Road to Recovery
By Jean Lian
Pain — that gnawing, tormenting sensation — has been wielding an unrelenting grip on Patricia Dodd, volunteer president of the Newfoundland and Labrador Injured Workers Association, since she had a nasty fall at work back in the...
Pain — that gnawing, tormenting sensation — has been wielding an unrelenting grip on Patricia Dodd, volunteer president of the Newfoundland and Labrador Injured Workers Association, since she had a nasty fall at work back in the mid-1980s.
“There was no fixing my injury,” says Dodd, who was off work for 14 months the first time around. She was given painkillers and underwent various rehabilitation programs that included physiotherapy, chiropractic sessions and acupuncture, which provided only temporary relief.
For many injured workers like Dodd, narcotic painkillers are indispensable. But at what price? While opioids alleviate pain, they can also hinder recovery and return to work — or worse, lead to dependency issues.
“Depression as a result of chronic pain has been a huge component for me — the persistent pain and being aware that there is minimal help in reducing pain,” says Dodd, who reports that her experience is similar to that of many injured workers struggling with chronic pain.
Dodd, who has been using pain medication for many years, says she has been trying to wean herself off painkillers, but the result is a decrease in functional abilities. She also has to constantly balance the need to manage pain against the negative effects that any medication can have on overall health.
Prescription opioids, commonly referred to as narcotic painkillers, are often prescribed to people with acute or chronic pain resulting from disease, surgery or injury. They are particularly valuable in controlling pain in the later stages of terminal illness when the possibility of physical dependence is not significant, since these patients have only months to live.
Opioids like morphine and codeine occur naturally in opium, while others like heroin are made by adding a chemical to morphine, notes information from the Centre for Addiction and Mental Health (CAMH) in Toronto. Many of today’s opioids are synthetically made from chemicals. They include oxycodone (Percodan/Percocet), meperidine (Demerol), hydrocodone (Tussionex) and hydromorphone (Dilaudid). The speed, intensity and duration of their effects vary, depending on the type of opioid and the manner of ingestion. When taken orally, the effects are usually felt gradually within 10 to 20 minutes. But the effects are most intense and can be felt in as little time as within a minute if injected into a vein.
Opioids reduce the perception of pain by attaching themselves to specific proteins called opioid receptors found in the brain, spinal cord, gastrointestinal tract and other organs, preventing the transmission of pain signals to the brain.
“They are good pain relievers for patients with acute pain like fracture, a broken bone or post-operative pain,” says Dr. David Juurlink, specialist in internal medicine and clinical pharmacology at Sunnybrook Health Sciences Centre in Toronto. “The big debate is how effective they are for long-term management of chronic pain like back pain or osteoarthritis,” says Juurlink, who charges that opioids are “grossly overused” in patients with work-related injuries.
“Right now, we are in the midst of this epidemic of the use of opioids,” he says. “I can tell you stories of people with simple work-related back pain who may only need a few days of rest and a little bit of general analgesia with anti-inflammatory, whose lives have become dominated by the need to be on progressively higher and higher doses of opioids.”
UP AND UP
Canada is the world’s second-largest per capita consumer of prescription opioids after the United States, according to 2013 data from the International Narcotics Control Board in Vienna. From 2000 to 2010, the use of opioids increased by 203 per cent — a hike steeper than even that in the United States.
While no national level data on prescription drug-related mortality is available in Canada, provincial data from the Canadian Centre on Substance Abuse (CCSA) in Ottawa are far from encouraging. Ontario reported a 250 per cent increase in the number of emergency room visits related to narcotics withdrawal from 2005 to 2006 and 2010 to 2011. Data from the Office of the Chief Coroner show that the rate of prescription opioid-related deaths doubled between 1991 and 2004 in the province.
In western Canada, deaths in Alberta that could be attributed to poisoning from narcotics or hallucinogenic drugs accounted for the second-highest prescription drug-related fatality rate (or 3.8 per 100,000 persons) from 2003 to 2006. In one region of British Columbia, the number of overdose fatalities stemming from prescription opioids was similar to that of residents killed in motor vehicle accidents involving alcohol (or 2 to 3 per 100,000 persons). Coroner files from the province between 2006 and 2011 indicate that 87 per cent of the deaths involved persons under 60 years old; of that number, 82 per cent had a documented source of chronic pain.
Prescription opioids and their associated downsides are a real concern in Canada, where 15 to 29 per cent of the population experiences chronic pain, the CCSA estimates. “There is a growing general awareness that perhaps, we have been prescribing these things a little too gleefully,” says Dr. Norman Buckley, professor and chair at the department of anesthesia with the Michael G. Degroote School of Medicine at McMaster University in Hamilton, Ontario.
While prescribing opioids to treat painful conditions has been rising over the past two decades, particularly for chronic non-cancer pain, Dr. Buckley believes that that trend has been declining. “Opioids have been responsible for considerable morbidity and some mortality, and so there is an active movement to reduce the total dose prescribed and dispensed to individual patients, as well as frequency.”
He cites Toronto’s Workplace Safety and Insurance Board (WSIB) as an agency in which strict restrictions apply to how opioids are reimbursed for injured workers suffering from acute and chronic pain. Compared to the past five years, “my guess is you would see something of a decrease rather than an ongoing increase,” he says in reference to opioid prescription.
At a keynote presentation on prescription drug abuse held at the National Safety Council Congress and Expo last June in Chicago, Dr. Gean Constantine, regional medical director with Liberty Mutual Insurance headquartered in Boston, said unless a person suffers from “very severe, very disabling pain,” opioids are not appropriate. “Except for these really severe cases, there is no evidence that they work,” he said. “It is a dangerous drug.”
South of the border, one recent development in the prescription of opioids for work-related injury or occupational disease is the introduction of the Guideline for Prescribing Opioids to Treat Pain in Injured Workers in Washington State.
Effective since July 1, 2013, the guideline requires that the use of opioids must result in clinically meaningful improvement in function. The continued prescription of opioids in the absence of clinically meaningful improvement in function, or after the development of a severe adverse outcome, is not considered proper and necessary care under Washington State’s workers’ compensation system.
“Over the past decade, there has been a dramatic increase in the use of opioids to treat chronic non-cancer pain,” the guideline states. “Opioids are also being prescribed in stronger potencies and larger doses for musculoskeletal injuries. In some cases, the use of opioids for work-related injuries may actually increase the likelihood of disability.”
Like its neighbour down south, Canada is trying to strike a balance between reining in rampant opioid prescription and managing pain. “It is a very polarized problem in Canada,” says Dr. Andrea Furlan, scientist with the Institute of Work and Health and physician at the University Health Network in Toronto.
The problem is two-fold: about one-third of physicians in Canada refuse to prescribe opioids, even to patients who suffer from chronic pain and have no risk of abuse, overdose or diversion. At the other extreme are doctors who freely prescribe opioids. “Opioids are the strongest analgesics that we know on the face of the earth,” Dr. Furlan says. While some types of chronic pain respond well to opioids, others get worse. For example, tapering opioid consumption often results in rebound pain that exacerbates a patient’s primary pain symptoms following discontinuation or reduced dosage of the drug.
Dr. Juurlink points to medical evidence indicating that some patients who have been prescribed high doses of narcotic painkillers suffer from opioid-induced hyperallergy. “The pain is made different, and it is made worse and miserable. And it is the drugs doing it,” he says.
Another issue with opioids is that they can trigger many adverse side effects, including constipation, nausea, sleepiness, dizziness and poor concentration as among the symptoms. Dr. Furlan says the last few symptoms can be of particular concern to workers operating heavy machinery. There are also factors that can put an individual at a higher risk of overdose, such as having sleep apnea, taking sleeping pills like benzodiazepine, consuming opioids along with alcohol, having liver or kidney damage or being cognitively impaired.
“Overdose means they are going to stop breathing when they are sleeping. They may not wake up,” Dr. Furlan explains.
While analgesics do not materially improve outcomes, they manage pain by providing some sedation, helping a patient to mobilize sooner and undergo a rehabilitation program. “There are workers who will not be able to return to work if not for the opioids. I have patients who had such severe pain, I can’t even rehabilitate them,” Dr. Furlan notes.
And then there is the issue of developing tolerance, even addiction. A patient who has developed tolerance may require an escalated dose to manage the pain, and withdrawing from the drug creates a physiological response that is uncomfortable or may even be dangerous. “The highest predictor if someone is going to get addicted to opioids is if they had a problem with any addictive substance in the past,” adds Dr. Furlan, citing depression and a history of psychological trauma as red flags.
The imbroglio involving OxyContin speaks to just how wrong things can go with opioids. “When OxyContin was first launched, it was said that addiction happened in less than one per cent of people who took these drugs,” Dr. Juurlink notes. And that cannot be further from the truth.
“The best evidence that we have [is] about a third of people on long-term opioids display abnormal behaviours regarding their drugs,” says Juurlink, who co-wrote a commentary on then federal health minister Leona Aglukkaq’s announcement in November of 2012 that she would not interfere with Health Canada’s approval process for a generic form of OxyContin.
“What we have learned is that the people who were teaching doctors how to use opioids back in the 1990s and 2000s — many of these people are specialists, they are well-intentioned — their services are paid by companies that make OxyContin,” Dr. Juurlink notes. In fact, some aspects of the marketing campaign were so misleading that the manufacturer pleaded guilty in a United States federal court to felony charges of “misbranding” in 2007 and was fined $634 million.
A study led by Dr. Irfan Dhalla, associate scientist at the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto and published in December of 2009, found that the addition of OxyContin to the drug formulary in 2000 was associated with a five-fold increase in oxycodone-related mortality and a 41 per cent increase in overall opioid-related mortality.
The effect of OxyContin, a time-released pain medication developed in 1995 for those who need round-the-clock pain relief, lasts for about 12 hours. It contains pure oxycodone, part of which is released when the pill is taken; the remaining portion is coated and released gradually into the body, information from CAMH notes. But when the pill is crushed or chewed, all the oxycodone is released at once and gives rise to a high. Another reason why OxyContin is so addictive is that it does not contain acetaminophen, which makes one sick if excessive quantities of it are consumed.
“One of the things we learned from it is [that] a potent opioid agent, which becomes widely available, can be diverted into non-medical use,” Dr. Buckley suggests. When OxyContin was widely misused in Ontario, Saskatchewan was experiencing a similar misuse with hydromorphone — an analgesic used to treat moderate to severe pain, he adds.
Pain is a sensation that all of us have experienced at some point in our lives, but this unpleasant feeling is often hard to define and measure, is subjective and varies widely from person to person. Pain, which is conveyed to the brain by sensory neurons to signal discomfort caused by actual or potential injury, is more than a physical experience. It is also a perception, which means that it can be felt despite removing the stimulus causing the pain, after an injury has healed or even in the absence of an actual injury or damage.
Dr. Furlan explains that chronic pain is often the result of a pain-induced change in the neuroplasticity of the central nervous system. “Because the brain was hyper-sensitized during that period of acute pain, now you continue having pain,” she says. “If you give Tylenol or anti-inflammatory, it would do nothing. So you need to treat with different medications” like opioids, anti-depressants and cannabinoids — drugs which Dr. Juurlink says “all have their own toxicities.”
There are essentially two types of pain: acute and chronic. While acute pain does not typically last longer than six months and usually disappears when the underlying cause of pain has been treated or healed, chronic pain persists even after an injury has healed, and the pain signals remain active in the nervous system for weeks, months or even years.
Physical effects of chronic pain include tense muscles, limited mobility and lethargy, while emotional effects range from depression, anger and anxiety to fear of re-injury, notes information from the Cleveland Clinic in Ohio.
Determining which type of pain a patient is suffering from can be a slippery slope. Dr. Constantine notes that while most doctors understand acute pain, they do not know in depth what happens in the sub-acute and chronic phase, which is often the kind that occurs among injured workers. “If someone is on narcotics for the first six weeks, that is called the acute phase. You really want to see an improvement in function,” he says. “In six to 12 weeks, you want to see resumption of activities.” And if it goes beyond 12 weeks, “which is where most of the deaths occur, you basically want structure.”
THE DARK SIDE
Research has shown that the use of opioids in workers’ compensation cases can lead to sub-optimal outcomes, such as longer duration of disability, increased risk of surgery, greater likelihood of prolonged narcotic use and higher medical costs. “Our experience showed that during a period of increasing number of narcotic prescriptions and dose escalation, workers were experiencing longer recovery times and poorer return-to-work outcomes,” WSIB spokesperson Christine Arnott says from Toronto.
“Opioid use can delay recovery, particularly when prescribed for non-specific musculoskeletal pain or injury, and can lead to dependency issues,” WorkSafeBC spokesperson Megan Johnston says from Richmond, British Columbia. “Long-term use of high-dose opioids can also be associated with heightened pain sensitivity, tolerance, dependence and occasionally, accidental overdosage and death.”
Apart from dealing with the physical fallout associated with a workplace injury, an injured worker often experiences anger and a sense of obligation or entitlement for treatment or care. They also have to deal with the frustrations of interacting with an employer and the insurer, or with the workers’ compensation board.
“Things like that make the whole recovery after a workplace injury more complicated,” suggests Dr. Buckley, adding that the social and psychological process associated with a workplace injury needs to be managed. “Part of the process may need to be a physical rehabilitation process, but sometimes, it also needs to be what is globally referred to as cognitive behavioural therapy, which involves frequently a lot of education to the patient about what is and is not reasonable, what can be expected,” he adds.
When used appropriately, prescription narcotics should improve a worker’s function and quality of life and support a safe, sustained return to work. “We have seen a significant reduction in the use of long-acting narcotics since the introduction of the WSIB’s Narcotic Strategy,” Arnott reports.
From 2009 to 2013, the number of workers receiving opioids in the first 12 weeks of injury declined by 85 per cent. The overall annual expenditure for narcotic medication has dropped by 27 per cent or $10 million from 2009 to 2013. “This means that fewer injured workers are exposed to the potential harmful effects of these medications,” she adds.
WorkSafeBC is moving in the same direction. Johnston reports that since 2008, the safety agency has been working with family physicians to reduce long-term opioid use and to consider alternatives for pain management. The use of opioids has been decreasing since 2009 — the year when WorkSafeBC rolled out a practice directive to apply best practices to opioid prescription.
“We actively engage prescribing physicians to consider whether the opioid is decreasing the individual’s pain and increasing their functioning. If the response is negative, we work with the physician to consider some alternatives,” Johnston says. Among the initiatives is a multidisciplinary pain-management program that includes education and training in pain and stress management, psychological counselling, exercise and physical activity, and return-to-work planning.
KEEP AN EYE
Before putting a patient on opioids, physicians can refer to the Opioid Manager, a step-by-step guide developed by Dr. Furlan and published in 2010. The guide condenses key elements from the Canadian Guideline for Safe and Effective Use of Opioids and serves as a point-of-care tool for physicians prescribing opioids for chronic non-cancer pain.
The first part of the guide requires physicians to assess a patient’s risk of overdose and check if there is a history of substance abuse — both family and personal. A closely monitored trial of opioid therapy is recommended before deciding whether a patient should be prescribed narcotics for long-term use. If opioids have been prescribed, the physician has to monitor the dosage and whether that has led to an improvement in functional status. The last section requires an assessment of when to decrease or stop the dose completely.
“If the person taking opioids come[s] and tell[s] you they are feeling better but not modifying their function — still in bed whole day, not washing dishes — it means that person should not be taking opioids,” Dr. Furlan stresses. She explains that this is often an indication that the patient is “getting some high, some euphoria.”
She recommends workers in safety-sensitive positions who have been prescribed opioids notify their employers. Work modifications should be made available to these workers until they are on stable dosages and their abilities to undertake safety-sensitive tasks are tested.
Injured workers can also play a more proactive role in their recovery by giving doctors feedback on how they respond to opioids and requesting that doctors document their opioid use in relation to their improvement in function. They should also ask about tapering or switching to less potent drugs and reviewing the pain to assess if it has progressed to the chronic stage and if so, what existing guidelines say about that. “These questions really deserve an answer,” Dr. Constantine says.
Dr. Buckley is likely to agree. “Your focus needs to be on recovery, and it has to be a pretty empirical process of reassessing and reassessing progress, and adjusting therapy according to progress.”
Aside from adjusting dosage and monitoring patients closely, Dr. Juurlink says the current thinking and approach towards occupational pain management needs to be reviewed. “Part of that rethinking involves much greater scrutiny and [a] much higher threshold to prescribe opioids, because while they do help some patients, there are many others they don’t help,” he argues.
Aside from medication, other modalities can be effective in treating chronic pain. They include acupuncture, electrical stimulation, physical therapy, surgery, psychotherapy, relaxation techniques and behaviour modification. But for injured workers suffering from chronic pain, these modalities may not always be affordable.
“The way the Workplace Health, Safety and Compensation Commission scheme works is that these modalities are paid for with the intent that the worker is going to return to work,” Dodd says. “Otherwise, the Commission’s policy is not for ongoing care and is used as a cost-saving measure to suspend medical benefits. We believe that the investment in injury treatment is worthy of the cost and should be done in conjunction with medications.”
A Measured Approach
To discourage the long-term use of opioids among injured workers suffering from chronic pain, British Columbia requires a WorkSafeBC physician to review all requests for extending an opioid prescription beyond eight weeks. If opioids are extended at the eighth week, WorkSafeBC will request more information from both the prescribing physician and the patient.
The physician must provide information related to the worker’s health condition, his or her medication history and the effectiveness of the opioids to date, while the patient must agree to certain conditions, such as using only one physician and one pharmacy. If those conditions are not met, WorkSafeBC can refuse coverage of the medication.
“At the end of the day, WorkSafeBC doesn’t interfere with the prescribing physician’s right to prescribe the medication; it can only make the decision not to pay for the medication,” says Megan Johnston, spokesperson for WorkSafeBC in Richmond.
Similar restrictions apply to Ontario’s Workplace Safety and Insurance Board (WSIB). In the first weeks following an injury, the WSIB’s narcotics strategy limits the use of opioids to milder, less addictive drugs. Nurse consultants regularly review opioid prescriptions, and where extended opioid use is contemplated or ongoing, nurse consultants will request a medical consultant to conduct a clinical file review to confirm clinical understanding, treatment goals and impact on return to work with the prescribing physician.
The WSIB covers physical modalities like physiotherapy and chiropractic care as alternatives to pain medication. Specialty clinic programs are also available to workers with complex injuries or illnesses and ongoing pain, who need quick access to specialized health professionals. In 2011, the WSIB introduced the Medication and Substance Program as a specialty clinic for the minority of workers whose prescription drug use is interfering with their recovery and return to work.
Similar restrictions apply to drugs. Dr. Furlan says many pain medications known to be effective are not covered by workers’ compensation. She cites duloxetine, an anti-depressant effective in treating low back pain and depression, and nabilone — a cannabinoid derived from marijuana. Other options include weaker opioids like tramadol and buprenophene patches that are harder to misuse, “but they are more expensive and not included in WSIB.”
Dr. Furlan says she is currently working on a guideline similar to the Opioid Manager she developed for physicians, but intended for use by patients. The document is undergoing validation with some patient groups and is expected to be ready this May.
If there is any useful advice out there that can help injured workers better manage pain, Dodd says she would like to hear about it. “Medication for pain is not a choice if we want to live with some quality of life. We just have to remain aware and be active in pursuing all reasonable medical options.”
Jean Lian is editor of OHS CANADA.
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