Pain, Pot and Prescription Drugs

At the 2017 Business Insurance/CLM Workers’ Compensation Conference, a panel discussed the problems with marijuana, opioids, and pain. The panel was:

• Jennifer Saddy – Director Workers’ Compensation, American Airlines
• Teresa Bartlett – SVP Medical Director, Sedgwick
• Bert Randall – Attorney, Franklin Prokopik PC

Opioids

The opioid crisis in the U.S. costs our society over $55 billion in 2011. This is not just the cost of the drugs themselves, but the workplace costs, healthcare costs and criminal justice costs. The US consumes 80% of the world’s opioid prescriptions and in 2015 there were almost 18,000 deaths in the U.S. due to opioid overdoses. Around 3% of group health spending is on prescription opioids. In workers’ compensation up to 40% of prescription drug costs is for opioids.

The high opioid utilization is in spite of the fact that numerous studies show the drugs are ineffective for treating pain long-term. In fact studies show the combination of Tylenol and ibuprofen is more effective than opioids for treating long-term pain. In addition, workers’ compensation patients taking opioids have longer duration of disabilities and less chance of returning to work.

One thing people lose track of is that opioids were designed for end of life use for terminal conditions. It suppresses breathing and in increasing doses will lead to death. With terminal cancer patients where keeping a patient comfortable until death, that is not a concern. However, for people with back injuries that is a big problem. Another issue with opioids is that by design they lose effectiveness very quickly which requires higher doses. Higher doses lead to more complications, and the problems associated with these drugs keep compounding.

Urine drug testing should be done on patients taking opioids at least once to twice per year to ensure compliance with the medication protocols. If you suspect they are taking too many drugs or not taking their medications it is imperative that you suggest to the physician that they drug screen the patient to ensure compliance.

One thing to watch out for is prescribing a dangerous combination of drugs. Opioid, Xanax and Soma. The combination of these drugs has tremendous street value and if patients are asking for these drugs it is likely they are selling them. There is no valid medical reason to take these drugs together.

Last year the CDC published guidelines on the use of opioids. These guidelines have not been well-received by physicians who feel it is intrusive in their practice of medicine. Payers should read these guidelines and push physicians to follow them.

Marijuana

Currently 28 states and DC allow for medical marijuana and legal for recreational use in eight states. This is in spite of the fact that the FDA still classifies it as a Schedule 1 drug which is illegal and has no legitimate medical purpose. There is conflict between state and federal law when it comes to marijuana law and this is causing issues around the country. For the last few years, the DEA has not been enforcing federal marijuana laws when it comes to state licensed medical marijuana dispensaries.

This is not your parent’s marijuana from the 1960’s. Marijuana these days has been genetically engineered (like many crops) and now the concentration of THC is 60 times higher now than it was 50 years ago.

Because of the conflict between state and federal law, there has been very little study on the effectiveness of it as a legitimate medication. Last year, the FDA declined to reclassify marijuana as a Schedule 2 drug, but they did authorize additional studies of the drug to determine whether it actually has a legitimate medical use.

New Mexico, New Jersey and Maine have all authorized medical marijuana use on workers’ compensation claims. This is complicated as it is a cash-only business so the injured worker has to purchase the drug and get reimbursed by the TPA/carrier. New Mexico has even developed a fee schedule pertaining to medical marijuana.

One of the big problems with marijuana is that the science of testing for impairment has not caught up with the social reality of widespread use. The drug can be detected in your system 30 days after use. This is not acceptable in states where use of the drug is legal as it only measures the presence of the drug, not impairment associated with the drug. We need to not only develop a standard for measuring impairment with marijuana, but also develop a quick, accurate way to test for impairment. When will we see the marijuana breathalyzer?

Interestingly enough, thus far the courts around the nation have upheld terminations for positive drug tests with medical marijuana as the termination was legal under federal employment law and that overrode state marijuana laws.  This has been tested repeatedly in the courts including in Colorado and New Mexico that have very liberal marijuana laws.

Because of the lack of study, it is unknown whether medical marijuana is really a legitimate alternative to opioids in the workers’ compensation setting. It will be interesting to see how this issue develops over time.