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In addition to the expense of opioids are concerns about side effects, overall effectiveness, and potential addiction. But experts say there is a place for opioids in the system and it is manageable -- with early intervention and monitoring.

According to a recent report by Express Scripts, opioid analgesics represented more than 41 percent of the total cost trend for pharmaceuticals among its workers' comp clients in 2009.While the generic combination of hydrocodone and acetaminophen was the most utilized medication among the drug class, 28 percent of spend was due to the drug OxyContin.

According to the experts, injured workers may progress to opioids from other pain medication when chronic pain persists; increasingly higher doses may be needed to adequately control pain; and injured workers may move from generic medications to brands that have no generic alternatives.

"The cost [of opioid analgesic therapy class medications] grows as claims age," said Celeste Player, senior clinical director for Express Scripts. "The emphasis has been on how do you deal with this early in a claim."

Why use opioids. Despite the costs and potential for abuse, pain physicians say opioids can be a valuable medical component in some workers' comp claims. "Using opioids for acute pain is totally acceptable and legitimate -- it's actually medically necessary," said Dr. Sanford Silverman, a member of the board of directors for the Florida Society of Interventional Pain Physicians. "The problem becomes when [pain] becomes chronic."

Another expert in pain medicine concurs. "Nothing is inherently wrong with using opioids as long as taking them improves function, reduces pain, and they don't cause unmanageable side effects," said Dr. Steven Feinberg of the Palo Alto-based Feinberg Medical Group.

"If I took a low to moderate dose of opioids and I could work and function well in my activities of daily living, that's good," he said. "The problem in workers' comp is we end up in a situation where the dosage keeps getting escalated while the injured worker becomes increasing dysfunctional. The incentives in workers' comp are out of whack. Doctors get paid better for procedures and in office medication dispensing rather than spending time talking to patients."

Feinberg advocates the use of opioids only when other methods of pain management have failed and there is adequate pathology to support their use. At that point, he says the clinician must evaluate each patient individually to see whether using opioids would be beneficial and the benefits outweigh the risks.

Preventing abuse. If the use of opioids is beneficial, Feinberg recommends following strict guidelines. "The lowest effective dose of opioids should be used," he said. "Behavioral screening, patient agreements, random, periodic, and targeted urine testing for opioids and other drugs should be strongly considered with any patients with noncancer pain who has been treated with opioids for more than six weeks."

Pain experts also say opioids should not be the sole remedy for pain relief. "It should be part of a comprehensive plan, not unidimensional," Silverman said. "The reason you do that is because you use less opioids if you use other things."

Finding physicians who use a conservative approach to opioids is key in preventing abuse. "A lot is how you partner with the prescribers," Player, of Express Scripts said. "Do they look at the patient to see what is appropriate and what is not? Are decisions made just on cost or is the patient getting better? Is he overmedicated? Undermedicated? It's not just should they have it or not, but are they taking the right one in the right dosage that relieves pain but helps them be functional?"

Player says it's important to consider the whole patient, a belief shared by Feinberg. "Many physicians do not understand the importance of a biopsychosocial, whole person approach," he said.

He too believes using opioids for chronic pain should be just one aspect of the treatment plan, along with "psychological counseling, physical activation, functional restoration, education to manage the pain, meditation, stress reduction, and stretching," he said. "What we should do as doctors is every three to six months take a step back and ask 'Why is this person on all these medications? Is this really making a difference in this person's life?'"

Read more at the WorkersComp Forum homepage.

November 29, 2010

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