Opioid Drug Therapy: Relieving Pain But Increasing the Duration of Disability

The speakers for this 2016 WCI conference session included:

• Nat Levine, Independent Medical Practice Consultant
• Marcos A. Iglesias, MD, MMM, FAAFP, FACOEM, Vice President and National Medical Director, The Hartford Fire Insurance Company

In addition to the ever-increasing costs of opioid drug therapy, research shows a link between the therapy and a longer duration of the claimant’s disability. One study showed that claimants were disabled longer with the therapy than without it.

Dr. Iglesias discussed the connections and solutions to opioids and disability. He opened the discussion with some opioid statistics in the U.S.:

• There were 259 million prescriptions for opioids in 2012.
• 2 million people are addicted to opioids.
• There were 21,103 deaths from prescribed opioids in 2014.

How did we get here? In the 1990s, physicians were told they were under treating for pain. In 1996, Oxycontin was created to control pain, mainly for those with terminal disease. This was the start of a new epidemic.

When opioids are used to treat chronic pain, aside from the more positive effects of analgesia and even euphoria, the adverse effects are numerous and come with great risks. These adverse effects can also greatly influence and increase the length of time it takes for a patient to get back to work.

Some of these adverse effects include:

• Fatigue, confusion
• Cognitive impairment
• Nausea, vomiting
• Central sleep apnea
• Decreased testosterone
• Decreased estrogen which could result in osteoporosis
• Respiratory issues, such as respiratory depression that can be deadly (9x higher risk with opioid prescription over 100 mg)
• Gastrointestinal issues, including bowel obstruction
• Pain! Yes, the use of opioids can also cause pain. (Doctors may then prescribe an even higher dose.)

Because of the many noted side effects of opioids, often doctors will add other drugs to help alleviate these issues. Also, a study showed that of those who survived opioid overdose, 91% continued to be prescribed opioids!

Claimants may not even realize they’re taking opioids. In a study of those prescribed opioids, only 29% of respondents realized they were taking an opioid.

Dr. Iglesias also pointed out that with non-cancer chronic pain there is no evidence that opioids should be used. “Evidence is insufficient to determine the effectiveness of long term opioid therapy for improving chronic pain and function.”

The use of opioids can significantly delay a claimants’ return to work. Dr. Iglesias talked about a study that was conducted with workers’ comp patients who were prescribed opioids when undergoing carpel tunnel release. These patients had a greater delay in return to work than those who did not use opioids.

The tide is turning but slowly. The need for new approaches is being realized and alternatives for chronic pain are starting to be used more frequently, perhaps contributing to the 10.9% drop in opioid prescriptions. These have been shown to be better alternatives in pain intensity reduction and include the use of tools such as:

• Sleep restoration
• Cognitive behavior therapy
• Acupressure/acupuncture
• Physical fitness

Finally, Dr. Iglesias stressed the need to focus on what is causing pain – those psychosocial issues. When dealing with someone with pain, instead of asking them their pain level (which reinforces pain), instead focus on function and activity, because as function goes up, pain goes down. So instead of a 1-10 pain scale, use a 1-10 function scale from 1 (can’t move) to 10 (doing everything you want to do).