By JARED SHELLY, senior editor/web editor of Risk & InsuranceŽ
In the 1980s and 1990s, thinking in the pain-management world focused on compassion -- give patients all the pain medicine they want so they feel better. After all, doctors agreed that the risk of getting addicted was pretty low. In 1986, Dr. Russell Portenoy and Dr. Kathleen Foley concluded in a scholarly article that "opioid maintenance therapy can be a safe, salutary and more humane alternative" to other types of treatment.
In fact, by the late 1990s, at least 20 states had passed new laws or regulations allowing the use of opioids without dosing guidance.
"I remember going to lectures and getting berated by speakers about not using enough opioids. The [doctor's presenting] said 'I have people on 200 mgs of morphine and they're doing just fine,' " said Dr. Sanford M. Silverman, director of comprehensive pain medicine and founding partner of Lorsand Continuing Medical Education in Pompano Beach, Fla.
He spoke during a Wednesday session titled Opioid Addiction: The Causes, Costs and Solutions, at the 21st Annual National Workers' Compensation and Disability ConferenceŽ & Expo.
Fast forward 20 years and many doctors and workers' compensation professionals don't mince words about the problems and addicts created by the antiquated thinking of years past.
"This is the worst public health emergency we've ever experienced and it's a man-made emergency," said Dr. Gary Franklin, medical director of the Washington State Department of Labor and Industries, to the audience of around 200 people.
State laws are also compounding the problem since many stipulate that there will be no disciplinary action taken against practitioners based solely on the quantity or frequency of opioids prescribed, said Franklin.
"You could be handing out bags of opioids and they can't do anything about it with that kind of language in the laws," said Franklin, also a research professor at the University of Washington. "Those laws were based on weak science."
Claimants who just want their next fix -- or just want to make some money -- can also amplify the problem.
"If you don't think your workers' compensation claimants are selling this stuff, think again," said Silverman, who estimates that 10 percent of those taking opioids are addicted. Besides marijuana, pain relievers are the most abused drug by people over the age of 12, he added.
Claimants also take their medications for the wrong reasons, like managing stress or to fall asleep -- which can lead to addiction.
Another problem, however, is prescribing doctors.
"It's easier for a doctor to write a prescription than to talk to a patient about family problems and what's bothering them," said Franklin.
While Franklin and Silverman recommend that doctors administer worksheets as long as 24 questions before prescribing opioids, their counterparts in the medical world are hardly on board.
"We're talking about deadly drugs," said Franklin. "It's not uncommon for a doctor to use a two-question chart."
Silverman identified an array of reasons that doctors are feeding the opioid crisis. Many are out of touch with today's standards regarding opioids, while others are simply dishonest and prescribe the pain medications for their own financial gain. Other times, the doctors are duped by addicts or are users of the pain medications themselves. Some, he said, are simply in denial that their course of pain treatment is wrong.
Joe Paduda, principal of Health Strategies Associates and a blogger at ManagedCareMatters, moderated the session and told the audience that many in the workers' compensation industry are focused on finding solutions. And if you want proof, just take a look at this year's expo floor.
"There are at least half a dozen booths, maybe 10, that reference some sort of [solution to] opioid abuse," said Paduda. "Everyone is making money off the misuse and abuse of opioids."
One of the scariest opioids is OxyContin, which has nearly the same chemical makeup as heroin, said Franklin who showed pictures of the eerily similar chemical compounds side by side. Another scary attribute of opioids is that they have a negative effect on the respiratory system. A patient might have built up a tolerance to many of the drug's effects, but their respiratory system may still go into a depression.
"People go to sleep and simply stop breathing," said Franklin. In 2007, there were 11,499 opioid overdose deaths in the United States, up from 2,901 in 1999.
To manage opioid use, Silverman recommends trying not to let the problem spin out of control in the first place. If a patient is on opioids for 30 days or more, they should be assigned a case manager to help. He also said he does neurotherapies and injections in an effort to curb the amount of opioids patients use.
State laws are also starting to come around. In 2012, Connecticut released a workers' compensation policy stating that the daily dose should not exceed 90mg per day unless the patient demonstrates a measured improvement in function. Also in 2012, the state of Washington released regulations stating that doctors should screen for substance abuse and work from a single pharmacy and a single prescriber.
In Washington, the anti-opioid efforts seem to be paying off giving hope to the industry. "The average daily dose has come down dramatically," said Franklin, "and there is a 50 percent decline in deaths in workers' compensation."
November 12, 2012
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