Wednesday, July 6, 2011

Narcotics in Work Comp is a Cultural Problem

Over prescription of narcotics in workers' compensation, indeed, general health, is getting lots of publicity lately, and for good reason - the general American population is either becoming hopelessly addicted (and consequently hopelessly nonproductive) to opioids, or there is a nice underground economy that is missing taxation, or both.

The Workers' Compensation Research Institute recently released a comprehensive study, “Interstate Variations in Use of Narcotics,” which may be purchased from WCRI, which studied the use of prescription narcotics to treat pain in a 17-state study group.

States in the study were California, Florida, Illinois, Indiana, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Tennessee and Wisconsin.

Some of the conclusions were not surprising. For instance Texas had the second highest number (10,432) of non-surgical cases with narcotic drugs prescribed in the first quarter after injury for which workers also received narcotic drugs in subsequent quarters. California was the highest with 14,455.

This makes sense because Texas and California were the most populous states surveyed, so raw numbers are going to be higher for those states.

Other statistical conclussions are more alarming. WCRI said Texas averaged 53 narcotic pills per prescription in non-surgical cases, compared to the median of 46. California topped the list with 68 pills per prescription. This is not the result of raw numbers but is a ratio analysis of the overall data.

Just recently the Institute of Medicine (IOM), in response to a request from Congress to study prescriptive narcotics in the general population, concluded that chronic pain was experienced every year by at least 116 million adult Americans, at a cost of between $560 billion and $635 billion annually ("Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research", available from the National Academies Press by calling 202-334-3313 or 1-800-624-6242 or on the Internet at

Chronic pain is extremely complicated to deal with from a medical standpoint because there are so many elements in the causation equation - from actual physical or neurological damage to comorbid psychological overlays. 

The IOM report says health care providers, insurers, and the public need to understand that although pain is universal, it is experienced uniquely by each person, and that care, which often requires a combination of therapies and coping techniques, "must be tailored" to the individual patient.

The Institute comments that pain is more than a physical symptom "and is not always resolved by curing the underlying condition."

"Moreover, people's experience of pain can be influenced by genes, cultural attitudes toward hardships, stress, depression, ability to understand health information, and other behavioral, cultural, and emotional factors," the Institute said.

Americans as a society have made great progress in convenience, and our society expects easy answers. 

The easy route for dealing with chronic pain are prescriptive pain killers - easy for physicians because medication is the path to least resistance for most patients (and for compensation by carriers) and easy for patients who either lack the fortitude or discipline to deal with the underlying cause of pain.

The WCRI study is not entirely surprising - we know there is a prescriptive pain pill problem in the United States, which of course is going to impact workers' compensation. The answer for dealing with this problem does not lie in statutory mandates or regulation, it lies in a fundamental cultural change which is going to be very, very difficult to manage, but not impossible.

An example of a deep rooted cultural health issue that has been managed to the point of positive health returns is this society's addition to nicotine - cigarettes. Through a combination of media bombardment, education, taxation, litigation, regulation (such as prohibition of smoking in public places) the public acceptance of nicotine consumption has declined markedly, and the health issues associated with nicotine consumption have improved dramatically.

The California State Compensation Insurance Fund's recent mandate that its physicians agree to limitations on prescribing opioids in order to participate in its Medical Provider Network is one attempt at challenging the culture of pills for pain. But this is only one small link in the chain of American's addiction to pills.

Increasing public awareness of the issues with opioid prescription drug abuse is a help. But to really deal with opioid issues there must be a cultural change in how we deal with, and manage pain. And, like this country's nicotine addiction, changing people's attitude is going to take some time.

1 comment:

  1. David,

    This is a huge issue in workers comp. The primary problem is the concept of pain. Lesson 101 about pain, is that pain is what the patient says it is. As a result, when the patient complains, medication is prescribed. Period.

    Whenever there are equivocal findings, a thorough psychological evaluation is crucial. A good psych evaluation can determine if complaints are out of proportion to the true injury.

    For example, if there is a 2 mm herniation, and the patient rates 10 out of 10 on the pain scale, then there is a psychological component, no question.

    On the other hand, a patient who complains of severe pain, in the presence of positive EMG findings, strongly suggestive of the radiculopathy, is a very different patient, and one who might even resist taking narcotics.

    Of course, the issue is further compounded, by individuals who take medical marijuana, or who have used marijuana recreationally, for many years.

    As a psychologist, I'm very interested and curious about the use of psychology in assisting the pain physician to determine the most appropriate pain regimen for a given patient. It has been my experience that the addition of a low dose of nortriptyline, can be very beneficial in individuals with mild to moderate back pain.

    Thanks for opening up this very important topic.