long-term relief from extended use or improved function without serious health effects.
When appropriately prescribed and taken for a limited time, opioid medications are effective pain relievers. However, the risk of death, overdose, addiction, and serious side effects outweigh the benefits in the treatment of chronic, non-cancer conditions–– including work-related low-back pain, according to a position paper published Sept. 20, 2014, in Neurology®.
The paper’s author, Gary Franklin, M.D., M.P.H., a board-certified neurologist, research professor in the Department of Environmental and Occupational Health Sciences at the University of Washington, Seattle, and medical director at the Washington State Department of Labor and Industries (L&I), is widely known for his passion on the subject.
“Prescription drug abuse is the worst man-made epidemic in history. It’s up to us to turn it around,” he told physician-colleagues at an occupational and environmental medicine conference. “How can we treat pain better and prevent the transition from acute and sub-acute pain to chronic pain? Opioids are not the answer; they are part of the problem.”
The human tragedy that plays out in association with opioid misuse and abuse simultaneously creates liability and increases risk for public and private-sector employers. In the workplace, prescription drug abuse is associated with:
- higher work-related injury and illness rates and workers’ compensation costs
- costly emergency room visits and hospitalizations
- long-term disability and lost productivity
- impaired performance and diminished judgment and decision-making capability
- sleep disruption leads to fatigue and inattention
- damage to company brands and business interests
- violent incidents
- motor-vehicle accidents
In addition, according to the National Safety Council (NSC), state courts have found employers and workers’ compensation insurers financially responsible when an injured worker fatally overdoses on his or her prescribed painkillers.
OPPORTUNITIES FOR INTERVENTION
There is a Chinese proverb that says, “A crisis is an opportunity riding the dangerous wind.” That seems to be true for occupational health professionals today. Expertise is needed to tackle the painkiller addiction problem on the front lines––from providing education on potential impairment and response, to designing effective injury prevention programs, to recommending non-narcotic approaches to pain management.
Here are some examples:
1. Market Differentiator:
Employers whose employees use dedicated occupational medicine clinics rather than primary care providers understand the benefits. For example, most employers are aware that an occupationally trained clinician is likely to recommend an over-the-counter, nonsteroidal anti-inflammatory medication (NSAID) rather than a prescription painkiller. The prescription medication OSHA-recordability requirement is one influencing factor; awareness of addiction risk is another.
2. Expertise:
Industry observers say the demand for expertise on prescription drug effects is becoming so pronounced that occupational medicine specialists are being encouraged to obtain advanced training in functional assessment, addiction medicine, and/or pain management. Some physicians are being recruited as consultants to present practical, cost-effective solutions for reducing exposure risk, especially in workplaces with safety-sensitive jobs.
3. Early Intervention:
Educational efforts may be combined with early intervention at injury onset or the first complaint of work-related physical discomfort to encourage safe work during recovery. This practice has been shown to prevent certain types of cases, such as non-specific low-back pain, from devolving into chronic pain, disability, and permanent disability.
4. Comprehensive Approach:
There appear to be lots of opportunities for occupational health programs 8 and their strategic partners to develop multiple interventions for employees experiencing the triple whammy of chronic pain from a work-related condition, related psychosocial issues, and addiction.
In a Feb. 22, 2016, article on detoxification programs, Roberto Ceniceros of Risk & Insurance reports that effective treatment and recovery models exist for workers’ compensation cases, but programs that combine detox with pain-management expertise are not available enough to address the scope of the problem. (Refer to www.riskandinsurance.com/rising-usedetox/.)
This suggests a potential niche for occupational health professionals; that is, to create local or regional programs with reimbursement structures compliant with workers’ compensation insurance requirements. “An ongoing attitude shift is underway among workers’ comp claims payers,” Mr. Ceniceros said. “More are funding functional restoration programs or biopsychosocial care models, found to work well in combination with detox services.”
Some functional restoration offerings are contained within the occupational health wheelhouse or available through collaborative partnerships. Examples include physical therapy, biofeedback, stress-reduction techniques, nutrition and fitness programs, and vocational rehabilitation. Functional restoration may be combined with mental health counseling and personal health coaching. Experts say such programs help people cope, especially when they are tapering off opioid painkillers. There is also the option of monitoring prescribing physicians. Mr. Ceniceros reports that Barnabas Health, an integrated healthcare delivery system in New Jersey, checks its workers’ comp claims for early warning signs of doctors prescribing painkillers for longer than appropriate durations. A worker receiving medications may be referred to another physician if a pain-management doctor continues to write scripts after receiving a warning.
BEST PRACTICES
The American College of Occupational and Environmental Medicine (ACOEM) advises physicians against prescribing opioids for the treatment of chronic or acute pain among workers who perform safety-sensitive jobs such as operating motor vehicles, forklifts, cranes, or other heavy equipment. Employees under treatment with opioids should be prohibited from performing safety-sensitive functions, ACOEM says.
John Holland, M.D., medical director of Union Pacific Railroad and a former ACEOM president, has examined numerous studies on drug dose-response relationships among drivers in the transportation industry. He recommends “restricting the use of drugs that impair safe work and educating workers, prescribers and employers about alternatives.”
Employers are driven to collaborate with medical professionals because they lack access to validated instruments, regulations, and guidelines for determining drug-related impairment. See the National Safety Council’s white paper on the Proactive role employers can take: Opioids in the workplace, saving jobs, saving lives, and reducing human cost for more information. (www.nsc.org/RxDrugOverdoseDocuments/proactive-role-employers-cantake-opioids-in-the-workplace.pdf.)
The white paper advises employers to:
- create partnerships with insurance, medical, pharmacy benefit management and employee assistance program (EAP) providers
- clarify terms and conditions for drug testing and drug-free workplace policies
- invest in management and employee education
- ensure impaired workers have confidential access to support and treatment
- use benefit programs and prescriber interventions to track opioid use and prescribing patterns for workers’ compensation claimants and other employees
Don Teater, M.D., a primary care physician and NSC medical adviser, points to the benefits of working with physicians and other clinicians who understand the gravity of the situation and exercise sound judgment when treating injured workers:
“Medical providers treating workplace injuries have a choice and should be focused on the use of non-opioid pain medications whenever possible. Non-opioids have been shown to be as effective as opioid medications for most pain. Employers should understand and insist on conservative prescribing guidelines for pain treatment for all participating providers in their medical, workers’ comp, and occupational health programs.”
The American Academy of Neurology’s position statement provides prescribing physicians with the following suggestions for encouraging safe and effective opioid dispensing practices:
- Create a provider-patient opioid treatment agreement
- Screen for current and past drug abuse
- Screen for depression
- Use random urine drug screening
- Do not prescribe medications such as sedative-hypnotics or benzodiazepines with opioids
- Assess pain and function for tolerance and effectiveness
