“In a fall on the ice, I broke my back and had to have it surgically repaired. The surgeon prescribed a high dose of a narcotic pain reliever, and I took it faithfully and gratefully during the early weeks of my recovery. As a nurse, I knew I needed to keep my pain under control so I could stay active to promote healing, but I worried as the weeks passed and I was still taking those same high doses every four hours around the clock and getting less relief.
About two months after my surgery, as I stopped taking the drug, I realized I had developed a physical dependence on it. I had every withdrawal symptom you can imagine. It was awful, but fortunately it lasted just a few days. In the process, I discovered that water exercise was just as effective as the narcotics at that point in my healing. This was three years ago, and I still continue to use water exercise to effectively manage my pain.”
The use of prescription narcotics in the treatment of pain is skyrocketing, while, at the same time, the effectiveness of these drugs is being questioned. Synthesized from opium poppies, prescription narcotics, also called opioids (oxycodone, codeine, etc.), were originally intended for controlling excruciating pain for short periods of time. For prolonged use, opioids were issued for terminal cancer patients, where drug dependency wasn’t an issue. But since 1995, the year OxyContin was approved, they have been regularly prescribed for other kinds of acute or chronic pain.
Just how bad is it?
Although the U.S. has 4.6 percent of the world’s population, it consumes 80 percent of the world’s supply of opioids and 99 percent of the oxycodone.
“It’s unprecedented, and it’s getting worse,” said Grant Baldwin, director, Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention:
- Deaths from opioid painkillers number more than the total of deaths from heroin and cocaine.
- In 1999, prescription opioids represented 11 percent of all deaths due to poisoning by medications and drugs.
- In 2008 in Oregon alone, prescription opioids represented 53 percent of all deaths due to poisoning by medications and drugs.
- From 1999 through 2006, the number of fatal poisonings involving opioid analgesics more than tripled, from 4,000 to 13,800 deaths.
- Nationwide, 38,000 people died of opioids in 2007, the most recent year that totals
Beyond the staggering numbers of those who die, Baldwin added that more than:
- 342,000 are admitted for the treatment of opioid abuse
- 1,330,000 visit emergency rooms for misuse or abuse of opioids
- 6,118,000 report abuse or dependence
- 17,518,000 report nonmedical use of opioids
Gary Franklin, M.D., medical director of Washington State’s Department of Labor and Industries, said “in the late 1990s, many states liberalized laws and regulations on use of prescription opioids.” (Franklin referred specifically to a Washington law that read, in part: “No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed.”)
It was a perfect storm for abuse, he added, propelled by “weak science (saying risk of addiction to long-term use was low), lobbying by pain advocacy groups, drug company marketing, and increased prescriptions for nonmalignant pain."
Within a few years, the number of unintentional deaths due to prescribed opioids climbed precipitously in Washington’s workers’ compensation system.
“The doses increased more than 50 percent in just a few years after the laws became more permissive,” said Franklin.
Oh, by the way, they are not the best choice
“Giving long-term opioids for injuries has had almost the opposite of the intended effect in some cases,” said Tammy McCoy, RN, SAIF medical services manager. “We strive for an immediate relief from pain, followed by increased mobility and functionality. That hasn’t been happening.”
With opioids, the injured worker may need higher and higher doses to relieve the same pain.
Lethargy and inactivity allow additional muscles to weaken. A short-term injury becomes a long-term drug dependency. And physicians are not always educating patients by encouraging them at each visit to do more.
“We tend, as a society, to lean toward quick and easy fixes,” said McCoy. “Some pain is normal in the healing process. Opioids are intended to decrease pain, but often do not take all of the pain away. The goal is to decrease the pain enough to allow for increased function.”
The primary aim of physicians, managed care organizations, and employers is the injured person’s return to functionality. Often prolonged use of narcotics is not effective in achieving that goal.
Nonsteroidal, anti-inflammatory drugs (NSAIDs) also are used to treat pain. These include aspirin, ibuprofen, and naproxen. In many cases, they are more effective than long-term use of opioids in treating the leading workplace medical issues, all of which are injuries of the musculoskeletal system: sprains, strains, breaks, cuts, and bruises.
McCoy said that exercise is also important in reducing pain and promoting healing.
“Pain is a compass, a gauge, for us to use in healing,” she said. “The objective is to regain use of our body to the greatest possible extent. We do that with physical therapy and exercise, gradually gaining full use again; the easing of pain can be an indicator of that progress over time.”
Keys to curbing the crisis
SAIF, along with its managed care partners, has identified some ways we can return to safe, effective strategies associated with managing the pain of injuries and illness.
The first is better physician and patient education. Instead of the normal hurried office visit, patient and doctor should discuss a combination of pain relief, physical therapy, and exercise to attain the desired outcome. In addition to the physical aspects when the patient experiences chronic pain, psychological and social issues relating to the pain should be assessed.
Other therapies are also gaining popularity and use, according to a pain management report issued last year by the U.S. Army surgeon general. It stated, “There is a wide range of therapies and treatments, such as acupuncture and yoga therapy, that have proven valuable in reducing an overreliance on use of medications to treat pain.”
SAIF is working with managed care organizations in Oregon to redefine how to achieve desired outcomes for injured workers. Working with providers on proper dosage for opioid use and setting benchmarks for the ideal timeframe for a patient to regain functionality are just two of the ways we can help limit narcotic use. We are also making sure our claims adjusters receive education that helps them provide a more proactive review of new claims.
This article is from the summer 2011 issue of Comp News. See other articles from this publication.