There is little argument with the statement that injured workers are suffering from a high incidence of opioid abuse.
With such widespread recognition of the problem, why is it so hard to correct? A partial explanation is reflected in the erosion of the “no fault” intent of workers' compensation. We want the problem to be fixed back to the pre-incident status without cost to the injured worker (which is reasonable) and without effort (which is not).
Perhaps this is reflected by society’s perception of health. Our society has tacitly defined health as indemnification against cost of health care procedures as well as our own poor personal choices, not just being of “sound mind, body and spirit”. In my view, this is patently false. Real health is a personal responsibility not a physician responsibility. There is so much money (public and private) in this system with so many stakeholders continually attempting to gain their share of that money that we are encouraged and many times required to abdicate responsibility for our own health.
In workers' compensation, this is reflected by the attitude that the injured worker is indemnified against not only cost but also any pain, discomfort or effort in the recovery from incident or injury. There are just too many perverse incentives at play. Secondary gain, a busted legal system and little motivation to get back to work are just a few of such conflicting incentives.
We at PRIUM have seen thousands of narcotics abuse cases. Of these cases, obesity is the number one co-morbidity. Psychological and other issues are frequently seen and mismanaged as part of the work incident, but obesity is still number one. We all know that obesity brings with it a myriad of other co-morbid conditions such as hypertension, hyperlipidemia, diabetes, reduced level of activity, etc. All of these issues tend to create a set of confounding variables that seriously complicate management of the case. Both narcotics and obesity tend to reduce desire for mobility which is probably the single best therapy for typical musculoskeletal workers' compensation injuries.
Instead of addressing this co-morbid condition (which admittedly requires an uncomfortable conversation), too many physicians increase dosage and medications to the detriment of the patient’s overall health. We hear all too often “the patient is stable with a reduced pain score” as sole rationale for long term prescription of opioids. We lose focus on function thereby creating a vicious cycle of reduced activity, increased caloric intake, feeling less well about one’s self, increased hypertension, potential onset of diabetes and more pain. Removing these confounding variables should be pre-requisite to considering long term use of opioids for chronic pain.
In order to address this pandemic of prescription opioid abuse we must educate the patient as to the high risk and questionable benefit of long term opioid therapy in chronic pain treatment. Patients must have sufficient information in order to exercise a responsible role in the decision making process for their own health. Unfortunately, many in the physician community have displayed poor performance in addressing opioid abuse without such shared responsibility.
So, to answer the original question (why is opioid abuse so hard to fix?), not only should there be a role for self management in addressing opioid abuse, it should be a requirement.
On Twitter @PRIUM1
On Twitter @PRIUM1