Musculoskeletal disorders in comp highlight prescribing changesPosted On: Aug. 26, 2020 7:00 AM CST
Musculoskeletal disorders can be treated more effectively by medications and therapies other than opioids, according to new research that shows injuries that make up the lion’s share of workers compensation claims can avoid dangerous drug remedies.
On Thursday, McMaster University in Hamilton, Ontario, published research funded by the Itasca, Illinois-based National Safety Council that reviewed 13 studies with more than 13 million participants with musculoskeletal disorders (MSDs), finding that treating these patients with nonsteroidal anti-inflammatory drugs, commonly known as NSAIDs, was more effective than treating the pain with opioids.
“Anytime where you can try other methods of (non-opioid) pain relief first, that’s better,” said Jenny Burke, senior director of impairment practice at NSC. “This research is telling us that these over-the-counter medicines can treat pain effectively.”
Common medications including aspirin and ibuprofen are considered NSAIDs.
The Department of Labor’s Bureau of Labor Statistics describes MSDs as musculoskeletal system and connective tissue diseases and disorders that are often caused by overexertion or repetitive motion. The bureau estimated that as many as 30% of comp injuries fall into this category.
Meanwhile, the most recent data for 2019 shows that opioid prescribing continues to decline in workers comp, and the shift toward alternatives is rising, according to Raji Chadarevian, director of medical regulation and informatics at the Boca Raton, Florida-based National Council on Compensation Insurance.
The share of all workers comp claims receiving opioids declined from 55% in 2012 to 34% in 2018, according to the ratings agency, and alternative treatments are up, Mr. Chadarevian noted. From 2012 to 2018, there was a 131% increase in the use of massage to treat chronic pain, a 26% increase in the use of orthotics and a 15% increase in the use of physical therapy, according to NCCI.
Frontline doctors and those handling comp claims are also seeing the shift.
Eight years ago, “every patient I saw was on four narcotics a day and four Soma a day,” said Dr. Steven Feinberg, a pain expert and founder of the Palo Alto, California-based Feinberg Medical Group. “Someone was in pain, you started them on a low-dose opioid. We’re so critical of what we did back then, but the reality is, that was the norm.”
Also at that time, it was difficult to get insurers and employers to authorize alternative therapies, he said. In California, non- drug treatments are continuing to grow, including alternative therapies such as acupuncture, which are now listed in the state’s workers comp treatment guidelines, he said.
“This is a whole interesting area — Thai Chi, yoga, mindfulness … and old standbys like heat and cold. … It’s also inexpensive,” Dr. Feinberg said of treating work-related MSDs.
Coventry Workers Comp Services has also seen an increase in the use of alternatives to opioids, said Nikki Wilson, Omaha, Nebraska-based pharmacy product director for the care and cost management program provider.
“In 2019, 25% of injured workers had an opioid filled, which is down from previous years,” she said. “I couldn’t tell you if this is specific to musculoskeletal disorders, but it’s certainly playing out.”
Ms. Wilson has also seen more willingness on the part of payers to provide alternative therapies, such as physical therapy.
“I believe there is a shift in attitude and more openness about adopting alternative therapies that are low risk and potentially beneficial,” Ms. Wilson said.
In the McMaster University study, the researchers analyzed the effectiveness of pain therapy for a group of participants with non-low back MSDs that included workers receiving workers compensation, veterans and group health patients with higher rates of substance use disorders.
They found that NSAIDs, both in topical and oral forms, followed by acetaminophen, provided the most “attractive benefit-to-harm ratio for patients with acute pain from non-low back musculoskeletal injuries” and that no opioid provided benefits greater than NSAIDs in their research.
“Our results demonstrate that opioids fail to achieve important benefits beyond alternative interventions with less harm,” said Jason Busse, principal investigator and associate professor in McMaster’s Department of Health Research Methods, Evidence and Impact. “These results provide compelling reasons to avoid opioid prescribing in the setting of acute, non-low back, musculoskeletal injury.”
Ms. Burke hopes the research will continue to support the movement away from using opioids for the treatment of ailments such as MSDs.
“Prescribing behaviors still need to be changed,” she said. “That’s still important.”
However, the medical community can go too far, Dr. Feinberg said, noting that there are times when a worker with a severe fracture in his arm and in terrible pain is unable to get a low opioid dose for a brief period.
“We’re just as concerned about a doctor being unwilling to prescribe opioids because he’s afraid to and patients who may need them and can’t get them,” he said. “It’s hard to find a balance.”
Another area of concern is the pandemic, as the U.S. population is more vulnerable to substance abuse because of the mental health stresses related to COVID-19, Ms. Burke said.
Experts say the uptick in opioid use during the pandemic and current prescribing behaviors need to continue to be evaluated, with an emphasis on shifting toward alternative therapies.
More than 40 states have reported increases in opioid-related deaths during the pandemic, according to the American Medical Association. The National Institutes of Environmental Health Sciences said the pandemic is negatively impacting opioid use due to social isolation, work-related stress, work-related ergonomics and COVID-19’s disparate impacts on communities.
More insurance and workers compensation news on the coronavirus crisis here.