Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort

Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review

PURPOSE

Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes.

METHODS

We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible.

RESULTS

From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes.

CONCLUSION

Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.

Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey

BACKGROUND

Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting.

METHODS

Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription.

RESULTS

There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06).

CONCLUSION

Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.

Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers

PURPOSE

Musculoskeletal (MSK) injuries are a major contributing factor for chronic pain. To date, little is known how pain medication use in MSK injuries has changed over time. We assessed pain medication prescription for MSK injuries in a representative sample of Swiss workers between 2008 and 2018.

METHODS

Retrospective analysis of the Swiss Accident Insurance Fund (Suva) data. We calculated annual pain medication use, treatment days, and costs associated with pain medication use in minor and major MSK injuries.

RESULTS

In total, 1,921,382 cases with MSK injuries with ≥ 1 pain medication were analyzed. Whereas MSK injuries with ≥ 1 pain medication increased by 9.4%, we observed a larger increase in metamizole (+ 254%), strong opioids (+ 88.4%), coxibs (+ 85.8%), and paracetamol (+ 28.1%). Strong opioids were increasingly used in minor (+ 91.4%) and major (+ 88.3%) injuries. The increase in metamizole (+ 390.6%) and coxibs (+ 115.5%) was larger in minor injuries compared to major injuries (+ 238.7% and + 80.6%, respectively). Medical expenses decreased in all medications except for strong opioids where a substantial increase was observed (+ 192.4% in minor; + 34% in major injuries).

CONCLUSIONS

We observed a disproportionate increase in metamizole, strong opioids, coxibs, and paracetamol prescriptions even in minor MSK injuries between 2008 and 2018. Whereas treatment costs decreased for all pain medications, there was a substantial increase in strong opioids. A more liberal prescription practice of opioids conflict with current evidence-based practice recommendations and need to be addressed by physicians and policy makers.

Factors influencing pain medication and opioid use in patients with musculoskeletal injuries: a retrospective insurance claims database study

Opioid use is only recommended in selected cases of musculoskeletal (MSK) injuries. We assessed factors associated with increased opioid use in MSK injuries. In a retrospective analysis of over four million workers with MSK injuries using the Swiss National Accident Insurance Fund (Suva) database, we analyzed risk factors by multivariate logistic regression. Injury severity was associated with pain medication, opioid, and strong opioid use. Whereas fractures, contusions, and ruptures had higher odds for any pain medication use, increased odds for strong opioids were observed in fractures, superficial injuries, and other injuries. Injuries of the shoulders, elbow, chest, back/spine, thorax, and pelvis/hips showed high odds for opioid use (odds ratio (OR) > 2.0). Injuries of the shoulders had higher odds for strong opioid use (OR 1.136; 95% CI 1.040-1.241). The odds for using strong opioids increased from 2008 OR 0.843 (95% confidence interval (CI) 0.798-0.891) to 2018 OR 1.503 (95% CI 1.431-1.578), compared to 2013. Injury severity, type of injury, and injured body parts influenced the use of pain medication and overall opioid use in musculoskeletal injuries. Strong opioids were more often used in fractures but also in superficial and other minor injuries, which indicates that other factors play a role when prescribing strong opioids.

Time to Service and Its Relationship with Outcomes in Workers with Compensated Musculoskeletal Conditions: A Scoping Review

PURPOSE

A comprehensive review of the literature on the time between the onset of symptoms and the first episode of care and its effects on important worker outcomes in compensated musculoskeletal conditions is currently lacking. This scoping review aimed to summarize the factors associated with time to service and describe outcomes in workers with workers' compensation accepted claims for musculoskeletal conditions.

METHODS

We used the JBI guidelines for scoping reviews and reported following the PRISMA-ScR protocol. We included peer-reviewed articles published in English that measured the timing of health service initiation. We conducted searches in six databases, including Medline (Ovid), Embase (Ovid), PsycINFO, Cinahl Plus (EBSCOhost), Scopus, and the Web of Science. Peer-reviewed articles published up to November 01, 2022 were included. The evidence was summarized using a narrative synthesis.

RESULTS

Out of the 3502 studies identified, 31 were included. Eight studies reported the factors associated with time to service. Male workers, availability of return to work programmes, physically demanding occupations, and greater injury severity were associated with a shorter time to service, whereas female workers, a high number of employees in the workplace, and having legal representation were associated with a longer time to service. The relationship between time service and worker outcomes was observed in 25 studies, with early access to physical therapy and biopsychosocial interventions indicating favourable outcomes. Conversely, early opioids, and MRI in the absence of severe underlying conditions were associated with a longer duration of disability, higher claim costs, and increased healthcare utilization.

CONCLUSION

Existing evidence suggests that the time to service for individuals with compensated musculoskeletal conditions was found to be associated with several characteristics. The relationship between time to service and worker outcomes was consistently indicated in the majority of the studies. This review highlights the need to consider patient-centred treatments and develop strategies to decrease early services with negative effects and increase access to early services with better outcomes.

Dose Escalations Among Workers' Compensation Claimants Using Opioid Medications-An 8 Year Postinjury Follow up Study

OBJECTIVE

The aim of the study is to determine the morphine equivalent dose in milligrams (MED)/day escalation trend after initial utilization.

METHODS

A total of 25,108 lost time claims filed between 1998 and 2007 were followed for 8 years from injury date. Claims were stratified by initial MED/day at 3 months after injury into four groups (0, 1 to < 15, 15 to < 30, and ≥30 MED/day). The slopes in MED/year of opioid dose escalation were determined for each initial MED/day group.

RESULTS

The slopes of MED/day escalation by initial MED categories were similar ( P ≥ 0.05) ranging from 5.38 to 7.76 MED annually. On average, MED/day increased in a liner pattern with a slope at 6.28 MED/year ( P < 0.01).

CONCLUSIONS

Opioid MED/day increased in a linear pattern, regardless of initial MED/day dose.

Effects of the 2016 CDC opioid prescription guidelines on opioid use and worker compensation case length in patients with back pain

BACKGROUND

Narcotic consumption in the workers' compensation population contributes to prolonged case duration, worse clinical outcomes, and opioid dependence. In 2016, the CDC provided recommendations guiding clinicians on prescribing opioids to adult patients with chronic pain. The objective of our study was to evaluate a cause-and-effect relationship between narcotic consumption and worker compensation claim length before and following guideline revision.

METHODS

An administration database was retrospectively queried to identify patients evaluated for spine-related workers' compensation claimants from 2011 to 2021. Data was recorded for age, sex, BMI, case length, narcotic usage, and injury location. Cases were grouped together by exam date before (2011-2016) and after (2017-2021) the 2016 CDC opioid guideline revision.

RESULTS

Six hundred twenty-five patients were evaluated. Males composed 58% of the study population. From 2011 to 2016, narcotic consumption was reported in 54% of subjects versus no narcotic consumption in 46% of subjects (135 cases). From 2017 to 2021, narcotic consumption decreased to 37% (P = 0.00298). Prior to the guideline revision, mean case length was 635 days. Following CDC guideline revision, there was a significant decline in mean case length duration to 438 days (31% reduction) (P = 0.000868).

CONCLUSION

This study demonstrates that following revised opioid prescription recommendations by the CDC in 2016, there was a statistically significant decline in opioid consumption and workers' compensation case length duration. Opioid use may influence prolonged worker disability and delayed return to work.

Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

OBJECTIVE

To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections.

SUMMARY OF BACKGROUND DATA

Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial.

METHODS

Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression.

RESULTS

Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (-0.7, 0.7)], leg pain intensity [-0.2 (-0.9, 0.4)], or back-related function [-0.8 (-2.1, 0.4)]. We found similar results at six weeks of follow-up.

CONCLUSIONS

Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.

Development and initial application of a harmonised multi-jurisdiction work injury compensation database

Objectives

Workers' compensation schemes provide funding for wage replacement and healthcare for injured and ill workers. In Australia, workers' compensation schemes operate independently in different jurisdictions, making comparisons of health service use challenging. We sought to develop and deploy a new database of health service and income support data, harmonising data from multiple Australian workers' compensation jurisdictions.

Methods

We worked with workers' compensation authorities from six Australian jurisdictions to combine claims, healthcare, medicines and wage replacement data for a sample of compensated workers with claims for musculoskeletal conditions. We designed a structured relational database and developed a bespoke health services coding scheme to harmonise data across jurisdictions.

Results

The Multi-Jurisdiction Workers' Compensation Database contains four data sets: claims, services, medicines and wage replacement. The claims data set contains 158,946 claims for low back pain (49.6%), limb fracture (23.8%) and non-specific limb conditions (26.7%). The services data set contains a total of 4.2 million cleaned and harmonised services including doctors (29.9%), physical therapists (56.3%), psychological therapists (2.8%), diagnostic procedures (5.5%) and examinations and assessments (5.6%). The medicines data set contains 524,380 medicine dispenses, with 208,504 (39.8%) dispenses for opioid analgesics.

Conclusions

The development of this database presents potential opportunities to gain a greater understanding of health service use in the Australian workers' compensation sector, to measure the impact of policy change on health services and to provide a method for further data harmonisation. Future efforts could seek to conduct linkage with other data sources.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Impact evaluation of a brief online training module on physician use of the Maryland, USA, Prescription Drug Monitoring Program

Background

Prescription Drug Monitoring Programs (PDMPs) are electronic databases that track controlled substance prescriptions in a state. They are underused tools in preventing opioid abuse. Most PDMP education research measures changes in knowledge or confidence rather than behavior.

Objective

To evaluate the impact of online case-based training on healthcare provider use of the Maryland (USA) PDMP.

Methods

We used e-mail distribution lists to recruit providers to complete a brief educational module. Using a pre-training and post-training survey in the module, we measured self-reported PDMP use patterns and perceived PDMP value in specific clinical situations and compared pre- and post-training responses. Within the module, we presented three fictional pain cases and asked participants how they would manage each, both before, and then after presenting prescription drug history simulating a PDMP report. We measured changes in the fictional case treatment plans before and after seeing prescription history. Finally, we measured and compared how often each participant accessed the Maryland PDMP database before and after completing the educational module. We used multivariate logistic regression to measure the effect of the intervention on actual PDMP use frequency.

Results

One hundred and fifty participants enrolled and completed the training module, and we successfully retrieved real-world PDMP use data of 137 of them. Participants’ decisions to prescribe opioids changed significantly after reviewing PDMP data in each of the fictional cases provided in the module. In the months following the training, the rate of PDMP use increased by a median of four use-cases per month among providers in practice for less than 20 years (p = 0.039) and two use-cases per month among infrequent opioid prescribers (p = 0.014).

Conclusion

A brief online case-based educational intervention was associated with a significant increase in the rate of PDMP use among infrequent opioid prescribers and those in practice less than 20 years.

Patterns of opioid dispensing and associated wage replacement duration in workers with accepted claims for low back pain: a retrospective cohort study

ABSTRACT

This study aimed to identify patterns of opioid dispensing in Australian workers with low back pain (LBP) and determine the association of dispensing patterns with wage replacement duration. Australian workers' compensation claimants with LBP and at least 1 day of wage replacement were included. We used group-based trajectory modelling to identify opioid dispensing patterns over a two-and-a-half-year period from reported LBP onset and quantile regression to compare wage replacement duration between each dispensing pattern group. Opioids were dispensed to one-third of workers with LBP (N = 3205, 33.3%) at least once during their claim. Three dispensing patterns were identified. Most had a short-term low-volume opioid dispensing pattern (N = 2166, 67.6%), whereas 798 (24.9%) had a long-term moderate-volume pattern and 241 (7.5%) had a long-term high-volume pattern. Workers with dispensed opioids had significantly longer wage replacement duration than those without dispensed opioids (median [weeks]: 63.6 vs 7.1, respectively). In addition, moderate-volume and high-volume long-term dispensing groups had significantly longer wage replacement duration compared with the short-term dispensing group (median [weeks]: 126.9, 126.0, and 30.7, respectively). Without controlling for pain severity, these results offer limited evidence that opioids lead to longer wage replacement duration. Further research controlling for pain severity, psychosocial factors, and recovery expectations is required to confirm whether the relationship between opioid dispensing pattern and wage replacement duration is causal in nature.

The effect of awarding disability benefits on opioid consumption

Strong empirical evidence points towards a significantly higher prevalence of opioid consumption among people receiving disability benefits (DB) than in the general population of the United States. However, no previous research established a causal relationship between the decision to award DB to applicants and their subsequent opioid use. We aim to contribute towards filling this gap. There are channels through which awarding DB may both increase and depress opioid consumption, and thus, ex ante, the sign of a potential causal relationship is ambiguous. To correct for the treatment endogeneity, since an individual's age at the time of the decision on an application impacts discontinuously at certain age cutoffs the award decision, we employ a fuzzy Regression Discontinuity model with three age cutoffs used for identification. We find that awarding DB increases the likelihood of using opioids by about 27-30 percentage points. This suggests that the positive association between DB receipt and opioid consumption is likely to be causal.

Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study

BACKGROUND

Although analgesics are initiated on hospital discharge in millions of adults each year, studies quantifying the risks of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) among older adults during this transition are limited. We sought to determine the incidence and risk of post-discharge adverse events among older adults with an opioid claim in the week after hospital discharge, compared to those with NSAID claims only.

METHODS AND FINDINGS

We performed a retrospective cohort study using a national sample of Medicare beneficiaries age 65 and older, hospitalized in United States hospitals in 2016. We excluded beneficiaries admitted from or discharged to a facility. We derived a propensity score that included over 100 factors potentially related to the choice of analgesic, including demographics, diagnoses, surgeries, and medication coadministrations. Using 3:1 propensity matching, beneficiaries with an opioid claim in the week after hospital discharge (with or without NSAID claims) were matched to beneficiaries with an NSAID claim only. Primary outcomes included death, healthcare utilization (emergency department [ED] visits and rehospitalization), and a composite of known adverse effects of opioids or NSAIDs (fall/fracture, delirium, nausea/vomiting, complications of slowed colonic motility, acute renal failure, and gastritis/duodenitis) within 30 days of discharge. After propensity matching, there were 13,385 beneficiaries in the opioid cohort and 4,677 in the NSAID cohort (mean age: 74 years, 57% female). Beneficiaries receiving opioids had a higher incidence of death (1.8% versus 1.1%; relative risk [RR] 1.7 [1.3 to 2.3], p < 0.001, number needed to harm [NNH] 125), healthcare utilization (19.0% versus 17.4%; RR 1.1 [1.02 to 1.2], p = 0.02, NNH 59), and any potential adverse effect (25.2% versus 21.3%; RR 1.2 [1.1 to 1.3], p < 0.001, NNH 26), compared to those with an NSAID claim only. Specifically, they had higher relative risk of fall/fracture (4.5% versus 3.4%; RR 1.3 [1.1 to 1.6], p = 0.002), nausea/vomiting (9.2% versus 7.3%; RR 1.3 [1.1 to 1.4], p < 0.001), and slowed colonic motility (8.0% versus 6.2%; RR 1.3 [1.1 to 1.4], p < 0.001). Risks of delirium, acute renal failure, and gastritis/duodenitis did not differ between groups. The main limitation of our study is the observational nature of the data and possibility of residual confounding.

CONCLUSIONS

Older adults filling an opioid prescription in the week after hospital discharge were at higher risk for mortality and other post-discharge adverse outcomes compared to those filling an NSAID prescription only.

Do Injured Workers Receive Opioid Prescriptions Outside the Workers' Compensation System?: The Case of Private Group Health Insurances

OBJECTIVES

We explored the impact of workplace injury on receiving opioid prescriptions from employer-sponsored private group health insurances (GHI) and how long injured workers receive opioid prescriptions after injury.

METHODS

We used a difference-in-differences method and MarketScan databases for the years 2013 to 2015.

RESULTS

Estimated odds for injured workers relative to noninjured workers to receive opioid prescriptions from the GHI within 60 and 180 days from the index date of injury were 4.9 and 1.5, respectively. In addition, the number of opioid prescriptions received within 60 days of injury was 2.5 times higher.

CONCLUSION

Workplace injury could be a risk factor for both short and long-term prescription opioid use. Studies that use only workers' compensation medical claim data likely underestimate the magnitude of the impact of workplace injuries on opioid prescriptions.

A Public Health Approach to Protecting Workers from Opioid Use Disorder and Overdose Related to Occupational Exposure, Injury, and Stress : APHA Policy Statement Number 202012, Issued October 24, 2020

Opioid overdose mortality, in combination with increased deaths from alcohol and suicide, is having a profound impact on American workplaces, compromising occupational health and safety and increasing workers' compensation and health insurance costs, absenteeism, and lost productivity. The President's Council of Economic Advisers estimates that more than 1 million workers are out of the workforce due to the opioid crisis. The impact on workers is equally profound, including job loss, divorce and family disruption, and potentially imprisonment, injury, illness, and death. Pain from occupational injuries and illnesses and stress are important pathways to opioid use disorder. Effective workplace programs that incorporate the public health approach to prevention offer a significant opportunity to prevent and respond to the opioid crisis. To date, the nation's efforts at combating the crisis have not included the necessary policy reforms to transform the workplace from a pathway to opioid misuse to a pathway to prevention, including education of workers, unions, employers, and health care providers and treatment and recovery of affected workers. Several key policy interventions are recommended to address this disconnect, including prevention of workplace injury, illness, and emotional distress; worker education and training; and replacement of stigmatizing, punitive workplace substance use programs with supportive programs. Increasing access to alternative pain treatment and preventing opioid misuse in workers' compensation systems are other key policy recommendations.

Expected Organizational Costs for Inserting Prevalence Information Into Lumbar Spine Imaging Reports

BACKGROUND

Modifying physician behavior to more closely align with guideline-based care can be challenging. Few effective strategies resulting in appropriate spine-related health care have been reported. The Lumbar Imaging With Reporting of Epidemiology (LIRE) intervention did not result in reductions in spine care but did in opioid prescriptions written.

OBJECTIVES

To estimate organizational resource needs and costs associated with implementing a pragmatic, decision support-type intervention that inserted age- and modality-matched prevalence information for common lumbar spine imaging findings, using site-based resource use data from the LIRE trial.

RESEARCH DESIGN

Time and cost estimation associated with implementing the LIRE intervention in a health organization.

SUBJECTS

Providers and patients assessed in the LIRE trial.

MEASURES

Expected personnel costs required to implement the LIRE intervention.

RESULTS

Annual salaries were converted to daily average per person costs, ranging from $400 to $2,200 per day (base case) for personnel (range: $300-$2,600). Estimated total average cost for implementing LIRE was $5,009 (range: $2,651-$12,020), including conducting pilot testing with providers. Costs associated with a small amount of time for a radiologist (6-12 hours) and imaging-ordering providers (1-8 hours each) account for approximately 75% of the estimated total cost.

CONCLUSIONS

The process of implementing an intervention for lumbar spine imaging reports containing age- and modality-appropriate epidemiological benchmarks for common imaging findings required radiologists, imaging-ordering providers, information technology specialists, and limited testing and monitoring. The LIRE intervention seems to be a relatively low-cost, evidence-based, complementary tool that can be easily integrated into the reporting of spine imaging.

Early High-Risk Opioid Prescribing Practices and Long-Term Disability Among Injured Workers in Washington State, 2002 to 2013

To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability.

Prolonged opioid use among opioid-naive individuals after prescription for nonspecific low back pain in the emergency department

ABSTRACT

Low back pain is a leading cause of disability globally. It is a common reason for presentation to the emergency department where opioids are commonly prescribed. This is a retrospective cohort study of opioid-naive adults with low back pain presenting to 1 of 4 emergency departments in Nova Scotia. We use routinely collected administrative clinical and drug-use data (July 2010-November 2017) to investigate the prevalence of prolonged opioid use and associated individual and prescription characteristics. In total, 23,559 eligible individuals presented with nonspecific low back pain, with 84.4% being opioid-naive. Our study population included 4023 opioid-naive individuals who filled a new opioid prescription within 7 days after their index emergency department visit (24.4%). The prevalence of prolonged opioid use after a new opioid prescription for low back pain (filling an opioid prescription 8-90 days after the emergency department visit and filling a subsequent prescription ±30 days of 6 months) was 4.6% (185 individuals). Older age and female sex were associated with clinically important increased odds of prolonged opioid use. First prescription average >90 morphine milligram equivalents/day (odds ratio 1.6, 95% confidence interval 1.0-2.6) and greater than 7-day supply (1.9, 1.1-3.1) were associated with prolonged opioid use in adjusted models. We found evidence of declining opioid prescriptions over the study period, but that 24.3% of first opioid prescriptions in 2016 would not have aligned with current guideline recommendations. Our study provides evidence to support a cautious approach to prescribing in opioid-naive populations.

Frailty status as a potential factor in increased postoperative opioid use in older adults

BACKGROUND

Prescription opioids are commonly used for postoperative pain relief in older adults, but have the potential for misuse. Both opioid side effects and uncontrolled pain have detrimental impacts. Frailty syndrome (reduced reserve in response to stressors), pain, and chronic opioid consumption are all complex phenomena that impair function, nutrition, psychologic well-being, and increase mortality, but links among these conditions in the acute postoperative setting have not been described. This study seeks to understand the relationship between frailty and patterns of postoperative opioid consumption in older adults.

METHODS

Patients ≥ 65 years undergoing elective surgery with a planned hospital stay of at least one postoperative day were recruited for this cohort study at pre-anesthesia clinic visits. Preoperatively, frailty was assessed by Edmonton Frailty and Clinical Frailty Scales, pain was assessed by Visual Analog and Pain Catastrophizing Scales, and opioid consumption was recorded. On the day of surgery and subsequent hospitalization days, average pain ratings and total opioid consumption were recorded daily. Seven days after hospital discharge, patients were interviewed using uniform questionnaires to measure opioid prescription use and pain rating.

RESULTS

One hundred seventeen patients (age 73.0 (IQR 67.0, 77.0), 64 % male), were evaluated preoperatively and 90 completed one-week post discharge follow-up. Preoperatively, patients with frailty were more likely than patients without frailty to use opioids (46.2 % vs. 20.9 %, p = 0.01). Doses of opioids prescribed at hospital discharge and the prescribed morphine milligram equivalents (MME) at discharge did not differ between groups. Seven days after discharge, the cumulative MME used were similar between cohorts. However, patients with frailty used a larger fraction of opioids prescribed to them (96.7 % (31.3, 100.0) vs. 25.0 % (0.0, 83.3), p = 0.007) and were more likely (OR 3.7, 95 % CI 1.13-12.13) to use 50 % and greater of opioids prescribed to them. Patients with frailty had higher pain scores before surgery and seven days after discharge compared to patients without frailty.

CONCLUSIONS

Patterns of postoperative opioid use after discharge were different between patients with and without frailty. Patients with frailty tended to use almost all the opioids prescribed while patients without frailty tended to use almost none of the opioids prescribed.

How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study

BACKGROUND

Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care.

METHODS

We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication.

RESULTS

In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%).

CONCLUSIONS

Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.

Impacts of Adherence to Evidence-Based Medicine Guidelines for the Management of Acute Low Back Pain on Costs of Worker's Compensation Claims

OBJECTIVE

American College of Occupational and Environmental Medicine's (ACOEM's) evidence-based guidelines for acute low back pain (LBP) were used to assess relationships between guideline adherence and worker's compensation costs.

METHODS

Treatments at first appointments were abstracted. Two scoring tools were utilized to assess each patient's treatment plan. One score assessed ACOEM Guideline compliance while the second utilized mean expert scores of the perceived value of each treatment. Claim costs were log-transformed and compared with scores.

RESULTS

There is a significant trend between increased compliance and decreasing costs. Medical and total costs trended lower by an average $352.90 and $586.20 per unit of compliance score respectively. No outlier cost claims were in the best guidelines compliance groups.

CONCLUSION

This study shows a statistically significant trend in the relationship between adherence to ACOEM guidelines for initial management of work-related LBP and decreasing claim costs.

Implementation of an Opioid Guideline Impacts on Opioid Prescriptions, Adverse Outcomes, and an Association with a State Opioid-Related Fatalities

OBJECTIVE

The aim of this study was to determine the efficacy of an evidence-based opioid guidelines-based program implemented at the largest worker's compensation insurer in Utah.

METHODS

All new claims, including surgeries, were included. Pre- and post-intervention comparisons included percentage of claims treated with an opioid, provision of a second opioid prescription, opioid use above 50 mg morphine equivalent dose (MED), opioid use more than 90 mg MED, and opioid use over 90 days.

RESULTS

There were significant (P < 0.001) reductions in all primary outcomes, with a reduction in MEDs in the 18 months after implementation totaling 65,502 mg.

CONCLUSION

This program significantly reduced the usage of opioids among acute claims. The year of program implementation, Utah experienced a 19.8% reduction in opioid-related fatalities, which may be partly related to the reduction in MEDs. Regardless, this study suggests that the implementation of an evidence-based guideline is impactful and feasible.

Drug overdose mortality is associated with employment status and occupation in the National Longitudinal Mortality Study

BACKGROUND

Since 1999, over 702,000 people in the US have died of a drug overdose, and the drug overdose death rate has increased from 6.2 to 21.8 per 100,000. Employment status and occupation may be important social determinants of overdose deaths.

OBJECTIVES

Estimate the risk of drug overdose death by employment status and occupation, controlling for other social and demographic factors known to be associated with overdose deaths.

METHODS

Proportional hazard models were used to study US adults in the National Longitudinal Mortality Study with baseline measurements taken in the early 2000s and up to 6 years of follow-up (n = 438,739, 53% female, 47% male). Comparisons were made between adults with different employment statuses (employed, unemployed, disabled, etc.) and occupations (sales, construction, service occupations, etc.). Models were adjusted for age, sex, race/ethnicity, education, income and marital status.

RESULTS

Adults who were disabled (hazard ratio (HR) = 6.96 (95% CI = 6.81-7.12)), unemployed (HR = 4.20, 95% CI = 4.09-4.32) and retired (HR = 2.94, 95% CI = 2.87-3.00) were at higher risk of overdose death relative to those who were employed. By occupation, those working in service (HR = 2.05, 95% CI = 1.97-2.13); construction and extraction (HR = 1.69, 95% CI = 1.64-1.76); management, business and financial (HR = 1.39, 95% CI = 1.33-1.44); and installation, maintenance and repair (HR = 1.32, 95% CI = 1.25-1.40) occupations displayed higher risk relative to professional occupations.

CONCLUSIONS

In a large national cohort followed prospectively for up to 6 years, several employment statuses and occupations are associated with overdose deaths, independent of a range of other factors. Efforts to prevent overdose deaths may benefit from focusing on these high-risk groups.

Changes in early high-risk opioid prescribing practices after policy interventions in Washington State

OBJECTIVE

To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices.

DATA SOURCES

Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015).

STUDY DESIGN

We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator.

PRINCIPAL FINDINGS

Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy.

CONCLUSIONS

Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.

Morphine Equivalent Dose-Days (MED-D): Predicting the Impact of Opioid Prescription on Total Workers' Compensation Claim Costs for Acute Low Back Pain

OBJECTIVE

To assess the effect of morphine equivalent dose-days (MED-D) on the total cost for acute low back pain (LBP) workers' compensation claims.

METHODS

Simple random samples of 123 opioid and 141 nonopioid acute LBP claims were obtained. Opioid claims were divided into low, medium, and high subgroups for MED-D, MED, and prescription duration. Subgroup mean total costs were compared to the nonopioid group using multivariate regression analyses.

RESULTS

MED-D and prescription duration were each, respectively, associated with significantly increased total costs at both medium and high levels. Increasing MED had a negative association with total cost, though stratification by duration abrogated this perceived trend. Interaction testing indicated MED and duration together better explained cost than MED alone.

CONCLUSION

MED-D is a better predictor of total cost in acute LBP claims than MED alone.

Opioids, Polypharmacy, and Drug Interactions: A Technological Paradigm Shift Is Needed to Ameliorate the Ongoing Opioid Epidemic

Polypharmacy is a common phenomenon among adults using opioids, which may influence the frequency, severity, and complexity of drug–drug interactions (DDIs) experienced. Clinicians must be able to easily identify and resolve DDIs since opioid-related DDIs are common and can be life-threatening. Given that clinicians often rely on technological aids—such as clinical decision support systems (CDSS) and drug interaction software—to identify and resolve DDIs in patients with complex drug regimens, this narrative review provides an appraisal of the performance of existing technologies. Opioid-specific CDSS have several system- and content-related limitations that need to be overcome. Specifically, we found that these CDSS often analyze DDIs in a pairwise manner, do not account for relevant pharmacogenomic results, and do not integrate well with electronic health records. In the context of polypharmacy, existing systems may encourage inadvertent serious alert dismissal due to the generation of multiple incoherent alerts. Future technological systems should minimize alert fatigue, limit manual input, allow for simultaneous multidrug interaction assessments, incorporate pharmacogenomic data, conduct iterative risk simulations, and integrate seamlessly with normal workflow.

Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care

OBJECTIVE

The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population.

DESIGN

This is a cross-sectional observational study.

SETTING

Subjects were recruited from six urban primary care health centers.

SUBJECTS

Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included.

METHODS

Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment.

RESULTS

Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics.

CONCLUSIONS

This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.

Factors associated with early opioid dispensing compared with NSAID and muscle relaxant dispensing after a work-related low back injury

OBJECTIVES

The objective of this historical cohort study was to determine the claimant and prescriber factors associated with receiving opioids at first postinjury dispense compared with non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) in a sample of workers' compensation claimants with low back pain (LBP) claims between 1998 and 2009 in British Columbia, Canada.

METHODS

Administrative workers' compensation, prescription and healthcare data were linked. The association between claimant factors (sociodemographics, occupation, diagnosis, comorbidities, pre-injury prescriptions and healthcare) and prescriber factors (sex, birth year, specialty) with drug class(es) at first dispense (opioids vs NSAIDs/SMRs) was examined with multilevel multinomial logistic regression.

RESULTS

Increasing days supplied with opioids in the previous year was associated with increased odds of receiving opioids only (1-14 days OR 1.62, 95% CI 1.51 to 1.75; ≥15 days OR 5.12, 95% CI 4.65 to 5.64) and opioids with NSAIDs/SMRs (1-14 days OR 1.49, 95% CI 1.39 to 1.60; ≥15 days OR 2.82, 95% CI 2.56 to 3.12). Other significant claimant factors included: pre-injury dispenses for NSAIDs, SMRs, antidepressants, anticonvulsants and sedative-hypnotics/anxiolytics; International Statistical Classification of Diseases and Related Health Problems, 9th Revision diagnosis; various pre-existing comorbidities; prior physician visits and hospitalisations; and year of injury, age, sex, health authority and occupation. Prescribers accounted for 25%-36% of the variability in the drug class(es) received, but prescriber sex, specialty and birth year did not explain observed between-prescriber variation.

CONCLUSIONS

During this period in the opioid crisis, early postinjury dispensing was multifactorial, with several claimant factors associated with receiving opioids at first prescription. Prescriber variation in drug class choice appears particularly important, but was not explained by basic prescriber characteristics.

Role of Opioid-Involved Drug Interactions in Chronic Pain Management

The use of opioids for chronic pain management is extraordinarily common despite substantial evidence of only modest benefits, when compared with nonopioid analgesics. Opioid use is also associated with serious risks, including overdose and death. A growing body of evidence suggests that opioids are involved in significant drug interactions that often go unrecognized in clinical practice. Understanding opioid-involved drug interactions is of great practical importance for all health care professionals caring for patients with chronic pain. In this article, we describe the mechanisms of opioid-involved drug interactions and their potential consequences, which have major public health implications. Additionally, this article provides practical strategies to aid health care professionals in avoiding and mitigating opioid-involved drug interactions in order to obtain a favorable balance in the risk-benefit ratio associated with opioid use. These strategies include using osteopathic principles for chronic pain management, separating the times of administration of the opioid(s) from the nonopioid(s) involved in the interaction, changing the opioid(s) adversely affected by the interaction, changing the nonopioid(s) causing the interaction, and partnering with pharmacists in clinical practice.

The Impact of Morphine Equivalent Daily Dose Threshold Guidelines on Prescribed Dose in a Workers' Compensation Population

BACKGROUND

Prescription opioid overdose has increased markedly and is of great concern among injured workers receiving workers' compensation insurance. Given the association between high daily dose of prescription opioids and negative health outcomes, state workers' compensation boards have disseminated Morphine Equivalent Daily Dose (MEDD) guidelines to discourage high-dose opioid prescribing.

OBJECTIVE

To evaluate the impact of MEDD guidelines among workers' compensation claimants on prescribed opioid dose.

METHODS

Workers' compensation claims data, 2010-2013 from 2 guideline states and 3 control states were utilized. The study design was an interrupted time series with comparison states and average monthly MEDD was the primary outcome. Policy variables were specified to allow for both instantaneous and gradual effects and additional stratified analyses examined evaluated the policies separately for individuals with and without acute pain, cancer, and high-dose baseline use to determine whether policies were being targeted as intended.

RESULTS

After adjusting for covariates, state fixed-effects, and time trends, policy implementation was associated with a 9.26 mg decrease in MEDD (95% confidence interval, -13.96 to -4.56). Decreases in MEDD also became more pronounced over time and were larger in groups targeted by the policies.

CONCLUSIONS

Passage of workers' compensation MEDD guidelines was associated with decreases in prescribed opioid dose among injured workers. Disseminating MEDD guidelines to doctors who treat workers' compensation cases may address an important risk factor for opioid-related mortality, while still allowing for autonomy in practice. Further research is needed to determine whether MEDD policies influence prescribing behavior and patient outcomes in other populations.

Opioid Fills for Lumbar Facet Radiofrequency Ablation Associated with New Persistent Opioid Use

Background

Zygapophyseal (facet) joint interventions are the second most common interventional procedure in pain medicine. Opioid exposure after surgery is a significant risk factor for chronic opioid use. The aim of this study was to determine the incidence of new persistent use of opioids after lumbar facet radiofrequency ablation and to assess the effect of postprocedural opioid prescribing on the development of new persistent opioid use.

Methods

The authors conducted a retrospective cohort study using claims from the Clinformatics Data Mart Database (OptumInsight, USA) to identify opioid-naïve patients between 18 and 64 yr old who had lumbar radiofrequency ablation. Patients who had either subsequent radiofrequency ablation 15 to 180 days or subsequent surgery within 180 days after the primary procedure were excluded from the analysis. The primary outcome was new persistent opioid use, defined as opioid prescription fulfillment within the 8 to 90 and 91 to 180 day periods after radiofrequency ablation. The authors then assessed patient-level risk factors for new persistent opioid use.

Results

A total of 2,887 patients met the inclusion criteria. Of those patients, 2,277 (78.9%) had radiofrequency ablation without a perioperative opioid fill, and 610 (21.1%) patients had the procedure with a perioperative opioid fill. The unadjusted rate of new persistent opioid use was 5.6% (34 patients) in the group with a perioperative opioid fill versus 2.8% (63 patients) for those without an opioid fill. Periprocedural opioid prescription fill was independently associated with increased odds of new persistent use (adjusted odds ratio, 2.35; 95% CI, 1.51 to 3.66; P &lt; 0.001).

Conclusions

Periprocedural opioid use after lumbar radiofrequency ablation was associated with new persistent use in previously opioid-naïve patients, suggesting that new exposure to opioids is an independent risk factor for persistent use in patients having radiofrequency ablation for chronic back pain. Opioid prescribing after radiofrequency ablation should be reevaluated and likely discontinued in this population.

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Impact of workplace injury on opioid dependence, abuse, illicit use and overdose: a 36-month retrospective study of insurance claims

OBJECTIVES

To examine the impact of workplace injury on opioid dependence, abuse and overdose (opioid-related morbidity) and if severity of injury increases the hazard of these health effects.

METHODS

We used MarketScan databases to follow injured and propensity score matched non-injured workers, both without prior opioid-related diagnoses. Using a Cox proportional hazard model, we examined the impact of workplace injury on opioid-related morbidity.

RESULTS

The hazard of opioid-related morbidity for injured workers was 1.79 times than that of matched non-injured workers (95% CI 1.89 to 3.60). For medical-only and lost-time injured workers, it was respectively 1.54 (95% CI 1.02 to 2.32) and 2.91 (95% CI 1.75 to 4.84) times that of non-injured workers.

CONCLUSIONS

Reducing workplace injury or severity of workplace injury, as well as efforts to ensure appropriate opioid prescribing for injured workers, may help to reduce the societal costs of opioid use.

Prescription opioid overdose and adverse effect hospitalisations among injured workers in eight states (2010-2014)

OBJECTIVE

High-risk opioid prescribing practices in workers' compensation (WC) settings are associated with excess opioid-related morbidity, longer work disability and higher costs. This study characterises the burden of prescription opioid-related hospitalisations among injured workers.

METHODS

Hospital discharge data for eight states (Arizona, Colorado, Michigan, New Jersey, New York, South Carolina, Utah and Washington) were obtained from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We calculated 5-year (2010-2014) average annual rates of prescription opioid overdose/adverse effect (AE) hospitalisations. Injured workers were identified using payer (WC) and external cause codes.

RESULTS

State-level average annual prescription opioid overdose/AE hospitalisation rates ranged from 0.3 to 1.2 per 100 000 employed workers. Rates for workers aged ≥65 years old were two to six times the overall rates. Among those hospitalised with prescription opioid overdose/AEs, injured workers were more likely than other inpatients to have a low back disorder diagnosis, and less likely to have an opioid dependence/abuse or cancer diagnosis, or a fatal outcome. Averaged across states, WC was the primary expected payer for <1% of prescription opioid overdose/AE hospitalisations vs 6% of injury hospitalisations.

CONCLUSIONS

Population-based estimates of prescription opioid morbidity are almost nonexistent for injured workers; this study begins to fill that gap. Rates for injured workers increased markedly with age but were low relative to inpatients overall. Research is needed to assess whether WC as payer adequately identifies work-related opioid morbidity for surveillance purposes, and to further quantify the burden of prescription opioid-related morbidity.

Increased overall and cause-specific mortality associated with disability among workers' compensation claimants with low back injuries

BACKGROUND

Mortality tends to be higher among people who do not work than among workers, but the impact of work-related disability on mortality has not been well studied.

METHODS

The vital status through 2015 was ascertained for 14 219 workers with an accepted workers' compensation claim in West Virginia for a low back injury in 1998 or 1999. Mortality among the cohort compared with the West Virginia general population was assessed using standard life table techniques. Associations of mortality and disability-related factors within the cohort were evaluated using Cox proportional hazards regression.

RESULTS

Compared to the general population, mortality from accidental poisoning was significantly elevated among the overall cohort and lost-time claimants. Most deaths from accidental poisoning in the cohort were due to drug overdoses involving opioids. Mortality from intentional self-harm was also significantly elevated among lost-time claimants. In internal analyses, overall mortality and mortality from cancer, heart disease, intentional self-harm, and drug overdoses involving opioids was significantly associated with lost time. Overall mortality and mortality from drug overdoses involving opioids were also significantly associated with amount of lost time, permanent partial disability, and percent permanent disability. Heart disease mortality was also significantly associated with the amount of lost time.

CONCLUSIONS

The results suggest that disability itself may impact mortality risks. If confirmed, these results reinforce the importance of return to work and other efforts to reduce disability.

Relationship Between Pain Alleviation and Disease-specific Health-related Quality of Life Measures in Patients With Chronic Low Back Pain Receiving Duloxetine: Exploratory Post Hoc Analysis of a Japanese Phase 3 Randomized Study

This post hoc analysis of a Japanese phase 3 randomized study (ClinicalTrials.gov identifier: NCT01855919) investigated relationships between pain severity (assessed by the Brief Pain Inventory [BPI]) and disease-specific health-related quality of life (assessed by the 24-item Roland-Morris Disability Questionnaire [RDQ-24]) in duloxetine-treated patients with chronic low back pain (CLBP).

Prescription Dispensing Patterns Before and After a Workers' Compensation Claim: An Historical Cohort Study of Workers With Low Back Pain Injuries in British Columbia

OBJECTIVE

Compare prescription dispensing before and after a work-related low back injury.

METHODS

Descriptive analyses were used to describe opioid, nonsteroidal anti-inflammatory drug (NSAID), and skeletal muscle relaxant (SMR) dispensing 1 year pre- and post-injury among 97,124 workers in British Columbia with new workers' compensation low back claims from 1998 to 2009.

RESULTS

Before injury, 19.7%, 21.2%, and 6.3% were dispensed opioids, NSAIDs, and SMRs, respectively, increasing to 39.0%, 50.2%, and 28.4% after. Median time to first post-injury prescription was less than a week. Dispensing was stable pre-injury, followed by a sharp increase within 8 weeks post-injury. Dispensing dropped thereafter, but remained elevated nearly a year post-injury, an increase attributable to less than 2% of claimants.

CONCLUSION

These drug classes are commonly dispensed, particularly shortly after injury and dispensing is of short duration for most, though a small subgroup receives prolonged courses.

Opioid-related overdose deaths by industry and occupation-Massachusetts, 2011-2015

BACKGROUND

Thousands of people in the United States continue to die from opioid overdoses every year. Work-related injuries and other factors associated with work may increase exposure to opioids and, subsequently, opioid-related overdose deaths (OROD). This study sought to determine whether OROD rates differed by industry and occupation and explored work-related factors that might contribute to these differences.

METHODS

We coded industry and occupation information on death certificates for all OROD among Massachusetts residents from 2011 to 2015. We estimated rates of OROD by industry and occupation using Massachusetts employment data. National survey data were used to explore whether work-related factors known to vary by occupation (occupational injury and illness, job insecurity, and paid sick leave) correlate to observed differences in OROD.

RESULTS

Several industries and occupation groups had rates of OROD that were significantly higher than the rates for other workers. Construction workers and fishing workers stood out for having OROD rates many times higher than the average for all workers. Occupation groups with high rates of occupational injuries and illnesses, high job insecurity, and low availability of paid sick leave had higher rates of OROD.

CONCLUSIONS

These findings underscore the need for policy and educational interventions to reduce OROD tailored to the needs of high rate worker populations. Interventions should address workplace hazards that cause injuries for which opioids are prescribed, as well as best practices in medical management and return to work following injury, safer prescribing, enhanced access to treatment for opioid use disorders, and overdose prevention education.

Mortality of older construction and craft workers employed at department of energy nuclear sites: Follow-up through 2016

BACKGROUND

To determine if construction and trades workers employed at U.S. Department of Energy (DOE) nuclear sites facilities are at significant risk for diseases associated with occupational exposures, we compared the mortality experience of participants in the Building Trades National Medical Screening Program (BTMed) to that of the US population.

METHODS

The cohort includes 24,086 BTMed participants enrolled between 1998 and 2016 and 5203 deaths. Cause-specific standardized mortality ratios were calculated based on US death rates.

RESULTS

Mortality was elevated for all causes, all cancers, cancers of the trachea, bronchus, and lung and lymphatic and hematopoietic system, mesothelioma, chronic obstructive pulmonary disease, asbestosis, transportation injuries, and other injuries, particularly those caused by accidental poisoning, suggesting a possible effect of the opioid epidemic.

CONCLUSIONS

Apart from other injuries, mortality patterns were very similar to those reported in the past in this population. Construction workers employed at DOE sites have a significantly increased risk for occupational illnesses. Risks are associated with employment during all time periods covered including possibly after 1990. The cancer risks closely match the cancers identified for DOE compensation from radiation exposures. The high risk of lung cancer supports the value of early lung cancer detection. Continued medical surveillance is important.

The Influence of a Guideline-Concordant Stepped Care Approach on Downstream Health Care Utilization in Patients with Spine and Shoulder Pain

BACKGROUND

Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories.

OBJECTIVE

To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.

DESIGN

Retrospective observational cohort.

METHODS

Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data.

RESULTS

From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001).

CONCLUSIONS

MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.

Free trade and opioid overdose death in the United States

Opioid overdose deaths in the U.S. rose dramatically after 1999, but also exhibited substantial geographic variation. This has largely been explained by differential availability of prescription and non-prescription opioids, including heroin and fentanyl. Recent studies explore the underlying role of socioeconomic factors, but overlook the influence of job loss due to international trade, an economic phenomenon that disproportionately harms the same regions and demographic groups at the heart of the opioid epidemic. We used OLS regression and county-year level data from the Centers for Disease Controls and the Department of Labor to test the association between trade-related job loss and opioid-related overdose death between 1999 and 2015. We find that the loss of 1000 trade-related jobs was associated with a 2.7 percent increase in opioid-related deaths. When fentanyl was present in the heroin supply, the same number of job losses was associated with a 11.3 percent increase in opioid-related deaths.

Relationship between early prescription dispensing patterns and work disability in a cohort of low back pain workers' compensation claimants: a historical cohort study

Objectives

To examine and compare whether dispensing of prescription opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) within 8 weeks after a work-related low back pain (LBP) injury is associated with work disability.

Methods

A historical cohort study of 55 571 workers’ compensation claimants with LBP claims in British Columbia from 1998 to 2009 was conducted using linked compensation, dispensing and healthcare data. Four exposures were constructed to estimate the effect on receipt of benefits and days on benefits 1 year after injury: drug class(es) dispensed, days' supply, strength of opioids dispensed and average daily morphine-equivalent dose.

Results

Compared with claimants receiving NSAIDs and/or SMRs, the incidence rate ratio (IRR) of days on benefits was 1.09 (95% CI 1.04 to 1.14) for claimants dispensed opioids only and 1.26 (95% CI 1.22 to 1.30) for claimants dispensed opioids with NSAIDs and/or SMRs. Compared with weak opioids only, the IRR for claimants dispensed strong opioids only or strong and weak opioids combined was 1.21 (95% CI 1.12 to 1.30) and 1.29 (95% CI 1.20 to 1.39), respectively. The incident rate of days on benefits associated with each 7-day increase in days supplied of opioids, NSAIDs and SMRs was 10%, 4% and 3%, respectively. Similar results were seen for receipt of benefits, though effect sizes were larger.

Conclusions

Findings suggest provision of early opioids leads to prolonged work disability compared with NSAIDs and SMRs, though longer supplies of all drug classes are also associated with work disability. Residual confounding likely partially explains the findings. Research is needed that accounts for prescriber, system and workplace factors.

Associations of Early Opioid Use With Patient-reported Outcomes and Health Care Utilization Among Older Adults With Low Back Pain

OBJECTIVES

The objective of this study was to compare outcomes and health care utilization of older patients who did versus did not fill opioid prescriptions within 90 days of initiating care for low back pain.

MATERIALS AND METHODS

For patients ≥65 years with new back pain visits, we used propensity scores to match those who filled no opioid prescriptions to those who filled ≥2 opioid prescriptions within 90 days (and the first opioid prescription within 30 d) of the index visit. Over 24 months, we examined patient-reported outcomes, health care utilization, and subsequent opioid prescription fills.

RESULTS

Among 1954 patients eligible for matching, 238 (12%) filled ≥2 opioid prescriptions within 90 days; 200 of these were matched to controls. Patients with versus without early opioid prescriptions had similar patient-reported outcomes but were more likely to have filled ≥1 opioid prescription 18 to 24 months after the index visit (odds ratio [95% confidence interval]=2.4 [1.5-3.9]) and to have had ≥1 visit to the emergency department in the subsequent 24 months (OR, 1.6; 95% confidence interval, 1.0-2.5).

DISCUSSION

Among older patients with new back pain visits, filling ≥2 opioid prescriptions within 90 days of the visit was associated with similar back pain-related outcomes but increased likelihood of filling opioid prescriptions 18 to 24 months later compared with matched patients who did not fill early opioid prescriptions.

Drug overdose deaths at work, 2011-2016

Drug overdose fatalities have risen sharply and the impact on US workplaces has not been described. This paper describes US workplace overdose deaths between 2011 and 2016. Drug overdose deaths were identified from the Census of Fatal Occupational Injuries and fatality rates calculated using denominators from the Current Population Survey. Fatality rates were compared among demographic groups and industries. Negative binomial regression was used to analyse trends. Between 2011 and 2016, 760 workplace drug overdoses occurred for a fatality rate of 0.9 per 1 000 000 full-time equivalents (FTEs). Workplace overdose fatality rates significantly increased 24% annually. Workplace overdose fatality rates were highest in transportation and mining industries (3.0 and 2.6 per 1 000 000 FTEs, respectively). One-third of workplace overdose fatalities occurred in workplaces with fewer than 10 employees. Heroin was the single most frequent drug documented in workplace overdose deaths (17%). Workplace overdose deaths were low, but increased considerably over the six-year period. Workplaces are impacted by the national opioid overdose epidemic.

Disability Benefits and Change in Prescription Opioid Dose

Among chronic low back pain (CLBP) patients, workers' compensation is associated with longer term prescription opioid analgesic use (OAU). The aim was to study the association between receiving Social Security Disability Insurance (SSDI) benefits and course of OAU. This prospective cohort study utilized data from primary care patients diagnosed with non-cancer CLBP. The outcomes were morphine equivalent dose (MED) - categorized as no OAU, 1-50mg MED, or >50mg MED - and change in MED over time using mixed multinomial logistic regression models. Covariates included sociodemographics, pain severity, pain management characteristics, continuity of care with their physician, health-related quality of life, number of comorbid health conditions, obesity, depression, and anxiety. In adjusted analysis, SSDI vs. non-SSDI patients were more likely to be receiving >50mg MED vs. no OAU at baseline (OR = 10.19; 95% CI:1.51-68.83). Differences in OAU trajectory between SSDI groups were nonsignificant (P = 0.204). Collection of SSDI benefits was an independent predictor of higher MED at baseline and persistently higher MED during 2 years of follow-up. Providers should consider the risk of persistent, high-dose opioid use in patients receiving SSDI benefits.

Initial Provider Specialty Is Associated With Long-term Opiate Use in Patients With Newly Diagnosed Low Back and Lower Extremity Pain

STUDY DESIGN

Retrospective longitudinal cohort analysis of patients diagnosed in 2010, with continuous enrollment 6 months prior to and 12 months following the initial visit.

OBJECTIVE

To determine whether provider specialty influences patterns of opiate utilization long after initial diagnosis.

SUMMARY OF BACKGROUND DATA

Patients with low back pain present to a variety of providers and receive a spectrum of treatments, including opiate medications. The impact of initial provider type on opiate use in this population is uncertain.

METHODS

We performed a retrospective analysis of opiate-naïve adult patients in the United States with newly diagnosed low back or lower extremity pain. We estimated the risk of early opiate prescription (≤14 d from diagnosis) and long-term opiate use (≥six prescriptions in 12 mo) based on the provider type at initial diagnosis using multivariable logistic regression, adjusting for patient demographics and comorbidities.

RESULTS

We identified 478,981 newly diagnosed opiate-naïve patients. Of these, 40.4% received an opiate prescription within 1 year and 4.0% met criteria for long-term use. The most common initial provider type was family practice, associated with a 24.4% risk of early opiate prescription (95% CI, 24.1-24.6) and a 2.0% risk of long-term opiate use (95% CI, 2.0-2.1). Risk of receiving an early opiate prescription was higher among patients initially diagnosed by emergency medicine (43.1%; 95% CI, 41.6-44.5) or at an urgent care facility (40.8%; 95% CI, 39.4-42.3). Risk of long-term opiate use was highest for patients initially diagnosed by pain management/anesthesia (6.7%; 95% CI, 6.0-7.3) or physical medicine and rehabilitation (3.4%; 95% CI, 3.1-3.8) providers.

CONCLUSION

Initial provider type influences early opiate prescription and long-term opiate use among opiate-naïve patients with newly diagnosed low back and lower extremity pain.

LEVEL OF EVIDENCE

3.

Brief report: Population-based reversal of the adverse impact of opioids on disability in Washington State workers' compensation

BACKGROUND

Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period.

METHODS

We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported.

RESULTS

Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010.

CONCLUSIONS

Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.

Are injured workers with higher rehabilitation service utilization less likely to be persistent opioid users? A cross-sectional study

BACKGROUND

Given its role in treating musculoskeletal conditions, rehabilitation medicine may be an important factor in decreasing the use of opioids among injured workers. The primary objective was to determine if increased utilization of rehabilitation services was associated with decreased persistent opioid use among workers' compensation claimants. The secondary objective was to determine the combined association of rehabilitation service utilization and persistent opioid use with days of work lost due to injury.

METHODS

Using Chesapeake Employers' Insurance Company claims data from 2008 to 2016, claimants with at least one filled opioid prescription within 90 days of injury were eligible for inclusion. The primary outcome was persistent opioid use, defined as at least one filled opioid prescription more than 90 days from injury. The secondary outcome was days lost due to injury. The primary variable of interest, rehabilitation service utilization, was quantified based on the number of rehabilitation service claims and grouped into five levels (no utilization, and four quartiles - low, medium, high, very high).

RESULTS

Of the 9596 claimants included, 29% were persistent opioid users. Compared to claimants that did not utilize rehabilitation services, patients with very high rehabilitation utilization were nearly three times more likely (OR: 2.71, 95% CI: 2.28-3.23, p < 0.001) to be persistent opioid users and claimants with low and medium levels of rehabilitation utilization were less likely to be persistent opioid users (low OR: 0.20, 95%: 0.14-0.27, p < 0.001) (medium OR: 0.26, 95% CI: 0.21-0.32, p < 0.001). Compared to claimants that did not utilize rehabilitation services, very high rehabilitation utilization was associated with a 27% increase in days lost due to the injury (95% CI: 21.9-32.3, p < 0.001), while low (- 16.4, 95% CI: -21.3 - -11.5, p < 0.001) and medium (- 11.5, 95% CI: -21.6 - -13.8, p < 0.001) levels of rehabilitation utilization were associated with a decrease in days lost due to injury, adjusting for persistent opioid use.

CONCLUSION

Our analysis of insurance claims data revealed that low to moderate levels of rehabilitation was associated with reduced persistent opioid use and days lost to injury. Very high rehabilitation utilization was associated with increased persistent opioid use and increased time from work.