by Barry Meier
Workplace insurers
are accustomed to making billions of
dollars in payments each year, with the biggest sums going to
employees hurt in major accidents, like those mangled by machines or
crushed in building collapses.
Now they are dealing with another big and
fast-growing cost — payouts to workers with routine injuries who
have been treated with strong painkillers, including many who do not
return to work for months, if ever.
Workplace insurers spend an estimated $1.4
billion annually on narcotic painkillers, or opioids. But they are
also finding that the medications, if used too early in treatment,
too frequently or for too long, can drive up associated disability
payouts and medical expenses by delaying an employee’s return to
work.
Workers who received high doses of opioid
painkillers to treat injuries like back strain stayed out of work
three times longer than those with similar injuries who took lower
doses, a 2008 study of claims by the California Workers Compensation
Institute found. When medical care and disability payments are
combined, the cost of a workplace injury is nine times higher when a
strong narcotic like OxyContin is used than when a narcotic is not
used, according to a 2010 analysis by Accident Fund Holdings, an
insurer that operates in 18 states.
“What we see is an association between the
greater use of opioids and delayed recovery from workplace
injuries,” said Alex Swedlow, the head of research at the California
Workers Compensation Institute.
The use of narcotics to treat occupational
injuries is part of a broader problem involving what many experts
say is the excessive use of drugs like OxyContin, Percocet and
Duragesic.
But workplace injuries are drawing particular interest because the
drugs are widely prescribed to treat common problems like back pain,
even though there is little evidence that they provide long-term
benefits.
Along with causing
drowsiness
and
lethargy,
high doses of opioids can lead to addiction, and they can have other
serious side effects, including fatal overdoses.
Between 2001 and 2008, narcotics
prescriptions as a share of all drugs used to
treat workplace injuries jumped 63 percent, according to insurance
industry data. Costs have also soared.
In California, for example, workplace insurers
spent $252 million on opioids in 2010, a figure that represented
about 30 percent of all prescription costs; in 2002, opioids
accounted for 15 percent of drug expenditures.
As a result, states are struggling to find ways
to reverse the trend, and some of them have issued new pain
treatment guidelines, or are expected to do so soon. These states
include New York, Colorado, Texas and Washington. Insurers are also
trying to influence how physicians prescribe the drugs.
Doctors in four states — Louisiana,
Massachusetts, New York and Pennsylvania — appear to be the biggest
prescribers of the drugs for workers’ injuries, according to a
review of data from 17 states by the Workers Compensation
Research Institute, a group in Cambridge, Mass.
Painkiller-related costs are also hitting
taxpayers, who underwrite coverage for public employees like police
officers and firefighters, experts say. In February, one major
underwriter, the American International Group, said that it would no
longer sell backup coverage to workplace insurers, citing rising
pain treatment expenses as one reason.
There is little question that strong
pain
medications can help some patients return to work
and remain productive. But injured workers who are put on high doses
of the drugs can develop chronic pain and face years of difficult
treatments. It is not clear how, or if, the drugs are involved in
the process, but when pain becomes chronic, the cost of a
commonplace injury can equal a crippling one, experts said.
“Some of these claims look like someone who fell
down an elevator shaft and had multiple injuries,” said Dr. Edward
J. Bernacki, the director of the division of occupational and
environmental medicine at Johns Hopkins University in Baltimore.
For decades, workers’ compensation plans, which
vary by state, have been plagued by problems like lengthy legal
battles over an injury’s financial value. But it is in recent years
that opioid painkillers have emerged as a major driver of costs,
experts said.
Accident Fund Holdings examined its claims and
found that the cost of a typical workplace injury — the sum of an
employee’s medical expenses and lost wage payments — was about
$13,000. But when a worker was prescribed a short-acting painkiller
like Percocet, that cost tripled to $39,000 and tripled again to
$117,000 when a stronger longer-acting opioid like OxyContin was
prescribed, said Jeffrey Austin White, an executive with the
insurer, which is based in Lansing, Mich.
In a sense, insurers are experiencing the
consequences of their own policies. During the last decade, they
readily reimbursed doctors for prescribing painkillers while
eliminating payments for treatments that did not rely on drugs, like
therapy.
Those policies may “have created a monster,” said
Dr. Bernyce M. Peplowski, the medical director of the State
Compensation Insurance Fund of California, a quasi-public agency.
For patients, such policies had consequences.
Dr. Eugenio Martinez, a physician in the Boston
area who specializes in rehabilitative medicine, said one patient, a
former waitress who hurt her back five years ago in a fall, recently
won a court fight to force her insurer to pay for
physical
therapy. The insurer had cut off those payments
five years ago after a few sessions, and the woman, now disabled,
had no option but to take strong painkillers, Dr. Martinez said. “It
certainly did not help that she was cut off,” he said.
Nationwide, data suggests that a vast majority of
narcotic drugs used to treat occupational injuries are prescribed by
a tiny percentage of doctors who treat injured workers; in
California, for example, that figure is just 3 percent. Also, the
bulk of such prescriptions go to a relatively small percentage of
injured workers, including those who might be addicted to the drugs
or those who sell them, experts said.
Several companies, like Accident Fund Holdings
and Liberty Mutual, have set up programs in which pain experts
contact doctors identified as high prescribers to discuss their
practices. The State Compensation Insurance Fund of California has
also instituted a policy that requires approval for a doctor to
prescribe an opioid for over 60 days.
Insurers say they are making progress in reducing
overuse of the drugs. But their ability to influence physicians is
limited because workers’ compensation plans can allow employees to
see any doctor. So several states have or will soon adopt new pain
treatment guidelines for doctors who treat workers.
In New York, one proposal would require a doctor
to refer a patient who is not improving to a pain specialist when an
opioid dose exceeds a certain level, said Dr. Elain Sobol Berger,
the associate medical director of the state’s workers’ compensation
board. Washington State has already adopted such a policy.
Dr. Sobol Berger added that the New York rules,
which are expected to be proposed this year, will also emphasize
nondrug treatments for pain. “We know that there is a significant
problem with the management of chronic pain and the use of opioids,”
she said.
Some insurers, like the California state fund,
have also started paying for alternative approaches like specialized
psychotherapy or are trying to get addicted workers into treatment.
Other companies are also checking on long-disabled workers.
Mark Kulakowski, a 57-year-old former warehouse
worker from Peabody, Mass., injured his back more than three decades
ago while lifting a box. He has not worked since 1995. Since his
injury, he has taken narcotic painkillers and has had a long list of
failed treatments.
Recently, his insurer, Liberty Mutual, sought to
have a nurse accompany him to his next doctor’s appointment, a
suggestion he welcomed if it could lead to taking fewer painkillers.
“It just drains everything out of you,” he said.
