By Peter Rousmaniere
A prominent expert on opioid use in the workers’ compensation field, Gary Franklin MD, says that prescribed opioids, such as Oxycontin and Fentanyl, comprise “ the worst man-made epidemic in modern medical history.”
The medical director of Washington State’s monopolistic state fund, Franklin and colleagues tracked deaths of injured workers from complications of opioid treatment since 2001. They were the first to sound the alarm in the workers’ comp industry.
Many doctors still often prescribe these drugs. But the tide of research and practitioner opinion turned against using these painkillers, especially for long-term care.
The expansion, halt and pullback of opioids in workers’ comp is a dark story involving perhaps 2,000 unintentional deaths and, over the years, upwards of one hundred billion dollars in claims payouts.
I narrate this story in We’re Beating Back Opioids – Now What? (PDF) It’s a free special report issued WorkCompCentral. I wrote the report in cooperation with CompPharma.
Let’s review the two hundred year history of opioids and point out how the workers’ comp industry has been profoundly affected since the mid 1990s.
The opium poppy contains substances that when digested directly, in a refined state, or replicated synthetically, relieves pain. The term opioid refers to drugs designed to mimic the effect of opium on the nervous system, that is, to block the perception of pain. Opioids are superior to native opium because care providers can better control and dosage and target expected effect.
The modern history of painkillers in medicine began in the 19th Century with successful attempts to produce opioids from opium. A German scientist, who experimented on himself, isolated morphine from the opium poppy in 1804, and a company later taken over by Merck started selling a product in 1827. Morphine’s use for surgery was replaced by ether or chloroform in the 1840s, but it continued to be used, particularly by Civil War medics on the Union side. Codeine was isolated from opium in 1832 in France.
Heroin, a semi-synthetic opioid, was engineered in the late 19th Century and until 1910 was put into cough medicine for children. Bayer introduced oxycodone in 1916; methodone (in 1937) and other opioids followed. The impetus behind these developments was a desire to offer a more precise and less addictive form of pain relief.
Opium and opioid production and use was virtually unregulated worldwide in the 19th Century, even though scientists and medical practitioners warned about addictive risks. One out of 400 Americans was estimated to be opioid addicts (mainly morphine) in 1911.
Public health officials in leading countries induced governments to assert control. The first international commission was founded in 1909. In the United States, the federal government and most states enacted laws in the 1910s which eliminated opioids from consumer products.
In the 1980s and 1990s the medical and regulatory communities in the United States moved to approving opioids outside narrow and extremely time-limited pathways, such as palliative case and post-surgery. (The special report tracks this shift.)
A Scientific American article of 1990 sent an urgent message in favor of broader and on-going use. The author, Ronald Melzack, encouraged a “more humane way to treat pain,” which was to maintain a patient on a constant, ongoing regime of opioids.
The most recent era of opioids in the United States began with the introduction of Oxycontin and its mass marketing to all kinds of doctors in the mid 1990s. Before long people began to document problems in opioid use among injured workers and expressed doubts about effectiveness over the long term:
- 2001: Washington State notices first death related to prescribed opioids. In 2004 it begins systematically to investigate incidence.
- 2005: RAND issues a report analyzing chronic pain guidelines for workers’ compensation
- Late 2000s: the number of “legacy” claims, open for years with opioid use, grows greatly.
- About 2010: pharmacy benefit managers introduce programs to consult with opioid prescribing physicians. Chronic pain / opioid treatment guidelines designed for workers’ compensation begin to appear.
- 2011: Texas introduces a closed formulary, discouraging unlimited opioid treatment.
- 2012: pharmacy benefit managers begin to report a tapering of or actual decline in use of opioids.
- 2013: IAIABC issues an growing array of strategies to contain opioid risks
The workers’ comp industry is at a threshold. Opioids are far better contained. But prevention and recovery from chronic pain urgently needs to be reframed. Tens of thousands of injured workers acquire chronic pain. Hundreds of thousands legacy claimants are on long-term opioid treatment.
The special report shows why today workers’ comp needs to reframe its approach to chronic pain. The core challenge is not opiods, but chronic pain, and its prevention and recovery. Most injured workers on long-term opioid treatment may never have been seriously presented with alternative treatment plans.
The special report shows how. Conservative care needs to be placed at a higher rank in priority than the claims community has placed it in the past. Conservative care includes functional restoration programs, cognitive behavioral therapy, and coaching.
Also, claims payers need to share a lot more data and insights as to what interventions work best for what kinds of injured workers. There is far too little transparency regarding chronic pain treatment.
Opioids may or may not be the worst man-made medical disaster in history, but opioids certainly have been the workers’ comp most difficult and costly claims challenge, perhaps ever. We’re finally in a position to beat this challenge.
Click here to read: We’re Beating Back Opioids – Now What? (PDF)
About Peter Rousmaniere
Peter Rousmaniere is a journalist and consultant in the field of risk, with a special focus on work injuries. Peter is an award-winning author of some 200 articles on many aspects of workers compensation. He is a columnist for WorkCompCentral. Holding an MBA from Harvard Business School, Peter has been in the workers’ compensation field for 25 years. He resides in Woodstock, VT, a picturesque New England village. Email: pfr@rousmaniere.com.