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Workers compensation pioneer Dr. Gary Franklin sounds opioid alarm

Workers compensation pioneer Dr. Gary Franklin sounds opioid alarm

Years before risk managers learned that opioid prescriptions would become a workers compensation liability, Dr. Gary Franklin was reviewing death certificates to document that large doses of the narcotics were killing injured workers.

Today, the neurologist and medical director for the Washington State Department of Labor & Industries is recognized in the workers compensation industry for his pioneering research and outspokenness on the overprescribing of opioid pain medications.

Claim files detailing a growing number of worker deaths after the prescribing of increasing amounts of the highly addictive narcotics first crossed his desk in 2001.

“The average daily doses were going through the roof, especially for the most potent Schedule II opioids, the OxyContin-type drugs,” Dr. Franklin said. “I had never seen that before.”

His investigation into the liberal use of opioids to treat injured workers and his willingness to speak out about his findings led to legal action against him and criticism by the drugs' proponents.

“I practically got yelled out of the room by these drug company surrogates” when first presenting the research findings at a 2003 conference for pain management clinicians, Dr. Franklin said. “The fellow who invited me to speak also got yelled at.”

That was several years before the topic of opioids became a part of risk managers' and workers comp insurers' working knowledge and long before many industry observers realized employers and insurers could be on the hook for related addiction services and overdose deaths.


That also was nearly a decade before federal agencies began warning of a deadly epidemic of prescription painkiller abuse across the nation.

Now, a growing number of risk managers and claims managers know that evidence-based medical guidelines warn that treating chronic, nonmalignant pain with opioids is controversial because increased doses of the prescriptions have not been tied to health improvements.

More risk managers also know that various medical guidelines recommend actively monitoring the use of opioid narcotics prescribed to workers through practices such as routine urine screening for potential abuse.

Experts say the early research of Dr. Franklin, who also is a research professor in the Department of Environmental and Occupational Health Sciences Medicine and Health Services at the University of Washington, helped spur the development of such guidelines. They also say his willingness to speak out on the controversial topic helped alert the workers comp industry to the dangers of improperly prescribing narcotics.

“He really worked diligently over the years to address the issues associated with” opioid abuse, said Rita Nowak, vice president of commercial lines and workers comp for the Property Casualty Insurers Association of America in Des Plaines, Ill.

“From everything I can see, he did a Herculean job. We in the industry need to really applaud his efforts.”

Less known about Dr. Franklin, though, is that his passion for helping injured workers emerged during the late 1970s when he maintained a solo medical practice in Springfield, Ore.


He was the blue-collar lumber mill town's only neurosurgeon, he said. So primary care doctors sent him their worst workplace injury and chronic pain cases. They often were mill and factory workers who already had undergone several failed back surgeries before seeing him because they were not improving.

“They were extremely frustrated and angry” because they wanted to be back at work and regain their previous lives, Dr. Franklin said.

“I really cared about these people, and I tried everything I could to help them,” he said.

“But I realized ... that unless I got into a position of preventing injuries from happening, there was nothing I could do no matter how much I cared.”

Their cases raised several questions of the type that would remain a driving force throughout his career.

Dr. Franklin wondered why those workers underwent several surgeries when the first one didn't work. How do you eliminate health care that doesn't work and find what does work? Why can't such disabilities be prevented in the workplace?

By 1980, the questions drove him to sell his private practice and move to Berkeley, Calif., to earn a masters degree in public health, Dr. Franklin said.

Now, even though he is medical director of Washington state's monopoly workers comp insurer, he still practices medicine, working on call on certain weekends at an Olympia, Wash., hospital.

Questions such as how evidence-based medicine is used to treat chronic pain have led to years of research on the medical procedures regularly used in treating injured workers. He has conducted extensive study on lumbar-fusion surgeries, for example.


But one of his greatest accomplishments has been sounding a wake-up call that before doctors increase injured workers' opioid doses beyond a certain level, they should seek additional medical opinions and other possible interventions such as cognitive behavioral therapy, Dr. Bernyce Peplowski said.

Dr. Peplowski knew Dr. Franklin while she was medical director of the California State Compensation Insurance Fund in San Francisco.

While other medical professionals also have led the way in developing medical guidelines for using opioids, Dr. Franklin has been more vocal than the others in raising public awareness about applying such guidelines, Dr. Peplowski added.

“Gary has been so right in being more public about what he is doing,” Dr. Peplowski said.

To spread the word, Dr. Franklin is a frequent speaker on the topic of opioids at workers comp conferences.

The early research he and a pharmacy manager colleague conducted on opioid-related worker deaths began after states passed laws in the late 1990s prohibiting the sanctioning of doctors for writing specific opioid dose amounts, he said.

Dr. Franklin and his colleague studied files and death certificates containing information on 32 worker deaths that occurred between 1999 and 2002.

That led to an early peer-review article in a scientific journal linking unintentional deaths to prescribed opioids, Dr. Franklin said.

“They had to be from prescribed opioids because we knew we were going to take some heat,” Dr. Franklin said.


Eventually, Washington became the first state in the nation to release medical guidelines suggesting a specific dose at which doctors should take additional precautions.

But the heat from detractors did come.

Around 2007, a doctor and an organization sponsored by pharmaceutical companies sued Washington state and the medical directors for several of its public agencies, including Dr. Franklin, he said.

The guidelines were voluntary, but the federal lawsuit claimed the guidelines prevented access to adequate pain treatment, Dr. Franklin said.

“It took two years, but it was finally thrown out,” he said.