With the recent publication of the ACOEM Guidelines for Opioid Use and new guidelines from the American Chronic Pain Association (ACPA) that include very specific recommendations to monitor opioid use, the question was raised generically as to whether opioid use is under control in workers’ compensation.  Certainly, with greater specificity in Morphine Equivalent Dosage (MED) directives, reducing the maximum threshold for potential concern for dependency to 50MED, our experiences and research have intensified our understanding of where and how the problem begins.  Does this, then, mean that opioid use is under control?

According to the CDC, the US makes up only 4.5% of the world’s population, yet consumes more than 80% of all opioids.  My short answer, then, is “No, opioid use is not under control in any industry in the US.”

 The title of the cover article in this month’s (April 2014) issue of ‘The American Legion Magazine’ is “Pain’s Addiction: Opioids and the Military Veteran.’  Quoting from the first line of the article,  

By the time Justin Minyard discovered the video of himself stoned, drooling and unable to help his daughter unwrap her Christmas presents, he was taking enough OxyContin, oxycodone and Valium every day to deaden the pain of several terminally ill cancer patients.

And later, from a veteran’s widow,

Just before Ricky’s overdose and death, his medication list included oxycodone (short-acting opioid, pain), hydrocodone (short-acting opioid, pain), Valium (anti-anxiety), Ambien (insomnia), Zoloft (anti-depressant), Gabapentin (Neurontin, neuropathic pain) and Tramadol (Ultram, ‘narcotic like’ medication for moderate to severe pain).

The shocking realization for me…  I can’t tell you the number of times I’ve seen this exact drug regimen in a legacy workers’ compensation claim referred to Tower for an MSA. 

Other Recent Opioid Related Announcements:

• March, 2014, Attorneys General from 29 states sent letters to the FDA to request the withdrawal of FDA approval for ZOHYDRO, a pure version of the opioid, hydrocodone.
• 6 days ago, Business Insurance released its latest white paper, “Opioid Abuse, How to Tackle a Growing Problem.”   
• March, 2014, the Reed Group announced that it dedicated an entire chapter to its Disability Guidelines to provide opioid guidance, documented and independently researched by ACOEM (the American College of Occupational and Environmental Medicine.)
• February, 2014, the ACPA (American Chronic Pain Association) released its 2014 Resource Guide to Chronic Pain Management.  The guide specifically noted that 30% of hospital admissions among the elderly can be linked to an adverse drug event or toxic effect of opioids and sedatives.

While it remains the exception, I believe this 16-20% segment of the workers’ compensation population consumes more than its reciprocal 85% of the system’s money, time and expertise.  I believe opioid use, combined with its side effects, interactions and impact on quality of life, to be the key driver of cost and appropriate care with the MSA and associated settlement. I support and follow PROP (Physicians for Responsible Opioid Prescribing  http://www.supportprop.org).  I will also continue use our blog, http://www.mspcomplianceblog.com to communicate issues, strategies, treatment guidelines, etc. 

The more we understand about chronic pain, as compared to acute pain, and the effects of long term opioid use, the more aggressive we will be in our efforts to identify and address its potential for misuse early in the claim.