Sarasota, FL (WorkersCompensation.com) – Weaning an injured worker off opioids without his consent just won’t work. Efforts by insurers, third-party administrators and others to get injured workers off long-term narcotics will fail if the patient doesn’t agree to it.
That was one of the key takeaways of experts discussing Pain Points in Pain Management, the latest Hot Seat webinar from WorkersCompensation.com. The panelists explored the ways opioids can hurt more than help, how and when someone can taper off the drugs, and the importance of recognizing those who truly need long-term opioid use.
For Better — or Worse?
Opioids can make a situation worse for an injured worker “if they become dependent upon it, if they can’t live without it and become addicted to it where if they don’t have it they go through withdrawals,” said Howard Weiss, DO, from the Jacksonville, Fla.-based Brooks Rehabilitation Medical Group. “It can make a situation worse if we can get their function back but they can’t return to work because it disables them from doing specific jobs.”
The medications can also have long-term impacts on the liver, brain and other body parts. The drugs can also increase a person’s pain. Those who experience Opioid Induced Hyperalgesia can actually have less pain when they are slowly and appropriately weaned off the drugs.
“Opioids themselves can cause pain, that’s correct. It’s crazy but it does happen,” Weiss said. “I didn’t believe it myself as a physician.”
Convincing those involved in a claim — especially the injured worker, is no easy task. But the situation in at least one state is such that injured workers, their attorneys and judges understand the magnitude of the problem and strive for the same goal.
“Claimant lawyers, I believe certainly in our state, have seen the high lack of success when somebody is taking nine medications and they don’t know what day of the week it is,” said Bob Burke, a notable claimants’ attorney in Oklahoma. “Many times in mediation [before COVID-19] sitting across the table would be the claimant and the claimant’s wife. And 100 percent of the time I would say, ‘have this many meds for the last 7 years, has that ruined his life?’ And 100 percent of the time the claimant’s wife said ‘yes.’”
After going through a period of what Burke called ‘over medication,’ Oklahoma is now in the situation where judges don’t want to send injured workers to providers who may prescribe them unnecessarily.
Additionally, Oklahoma was the site of the first major trial and subsequent verdict against Johnson & Johnson, in which the company was found liable for nearly half $1 billion for its role in the opioid epidemic. “We were inundated by radio, TV, and newspaper coverage for a 2-year period,” Burke said. “Hardly any claimant I run into in mediation is not aware of that. That’s why I’ve had less reluctance in mediations from claimants who may have been on oxycontin for 10 years, but their real world understand that ‘because of all the adverse publicity, our judges are probably not going to give you that in the future.”
A particular statute in Oklahoma allows judges to bring in an independent medical examiner “on any issue at any time,” Burke explained. “So when anyone feels like there is abuse or it’s been too long then the judge simply appoints an IME and then our law says that the judge must follow the IME, unless finding a deviation based upon clear and convincing evidence.”
Judges have been “very good” about involving an IME if an injured worker is on multiple medications, Burke said.
The use of pain management beyond an acute situation has been greatly decreased in recent months. Burke estimates it to be 60 percent to 70 percent less.
Legislation adopted two years ago has definitely changed opioid prescribing in Florida. HB 21 limits opioid prescriptions for acute pain to 3 days, up to a maximum of 7 days if the provider feels it’s necessary. The patient must be seen by the provider every seven days.
“’Chronic’s’ definition is six months, so this makes it much harder to have patients on long-term opioids to start,” Weiss said. “I think we’re making less chronic opioid dependent patients now since these rules came about then before.”
Physicians, he said, start decreasing their medications sooner. “Otherwise you have to see the patient every 7 days to continue doing prescriptions. So when you see them every 7 days you’re like, ‘wow, this is no fun. I’m going to start decreasing them,’ which is the ultimate answer you should be doing anyway.”
Weaning — or Not
“My biggest problem I have is sometimes these TPAs will call me and say ‘we want this patient who’s been on the medication for 25 years, you need to take them off,’” Weiss said. “The first question I ask is, ‘OK, I’ve asked the patient every time they come in and if they don’t want to voluntarily come off you really can’t do it.’ You’re basically doing something non-voluntary to a patient who’s been on it a significant amount of time.”
For injured workers who are interested in tapering off opioids, it must be done slowly and adhere to protocols set by various associations. Weiss also advocates getting an addiction specialist involved and bringing in psychological services to help.
Weiss is a big advocate of educating patients before prescribing opioids to them. He has his patients watch videos of various problems that can be caused by their use.
For those injured workers unwilling to taper off opioids, “I monitor their kidney function, I monitor their liver functions, I monitor their cognitive functions, their emotional status, talk to their family members about whether they are depressed, are they getting out of the house,” Weiss said. “So to me if they are going to stay on the opioids I better see their functional levels saying at a reasonable level. If they are declining in function then I am going to put pressure on them to come off [the drugs] … for the ones that are doing OK and are not having any dysfunction and don’t want to come off it you’ve got to let them, you have to maintain it and there has to be an exception for that.”
Despite the intense anti-opioid efforts, there are some people who need them and function with them, the speakers said.
“There are people taking one methadone pill a day instead of taking other opioids,” Weiss said. “Methadone can be very dangerous and should only be prescribed for people who are very aware of its usage, but it works perfect. I have patients who can work. They can’t have a Department of Transportation [commercial driver’s] license but they can do jobs and be successful. And if they’re not having problems, I’ll tell you that I’ll stand for them, I’ll defend them in that they should be able to be maintained on a pain medication.”
The issue of keeping injured workers on long-term opioids is controversial. In fact, concerns about these workers being completely cut off from their medications may be one reason some claimants’ attorneys are reluctant to allow peer-to-peer medication reviews for their clients.
While the nation has come from a point of over-prescribing of opioids, it’s important not to sway too far in the other direction.
“What I want to see us coming from that era, where we’ve seen some lives ruined, don’t overact to the point that we leave that injured worker who really, really needs strong pain medications out in the cold,” Burke said. “That injured worker must be taken care of. That might be the exception to the rule. All injured workers do not need long term opioids but let’s don’t do anything to leave out those injured workers who really do need continuing maintenance medical.”