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.
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