Opioid Use in Workers’ Compensation Suzanne Novak, MD, PhD November 2008

Setting the Stage

What is the Current Data? Americans consume 80% of the global supply of opioids This includes 99% of the world’s hydrocodone and 2/3s of the world’s illegal drugs They constitute 4% of the world’s population Manchikanti L. National drug control policy and prescription drug abuse: facts and fallacies. Pain Physician. 2007;10:

What is the Current Data? The US population increased by 14% between 1992 and 2003 The number of people that abused controlled prescription drugs increased by 81%

Why am I Telling You This? Only 19% of surveyed physicians received any medical school training in identifying prescription drug diversion Only 40% received any training in identifying prescription drug abuse and addiction 43% do not ask about prescription drug abuse and addiction 1/3 do not obtain old records before prescribing controlled drugs Manchikanti

Opioids and Workers’ Compensation After controlling for age, gender, job tenure, and LBP severity, the receipt of higher amounts of morphine equivalent medications in early treatment was associated with: Prolonged disability Higher medical costs Higher costs of surgery Late use of opioids Webster BS, et al. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine Sep 1;32(19):

140 mg of Morphine Equivalents/Day vs. None There was no significant difference in the proportion of claimants with more severe injuries among those who received no early opioids and those who received up to 140 mg of MEA in the first 15 days There was a significant increase in risk for those who received up to 140 mg MEQ to undergo surgery, continue opioid use, and have a marginal increase in medical costs. These findings suggest that even a limited course of opioids may have a negative effect on long-term outcomes.

Opioids and Workers’ Compensation These findings suggest that the intensive use of opioids for the management of acute LBP may not be effective for Long-term pain reduction Improving function May be counterproductive to recovery

What is Recommended Before Starting Opioids

Pre-Trial Determine the diagnosis Include a risk assessment of substance abuse, misuse, or addiction Determine a benefit-to-risk assessment of the use of opioids Obtain informed consent

Therapeutic Trial Opioid selection should be individualized This depends on factors such as the psych evaluation, underlying health, risk of abuse, and risk of adverse events Monitor: pain, function, adverse events and adherence

What about Patients at High Risk Closer monitoring Random urine drug screens Involvement of family/partner Consider consultation with a mental health or addiction specialist Urine drug screens are also recommended periodically for all patients to confirm adherence

What about those frequent escalations? WHY? Is there evidence of disease progression? Is there evidence of another pain generator? Is there evidence of issues such as secondary gain, exacerbation of underlying depression or anxiety? Is there evidence of development of addiction?

What about those frequent escalations? HISTORY OF RESPONSE TO OPIOIDS Has the patient responded to opioids in the past? IF SO: IS THIS TOLERANCE? IS THIS OPIOID HYPERALGESIA?

Opioid Hyperalgesia Patients who receive opiate therapy sometimes develop unexpected changes in their response to opioids. Development of abnormal pain (hyperalgesia) Change in pain pattern Persistence in pain at higher levels than expected. Opioids in this case actually increase rather than decrease sensitivity to noxious stimuli.

Diagnosis of Opioid Hyperalgesia Opioid trial (assumes there has been previous improvement) IMPROVEMENT Tolerance NO IMPROVEMENT Possible opioid hyperalgesia A pain condition that is non-opioid responsive

Treatment of Opioid Hyperalgesia Wean the dose Rotate opioids Use of adjuvant pain medications Further evaluation by a specialist with additional expertise in psychiatry, pain medicine, or addiction medicine

What if the diagnosis is addictive disease? YOU ARE GOING TO DO THE EXACT SAME THING

Screening Tools Have not yet been shown in prospective studies to accurately predict who will become addicted Opioid Risk Tool: 1) Family and personal history of alcohol and substance abuse 2) Age 3) Sexual abuse in females 4) Mental health disease: schizophrenia; bipolar; OCD; ADD; depression Kahan M, et al. Misuse of and dependence on opioids: study of chronic pain patients.Can Fam Physician. 2006;52:1081-7

Screening Tools CAGE test The Screener and Opioid Assessment for Patients with Pain (SOAPP) 1) history of substance abuse 2) legal problems 3) craving medication 4) heavy smoking 5) mood swings.

Behavior Suggesting Opioid Dependence/Misuse Adverse consequences Decreased functioning Observed intoxication Negative affective state Reports of withdrawal

Behavior Suggesting Opioid Dependence/Misuse Impaired control over medication use Failure to bring in unused medications Dose escalation without approval Requests for early refills Lost or stolen prescriptions Unscheduled clinic appointments in “distress” Frequent visits to the ER Family reports of overuse/intoxication

Behavior Suggesting Opioid Dependence/Misuse Craving and preoccupation Non-compliance with other treatment modalities Failure to keep appointments No interest in rehabilitation No relief of pain or improved function with opioid therapy Overwhelming focus on opiate issues

Behavior Suggesting Opioid Dependence/Misuse Adverse behavior Selling prescriptions Forging prescriptions Stealing drugs Using drugs in ways other than prescribed Concurrent use of other illicit drugs (UDS) Obtaining drugs from other sources

Management At risk: Don’t use opioids unless other treatment fails More frequent visits, pill counts, UDS Misuse Avoid oxycodone and hydromorphone Taper Evidence of diversion/addiction to other drugs/illegal activity: Send to a specialist

Management Steps to avoid misuse/addiction Opioid therapy agreements Limit prescribing to one pharmacy Urine toxic screens Frequent evaluation of clinical history (e.g. asking if recovered addicts are craving the former drug of abuse) Frequent review of medications (pill counts, electronic medical records)

Management Steps to avoid misuse/addiction Communication with pharmacists Communication with previous providers, including obtaining old records Evidence of participation in a 12-step program Establish realistic treatment goals Initiate appropriate adjunct meds and therapy programs Document

How do we stop opioids? IDEAL SITUATION: A mutual agreement WHAT MAY HAPPEN: A unilateral decision

How do we stop opioids? Let’s ask the panel……..