A common issue faced by workers’ compensation insurers and medical providers is the prevalence of chronic opioid use by injured workers with chronic pain. Longterm use of opioids for chronic non-cancer pain increased dramatically over the past two decades, despite very little evidence that long-term (at least 16 weeks) opioid use for such pain is effective. (1) As many claims handlers are aware, injured workers often remain on opioid pain medicine for months or years – at great expense – with little to no benefit.
Research has shed some light on this phenomenon, suggesting that, in addition to opioid tolerance, chronic opioid use may actually worsen chronic pain by causing a condition known as “opioid induced hyperalgesia.” Patients with this condition can, over time, develop an increasing sensitivity to painful stimuli, even developing a pain response to previously non-painful stimuli. (2). This heightened pain sensitivity can combine with opioid tolerance, causing a patient to take larger and larger doses of opioids without benefit, and even increasing pain. This leads to skyrocketing medical costs and exposure and can undermine a potential settlement by significantly increasing the cost of a Medicare set-aside (MSA).
To make matters worse, evidence is emerging that chronic opioid use may actually increase the risk of developing major depression, another will bar to return-to-work efforts. A 2013 study found that patients who remained on opioids for 180 days or longer were at a 53 percent increased risk of developing a new episode of depression, and those using opioids for 90-180 days were at a 25 percent increased risk compared to those who took opioids for less than 90 days. (3). “These findings suggest that the longer one is exposed to opioid analgesics, the greater is their risk of developing depression,” says Jeffrey Scherrer, Ph.D., lead investigator of the study.
These findings highlight the importance of addressing long-term opioid use as early as possible. If possible, one could attempt a weaning program coordinated with the treating physicians. Alternative pain management could also be attempted. Finally, for those difficult cases, there is the utilization review process.
(1) Von Korff, Michael et al., Long-Term Opioid Therapy Reconsidered. Ann Intern Med. Sep 6, 2011; 155(5): 325–328.
(2) Lee, M. et al., A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician. 2011 Mar-Apr;14(2):145-61.
(3) Scherrer, Jeffrey et al., Prescription Opioid Analgesics Increase the Risk of Depression. Journal of General Internal Medicine, Mar. 2014, Vol. 29, Issue 3, pp 491-499.
(4) Wuitchik, M. & Feehan, GG, Opioid withdrawal versus opioid maintenance for persons with chronic non-cancer pain: The experience of the Canmore Pain Clinic. Rehab Review 2006; 2:19-21.