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For some injured employees, opioid prescriptions spell double trouble

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BOSTON — Opioid painkillers aren't appropriate for most workers compensation patients, yet, many injured workers are prescribed more than one of the powerful drugs.

That some workers injured on the job receive two or more opioids is based on preliminary research from the Cambridge, Massachusetts-based Workers Compensation Research Institute.

While about 30% of injured workers received one prescription for opioids in most of the 25 states studied, the percentage of injured workers who received more than one ranged from 27% in New Jersey to 59% in Louisiana, WCRI researchers found.

The study, compiled using data from injuries that occurred from October 2009 through September 2012 with prescriptions filled through March 2014, was presented by WCRI Policy Analyst Vennela Thumula at the institute's 2016 Annual Issues and Research Conference in Boston this month.

Though most states saw opioid use decrease between 2010 and 2012, about three in four injured workers with pain medications in most states received at least one opioid prescription, Ms. Thumula said, adding the amount of opioids per claim was “unusually higher” in Louisiana, New York and Pennsylvania.

Joseph Paduda, principal of Madison, Connecticut-based Health Strategy Associates L.L.C., said that while opioids are prescribed more often in some states, “their use of opioids is fundamentally different.”

For example, New York physicians may “write more scripts for opioids, (but) those scripts are for Vicodin and Percocet as opposed to” more potent narcotics such as OxyContin, added Mr. Paduda, who attended the conference.

“Doctors in different areas of the country just practice medicine differently,” Mr. Paduda said. “That means that some prescribe Vicodin, some prescribe Percocet, some prescribe (nonsteroidal anti-inflammatory drugs). This is more evidence of the need to inject more science into the practice of medicine, specifically around the use of pharmaceuticals in the workers compensation system.”

Opioid use in workers comp is down overall, said Dr. Marcos Iglesias, vice president and medical director at Hartford Financial Services Group Inc. in Hartford, Connecticut.

Dr. Iglesias, who also attended the conference, noted that Hartford saw a 20% drop in the number of opioid prescriptions last year.

Hydrocodone-acetaminophen combination drugs such as Vicodin were the most frequently used opioids among injured workers, according to WCRI's study. However, Ms. Thumula noted that the drugs, which were classified as Schedule III controlled substances during the study period, became more tightly regulated under Schedule II in October 2014.

Unlike Schedule III and Schedule IV drugs that have less abuse and addiction potential, Schedule II drugs cannot be refilled under the same prescription, according to the U.S. Drug Enforcement Administration.

As a result of the reclassification, “we might, when we update the study, see a different mix of pain medications here,” Ms. Thumula said.

Hydrocodone-acetaminophen and oxycodone-acetaminophen drugs “have long been the market share leaders in opioid use, so I don't see that changing,” said Dr. Jacob Lazarovic, chief medical officer at third-party administrator Broadspire Services Inc. in Sunrise, Florida, who attended the conference.

At the same time hydrocodone-acetaminophen combination drugs were rescheduled, the DEA classified tramadol as a Schedule IV controlled substance. The drug, sold under the names Ultram and Ryzolt, was previously unregulated by the DEA.

“Some pain experts do recommend that tramadol be the first choice after more conservative choices like (nonsteroidal anti-inflammatory drugs) and (acetimenophen), prior to using more potent opioids,” Dr. Lazarovic said.

Occupational health guidelines say not to prescribe opioids with other powerful drugs, but Ms. Thumula said the percent of claims with opioids and benzodiazepines, such as Xanax and Valium, ranged from less than 1% in Texas to nearly 9% in Massachusetts.

“This probably is an underestimate,” Ms. Thumula said, noting that “using these two medications together increases the risk of (emergency department) visits and also opioid-related deaths.”

She added that the low percentage in Texas is probably due to the state's closed drug formulary, which went into effect in September 2011 for new injuries and in September 2013 for all injuries.

“Pain is often accompanied by insomnia and anxiety,” so it's not surprising that opioids and benzodiazepines are used together, Dr. Iglesias said.

Sources agreed that educating patients and prescribers about possible drug interactions is one way to combat the problem.