Work Comp and Illicit Drug Use: A Physician's View

Last week, I wrote about an analysis from Ameritox that suggested the rate of illicit drug use in workers' compensation was comparably lower than in other payer classes.  I asked readers to weigh in on one of two possible explanations:

A) Injured workers, generally speaking, have a goal to return to work and dealing with chronic pain through medication therapy is something injured workers, because they are "workers", do responsibly. We know this isn't true for 8.6% of them, but those are bad apples and shouldn't spoil our view of the bunch.

B) Injured workers in chronic pain enjoy a higher rate of iatrogenic (physician-caused) tolerance, dependence, and addiction. Work comp claimants don't need illicit drugs because they're getting all the narcotics they need from their physicians. The existence of an indemnity benefit (which doesn't exist in the other payer classes) drives patient-directed care and higher levels of narcotics use without the need to seek out illicit drugs. 
The overwhelming response (via direct blog comments, emails to me, and LinkedIn group comments) was B.  A few of you weighed in with an "A... then B" perspective that suggested a lot of claims start out on the right track and then get derailed due to a number of factors ranging from legal representation to iatrogenic causes. 

One of PRIUM's physician reviewers, Dr. Bob Taber, offered an option "C":

Many WC chronic pain patients have learned by research (info readily available on internet sites), word of mouth or personal experience that many drugs (licit and illicit) are quickly cleared by the body. A Urine Drug Test (UDT) will not be able to detect the presence of such drugs if it has been more than 5-7 days since the drug was last used/abused. UDTs are recommended to be performed randomly on chronic pain patients receiving opioid therapy but this almost never happens. The patient knows that the only time s/he will possibly be subjected to a UDT is on the day of a scheduled follow up appt with their Doc. They know this date a month or two ahead of time. They are free to use their illicit drug of choice until about a week before their appt date without risk of detection. THC can linger much longer in the body than other drugs so frequent users risk a positive UDT for THC if they continue using until a week before their appt. (assuming that THC is in the test panel).

Dr. Taber suggests that the solution is to make UDT testing truly random and to ensure real, enforceable consequences for positive tests and/or non-participation.  In fact, he suggests that such an approach would mitigate the use of illicit drugs across payer classes, not just workers' compensation.

Many thanks to Dr. Taber for his insights.

Michael
On Twitter @PRIUM1