Comp embracing physical medicine, non-opioid meds

Opioid dispensing in workers compensation continues to be a hot issue as experts see the number of prescriptions continue to decrease in favor of physical medicine, non-opioid medications and behavioral interventions to treat pain.

The issue now is: Could other medications prove problematic? Experts say that’s to be determined. Deadly opioids, however, are under better control, they say.

Providers oftentimes feel that they should provide an injured worker some medication, and it can be difficult to “step back” and look at the medical evidence and whether medication is necessary, said Dr. Albert Rielly of Massachusetts General Hospital in Boston, noting that opioid prescribing is  trending downward.

A study of 27 states conducted by the Cambridge, Massachusetts-based Workers Compensation Research Institute between 2012 and 2016 found that the percentage of workers comp claimants who received prescription opioids declined in all of the states studied. The average amount of opioids prescribed also declined in nearly all of the states during the study period.

Meanwhile, the use of non-opioid medications, and both active and passive physical medicine, has ticked up across study states, according to WCRI’s data. For instance, prescriptions of anticonvulsants, antidepressants and topical analgesics for pain have been increasing, data shows.

At Zurich North America, a halving of the amount of opioids dispensed to injured workers has had a positive impact on worker outcomes and indemnity payments, said Dr. Nina McIlree, vice president of medical management for the Schaumburg, Illinois-based company.

Yet Dr. McIlree said she is concerned that prescriptions of benzodiazepines, which are addictive, have been rising.

Requests for medical marijuana are also on the rise, said John Christian, president and CEO of Modern Assistance Programs, which provides mental health and substance abuse help in Quincy, Massachusetts.

According to marijuana advocacy group American Marijuana, 15 of 19 states showed a reduction in opioid prescribing one year after medical marijuana legalization. For some conditions, such as anxiety, marijuana may actually do more harm, Dr. Rielly said.

Some comp experts have maintained the stance that marijuana remains unproven, as there is little data on efficacy and dosage.

Stepping away from medication, states are reporting upticks in nonpharmacological treatment, said Vennela Thumula, a policy analyst at WCRI.

In California in 2012, 45% of workers with more than a week of lost time but no surgery received an opioid prescription, but that dropped to 22% in 2016, while there was a 13% increase in claims that received neither opioids nor other prescription pain medications. In New Jersey, the percent of injured workers with seven days of lost time who received an opioid dropped 16% between 2012 and 2016, according to the research.

“Overall, we do see a shift in treatment patterns,” Ms. Thumula said, which could indicate increasing compliance with treatment guidelines and the adoption of alternative treatments, as well as reflect concerns about access to opioids.

Specifically, the use of physical medicine, chiropractic care and even massage for pain treatments is on the rise in some states, according to the WCRI data. Mr. Christian said he’s seen his patients turning to acupuncture and massage more frequently as pain treatments, possibly as a result of more education on the use of physical medicine as an opioid alternative.

The use of behavioral therapies is also gaining traction, and Dr. McIlree said she believes that addressing injured workers’ coping mechanisms will be used more in the future to help them through their pain.

A study published in February by researchers at the State University of New York in Albany found that most individuals with chronic pain are interested in non-medication treatment options, and nearly 70% sought behavioral treatments.

“Doctors should be encouraged to discuss non-medication treatment options for chronic pain management with their patients rather than assume patients prefer to treat chronic pain solely with medication,” said Lisa McAndrew, an assistant professor of educational and counseling psychology, who led the study.

“Our country likes pills and surgeries and techniques,” Dr. McIlree said. “We’ve got to take the approach that empowering and engaging the injured worker and using a combination of nonopioid treatments (including coping skills) be the focus first. There’s still work that needs to be done, but the trends are positive.”