If a new occupational risk were to emerge to cripple workers and burden employers and insurers with tens of billions of dollars in costs, how would people respond? The history of the past three decades suggests that it takes seven to ten years for a consensus for action to form, and another seven to ten years to act with significant widespread impact. 

The history of prescribed opioids and football concussions suggest this to be the case.  The risk becomes more transparent, responses begin with half measures then become more convincing, and entangled secondary effects emerge.  A case in point: Inducing doctors to prescribe opioids less often has led to a rise in heroin use.

Many opioid-related responses appeared since the mid 2000s, when researchers and lawyers documented the fatal risk of widespread opioid use, ill effects of poor doctoring, and drug company deceptions.  A prime example of a half-measure response was the relatively small fine Purdue Pharma and some of its executives paid in 2007 for deceptive Oxycontin sales practices. The $634.5 million fine was negotiated for Purdue Pharma by former New York City mayor Rudolph Giuliani.  The settlement did not seriously disrupt sales and distribution. Purdue Pharma sold over $6 billion of the drug in the three years after the fine was levied. 

And take New Hampshire’s response to prescribed opioids.  The toll on injured workers and the public from casual prescribing of opioids was clear by the late 2000s to anyone who chose to look.  Opioid-related deaths soon exceeded auto accident fatalities, in-state.  Yet organized labor and medical associations not only did not join efforts to inform doctors and influence prescribing practices, and tended to argue against proposals to do so.

The American Medical Association consistently pushed back nationally against mandatory training for doctors. Years after the Food and Drug Administration published a blueprint for education, the New Hampshire Medical Society only this December agreed to a legislative package of doctor training and other measures, which Gov. Maggie Hassan pretty much forced on it.

Texas, to its credit, introduced in 2011 a formulary to control opioid prescribing, with enlightened support of the state Medical Society. In February, 2016, it will expand the number of so-called N drugs, or opioids needing pre-authorization. The Texas initiative does not provide for monitoring patients after opioid treatment is cut back or eliminated.  There have been no studies of the after-effects on patients of drug formularies, now being adopted by more states and pharmacy benefit managers. Yet the-after effects can be negative. Take the case of heroin.

MyMatrixx’s recently published and well-researched white paper, A Brief History of Heroin Use in the United States: Evolving Impact on Rx Drug Abuse, reports that “the possibility of injured workers becoming addicted to heroin is quite high. In fact, individuals who were addicted to prescription opioids are 40 times more likely to become addicted to heroin.”

Researcher Angela Kilby looked at how state-mandated prescription drug monitoring programs could lead to heroin use.   PDMPs ensure a modicum of transparency on prescribing of opioids, allowing, for instance, doctors to discover multiple prescriptions by a patient. She estimates that PDMPs reduce the number of opioid-related deaths by 12%.  But shutting off opioids has contributed, she estimates, to a national 40% annual increase in heroin deaths. Some patients revert to heroin, which has a higher overdose risk than prescribed opioids. She estimates that in the year after a PDMP is implemented, heroin deaths actually rise more than opioid deaths fall.

The workers’ comp industry habitually looks at the world of medicine and patient behavior within the context of the work injury.  It’s sobering and necessary to look at patient health in a broader societal context. Opioid use and misuse long ago became enmeshed with societal patterns of substance abuse.  And the workers’ comp industry is heading into trouble as legal marijuana works its way into care. 

The federal government lists as major categories of common substance abuse the following: alcohol (17 million “abusers”), tobacco (70 million total users), marijuana (22 million total users) stimulants (about 1 million cocaine users alone), hallucinogens (about a quarter of a million abusers) and opioids (almost 2 million abusers linked to prescribed opioids).

Abusers are a subset of users. For example, there are 2 million prescribed opioid abusers and about 15 million who have active prescriptions for opioids.  What’s important is that substance abusers, and the larger population of users, often consume several categories of substances.  Workers’ comp people have noticed, as have researchers, a close relationship between smoking and long-term opioid use.  Public policy that turns access to a substance off (as in opioids) or on (as in legal pot) tends to lead to undesirable secondary effects. 

Researcher Rosanna Smart has looked at the effect of legalizing pot.  “I find,” she writes, “that growth in the legal medical marijuana market significantly increases recreational use among all age groups.”  Among older adults, who often use pot as a substitute for other substances, more pot use turns people away from fatal alcohol and opioid abuse. But the perception of lower risk propagated by legal pot increases both pot use and alcohol use by teenagers and young adults, leading to more traffic fatalities and alcohol poisoning deaths among them.  Thus, treating a work injury with legal pot “kills,” if one follows the bread crumb path of cause and effect far enough.

Phil Walls, author of the MyMatrixx paper, told me that PDMPs will not pick up heroin usage because it’s not reported, nor pick up medical marijuana usage because legal pot bypasses the pharmacy and doctor data trail.  “We have to fall back on good old common sense, watch for warning signs, such as changes in behavior, cancelled doctor appointments, and such,” he says. “My fear is that these injured workers are going to switch to street drugs and fall off the radar. So it’s imperative that we identify patients at risk while we can monitor them.”

Further Reading:

Kilby, Angela. Opioids for the Masses: Welfare Tradeoffs in the Regulation of Narcotic Pain Medications. 2015

MyMatrixx, A Brief History of Heroin Use in the United States: Evolving Impact on Rx Drug Abuse. 2015

Smart, Rosanna. The Kids aren't Alright but Older Adults are Just Fine: Effects of Medical Marijuana Market Growth on Substance Use and Abuse. 2015