Thursday, March 22, 2012

Lack of Predictability: Yet Another Challenge in Chronic Opioid Therapy

Consider three workers.  I'll call them John, Joe, and Jim.  All three are 42 year old males.  All work for the same company and in the same function/position.  All suffer from work-related low back pain derived from the same mechanism of injury.  All three have failed initial conservative therapy and have had back surgery... with mixed results at best.  The physicians for all three have tried prescribing NSAIDs, but with little impact. 

For all three, a trial of a low-dose opioid is initiated.  From this point, John, Joe, and Jim head down very different paths.

John experiences pain relief, increase in function, does not up-titrate, and returns to work fairly quickly.  The opioid is used "as needed" for flare up pain in the short-term, but as John leverages his increase in functionality to engage in light/moderate exercise, his back gets stronger and he no longer needs any pharmacological therapy. 

Joe experiences pain relief, but instead of increase in functionality, he experiences opioid tolerance and his physician escalates his dosage.  Eventually, the doctor switchtes Joe to Oxycontin.  He develops dependence on the drug.  He fails to return to work.  The dosage of the Oxycontin goes from 20 mg... to 40 mg... to 80 mg.  Eventually, Joe is referred to a functional restoration program with a focus on addiction/rehab.  But Joe is motivated to change his life.  He knows the drugs don't work for him and cause him more harm than good.  He is highly engaged in his treatment and eventually gets back to work.

Jim, like Joe, ends up going down the path of tolerance, dependence, and addiction.  But Jim lacks the motivation that Joe had to change his life and get rid of the drugs.  In fact, Jim wants more drugs, not less.  He needs drugs to treat all of the side effects of the opiods (sexual dysfunction, constipation, depression, etc.)  And he's not interested in working.  He was hurt on the job and his view of the world is that he's entitled to every penny the employer pays, either directly to him or on his behalf for his medical treatment.  He has an attorney and he's going to fight tooth and nail to maximize his settlement such that he never needs to work again. 

Here's the problem: At the date of injury, it's really hard to distinguish John from Joe from Jim.

I've heard lots of talk of genetic testing that might help predict likelihood of addiction.  The path to actually applying that science is so fraught with complication and complexity, it's difficult to even wrap my head around it.

There is one area, though, where we can put some focus that will yield results: Understand the psycho-social disposition of the injured worker early and assess the likelihood of addiction in this context.  Stop being afraid of psych evals because you're nervous that will open up the claim for additional compensable issues. 

When it comes to work comp and opioids, those that avoid dealing with the psycho-social elements of the patient's care do so at their peril. 

On Twitter @PRIUM1

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