Just how risky are prescribed opioids for injured workers? And what are the main barriers to cutting this risk? One of the barriers, we shall see, is that conventional claims operations almost certainly have led to underestimating this tragedy.
The Centers for Disease Control and Prevention reports that more than 27,000 people died from all kinds of prescribed drug misadventures in 2007, a number that had risen five-fold since 1990.
Deaths linked specifically to opioids have risen steadily in the U.S. from the late 1990s. In 2008, deaths associated with all prescribed painkillers approached 15,000.
To estimate the toll among injured workers, we are dependent on one research team, supported by the Washington State Department of Labor and Industries, which includes the state's monopolistic state fund.
The team's study of Washington worker death reports from 1996 through 2002 suggests, roughly, that about six injured workers per year definitely or probably died due to accidental overdoses of prescribed opioids. The immediate cause of death was respiratory failure.
The researchers found over this six-year period "a modest overall increase in opioid prescriptions; a dramatic shift from use of Schedule III/IV opioids to use of more potent Schedule II opioids; and among the long-acting opioid prescriptions, a 50 percent increase in average daily morphine equivalent dose." Patients who received higher opioid doses were nine times more likely to overdose than were those receiving low doses.
With the conservative figure of six deaths per year and the fact that Washington holds roughly 2 percent of the nation's population, one can estimate that, at that time, the annual national opioid-related deaths of injured workers nationwide exceeded 200.
That was at the start of the surge in opioid prescribing. Washington researchers tracked opioid related deaths since 2002 and reported this month a disturbing increase, about a doubling or more, of deaths "definitely" related to opioid use through 2009.
The CDC estimates that in 2008, Washington state had an above-average rate of prescribed drug overdoses. But even taking this into account, it is hard to see how total annual deaths in the last decade could be under, say, 200 per year or 2,000 for the entire decade. One could just as reasonably estimated 3,000 for the decade.
An estimate of between 2,000 and 3,000 deaths is buttressed by a close examination of opioid-related deaths by a prominent regional East Coast carrier.
Yet many medical doctors, claims and managed-care professionals show little awareness of anything like this pattern of deaths. Is this admittedly crude estimate of 2,000 deaths a mirage?
The truth, a disturbing one, is likely that standard operating procedures of claims adjusters steered claims departments toward seriously undercounting the number of such deaths. Claims experts said that claims adjusters are often coached not to inquire about the cause of death of a worker who had settled an indemnity claim and continued to use prescribed opioids. These are precisely the workers at greatest risk.
Claims adjusters can be expected to more diligently search out death certificates for workers who died while on disability, to affirmatively close a file. But even this cannot be assured. One retired medical director of a major insurer never had occasion, over decades of service, to review the quality of evidence obtained about deaths.
These opioid-related deaths are the lost, invisible cases. OSHA recording does not pick them up and insurers are not required to report them to state agencies. Had there been more accurate and timely reporting of these deaths, it is likely that the workers' comp system would have responded earlier and more forcefully to the risks inherent in opioid prescribing.
Happily, the tide has turned in Washington.
For publicly sponsored health programs including workers' comp, Washington set a "yellow flag" threshold of a daily dose of 120 milligram in morphine equivalent. The guidelines are available here. Gary Franklin, medical director of Labor and Industries, said that "since late 2009 and 2010, we have seen substantial declines in the highest doses and a decline in mortality in workers' comp for the first time in the U.S."
According to Franklin, the single greatest barrier to bending the curve on this problem is "failure to identify the risk as a public health emergency of the highest order."
Another doctor, employed by a managed care firm, attests to the opportunities and barriers to inducing better opioid prescribing.
Marianne Cloeren is medical director of a company that provides workers' comp case and disability management products and consulting services and has reviewed thousands of workers' comp files in the past few years, most of them complex cases involving work disability and chronic pain.
She said that "chronic opioid prescriptions, usually at high doses, are almost always a major complicating factor in these cases, and I cannot recall a single case in which published opioid management guidelines were being followed."
Cloeren initiated an early intervention approach that kicks in when opioids are prescribed for more than 30 days. "We request a copy of the injured employee's opioid management plan for their claims file. If indicated, resources such as the ACOEM opioid management guidelines and a proprietary activity prescription tool will be shared with treating providers."
Much of Cloeren's work is with injured federal employees. The major barrier to reducing opioid-related risks for these cases is a lack of accountability.
"The treating provider is not required to follow standards," she said. "The claims examiner is not required to review the treatment plan for appropriateness. The injured worker is not required to actively participate in recovery."
Opioid-related deaths of injured workers have been a particularly tragic kind of on-the-job death, as the deaths arise out of legal drug prescriptions. To be sure, many of these deaths involve the additional use of illicit drugs and alcohol. But, in the words of a member of the Washington research team, Michael Von Korff, "our results suggest that many overdoses may occur among people using prescribed opioids."
January 24, 2012
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