Impact of the Combined Use of Benzodiazepines and Opioids on Workers' Compensation Claim Cost

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.

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.

Early Drug Prescription Patterns as Predictors of Final Workers Compensation Claim Costs and Closure: An Updated Analysis on an Expanded Cohort

OBJECTIVE

The aim of the study is to determine the associations of workers' compensation claim costs and return to work with drugs prescribed for early symptom management.

METHODS

Claims filed from 1998 to 2007 were followed for 10 years from the injury date. Drugs analyzed included gabapentin, pregabalin, antipsychotics, antidepressants, sedatives, benzodiazepines, carisoprodol, and opioids, controlling for initial reserve, sex, age, physical therapy, attorney involvement, and surgery.

RESULTS

Gabapentin, antipsychotics, antidepressants, and sedatives used in the first 3 months after injury were significantly associated with higher claim cost (≥$100,000). All opioid morphine equivalent doses greater than or equal to 5 mg/d for the first 6 months was significantly associated with higher cost (≥$100,000) and not being released to work at end of third year after injury with dose-response relationships.

CONCLUSIONS

Prescription patterns in the first 3 months or first 6 months of workers' compensation claim development may be used as predictors of claim outcomes.

Opioid prescriptions for individuals receiving workers' compensation in Michigan

PURPOSE

We evaluated the prevalence of opioid prescriptions after injury and associated characteristics among workers receiving workers' compensation for a lost work time injury.

METHODS

Injured workers identified in Michigan's Workers' Compensation records from 2016 to 2018 were linked to the opioid prescription history in the Michigan Automated Prescription System.

RESULTS

Among the 46,934 injured workers with paid claims, the prevalence of receiving an opioid prescription, morphine milligram equivalents (MME) per prescription, number of opioid prescription and probability of receiving opioids prescription>90 days after injury decreased from 2016-2018. Despite the decrease over 50% of the injured workers received an opioid prescription. Being over 34 years, a male, having had an opioid prescription before the injury, working in construction or having an amputation or sprain/strain of the shoulder had a significantly higher probability of receiving an opioid prescription, a higher MME per prescription, a higher number of opioid prescriptions and a higher probability having opioids prescription >90 days after the injury.

CONCLUSIONS

Even though opioid prescribing patterns generally decreased from 2016 to 2018 (64.5-52.8%), injured workers in Michigan had a higher prevalence of opioid prescription after injury, than those reported from other states.

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.

Workers' compensation prescription medication patterns and associated outcomes

BACKGROUND

Opioid use in the treatment of musculoskeletal injuries is a complex decision where benefits must be balanced with risk. Previous research has shown an association between higher opioid doses and adverse health effects. The study's objective was to investigate whether opioid prescriptions are associated with increased costs and deaths through an injury mechanism or as a direct result of the opioid prescription.

METHODS

Data for 144,553 deidentified Ohio Bureau of Workers' Compensation claims from 2010 to 2014 with shoulder, knee, and low back injuries were obtained and followed until 2016. Each claim had associated prescription information. Injury claims were further classified using the allowed diagnoses by single or multiple body areas affected and injury severity ("simple" or "complex"). The outcome variables were medical and indemnity costs, lost days, MaxMED (maximum claim-prescribed daily morphine equivalent dose), and death status. Association between maximum opioid dose with deaths was determined by logistic regression analysis.

RESULTS

Several outcome variables, including claim medical and indemnity costs, and the likelihood of claimant death, showed significant associations with the MaxMED. In the analysis of claim deaths, these associations held for all claim types (except complex), even after adjusting for age, gender, surgery, and lost time.

CONCLUSION

The association between increasing opioid doses and deaths for low-severity diagnoses was disturbing given the lack of demonstrated efficacy of opioids for treatment of minor injuries. A focus on provider education, increased utilization of non-opioids, and early intervention for minor soft-tissue injuries could reduce claims costs, disability, and future deaths.

Prescription opioid use by injured workers in Tennessee: a descriptive study using linked statewide databases

PURPOSE

This is the first study in Tennessee to measure opioid use in injured workers and among the first nationally to use a prescription drug monitoring program to do so. We conducted a retrospective cohort study to evaluate the prevalence of opioid use after injury and associated characteristics among workers reporting one injury to Tennessee Workers' Compensation.

METHODS

Injured workers identified in Workers' Compensation records 2013-2015 were linked to their prescription history in Tennessee's prescription drug monitoring database.

RESULTS

Among 172,256 injured workers, the prevalence of receiving an opioid after injury was 22.8% in 1 week, 29.7% in 1 month, and 33.3% in 6 months. Receiving an opioid was associated with having a fracture (odds ratio, 4.9; 95% confidence interval, 4.64-5.11 vs. other injuries). Hydrocodone short-acting was the most commonly received opioid (69.5% of injured workers), and the mean of each worker's maximum dose was 42.8 morphine milligram equivalents (SD 39.26). Ten percent of injured workers who received opioids also received a benzodiazepine.

CONCLUSIONS

Injured workers have a high prevalence of opioid use after injury, but prescribing patterns generally tend to follow Tennessee prescribing guidelines.

Characterizing the Interrelationships of Prescription Opioid and Benzodiazepine Drugs With Worker Health and Workplace Hazards

OBJECTIVE

Prescription opioid and benzodiazepine drug use, which has risen significantly, can affect worker health. Exploration of the scientific literature assessed (1) interrelationships of such drug use, occupational risk factors, and illness and injury, and (2) occupational and personal risk factor combinations that can affect their use.

METHODS

The scientific literature from 2000 to 2015 was searched to determine any interrelationships.

RESULTS

Evidence for eight conceptual models emerged based on the search yield of 133 articles. These models summarize interrelationships among prescription opioid and benzodiazepine use with occupational injury and illness. Factors associated with the use of these drugs included fatigue, impaired cognition, falls, motor vehicle crashes, and the use of multiple providers.

CONCLUSION

Prescription opioid and benzodiazepine drugs may be both a personal risk factor for work-related injury and a consequence of workplace exposures.

Narcotic Consumption Following Anterior and Lateral Lumbar Interbody Fusion Procedures

STUDY DESIGN/SETTING

This is a retrospective analysis of a prospectively maintained surgical registry.

OBJECTIVE

To characterize postoperative narcotic consumption in patients undergoing either an anterior lumbar interbody fusion (ALIF) or a lateral lumbar interbody fusion (LLIF).

BACKGROUND CONTEXT

There is substantial interest in evaluating the safety, efficacy, and outcomes following minimally invasive techniques for lumbar fusion procedures. However, few studies have characterized postoperative narcotic consumption in patients undergoing ALIF or LLIF procedures.

METHODS

Consecutive patients who underwent either an ALIF or LLIF during 2007-2014 were identified. Inpatient narcotic consumption was recorded in oral morphine equivalents and dichotomized as greater or less than the 75th percentile total consumption (elevated or normal inpatient consumption). Demographic, comorbidity, and perioperative characteristics were tested for independent association with inpatient narcotic consumption and with continued narcotic usage during the months following surgery.

RESULTS

A total of 169 patients met inclusion criteria. Of these, 118 (69.8%) underwent ALIF and 51 (30.2%) underwent LLIF procedures. The risk for elevated inpatient narcotic consumption was greater in patients whose body mass index was≥30 kg/m [relative risk (RR), 2.8; 95% confidence interval (CI), 1.6-4.8; P<0.001). The risk for continued narcotic usage at the first postoperative visit was elevated in patients with worker's compensation payment status (RR, 2.0; 95% CI, 1.5-2.7; P<0.001). The risk for continued narcotic usage at the second postoperative visit was elevated in patients with worker's compensation payment status (RR, 2.6; 95% CI, 1.7-4.1; P<0.001) and in patients with preoperative narcotic utilization (RR, 2.2; 95% CI, 1.4-3.5; P<0.001).

CONCLUSIONS

The present study suggests that while patients with greater body mass index have increased narcotic consumption as inpatients, preoperative narcotic consumption and worker's compensation payment status are the best predictors of continued narcotics usage during the months following surgery. Worker's compensation patients and patients who utilize narcotics preoperatively should be the targets of efforts to reduce continued postoperative narcotic usage.

A Seven-Year Longitudinal Claim Analysis to Assess the Factors Contributing to the Increased Severity of Work-Related Injuries

BACKGROUND

In recent decades, the frequency of Medical Only (MO) and Lost Time (LT) workers' compensation claims has decreased, while average severity (medical and indemnity costs) has increased.

OBJECTIVE

The aim of this study was to compare claim frequency, mix, and severity (cost) over two periods using a claim cohort follow-up method.

METHODS

Sixty-two thousand five hundred thirty-three claims during two periods (1999 to 2002 and 2003 to 2006) were followed seven years postinjury. Descriptive analysis and significant testing methods were used to compare claim frequency and costs.

RESULTS

The number of claims per $1 M of premium decreased 50.4% for MO claims and 35.6% for LT claims, consequently increasing the LT claim proportion. The average cost of LT claims did not increase.

CONCLUSION

The severity increase is attributable to the proportional change in LT and MO claims. While the number of LT claims decreased, the inflation-adjusted average cost of LT claims did not increase.

Trends in the Concomitant Prescribing of Opioids and Benzodiazepines, 2002-2014

INTRODUCTION

Although many clinical guidelines caution against the combined use of opioids and benzodiazepines, overdose deaths and emergency department visits involving the co-ingestion of these drugs are increasing.

METHODS

In this ecologic time series study, the IMS Health Total Patient Tracker was used to describe nationally projected trends of patients receiving opioids and benzodiazepines in the U.S. outpatient retail setting between January 2002 and December 2014. The IMS Health Data Extract Tool was used to examine trends in the concomitant prescribing of these two medication classes among 177 million individuals receiving opioids during this period. The annual proportion of opioid recipients who were prescribed benzodiazepines concomitantly was calculated and stratified by gender, age, duration of opioid use, immediate-release versus extended-release/long-acting opioids, and benzodiazepine molecule. The proportion of patients with concomitancy receiving opioids and benzodiazepines from the same prescriber was also analyzed. Analyses were conducted from April to June 2015.

RESULTS

The nationally projected number of patients receiving opioids and benzodiazepines increased by 8% and 31%, respectively, from 2002 to 2014. During this period, the annual proportion of opioid recipients dispensed a benzodiazepine concomitantly increased from 6.8% to 9.6%, which corresponded to a relative increase of 41%. Approximately half of these patients received both prescriptions from the same prescriber on the same day. Concomitancy was more common in patients receiving opioids for ≥90 days, women, and the elderly.

CONCLUSIONS

Concomitant prescribing of opioids and benzodiazepines is increasing and may play a growing role in adverse patient outcomes related to these medications.

Postoperative Narcotic Consumption in Workman's Compensation Patients Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort analysis of a prospective registry.

OBJECTIVE

To assess the differences in perioperative narcotic consumption between Workman's compensation (WC) and non-Workman's compensation (non-WC) patients after a single-level minimally invasive transforaminal lumbar interbody fusion.

SUMMARY OF BACKGROUND DATA

There is concern regarding the potential overutilization of opioid pain medication in WC patients. However, the impact of WC status on perioperative narcotic consumption after lumbar spine procedures has not been previously reported.

METHODS

A cohort of patients who underwent primary 1-level minimally invasive transforaminal lumbar interbody fusion procedures for degenerative spinal pathology between 2007 and 2013 was retrospectively analyzed using a prospectively collected registry. First, preoperative and perioperative characteristics were compared between WC and non-WC patients. Second, mean oral morphine equivalent was compared between WC and non-WC patients with adjustment for any preoperative or perioperative differences between cohorts.

RESULTS

A total of 136 single-level, primary minimally invasive-transforaminal lumbar interbody fusion procedures were included in the analysis, of which 46 (33.8%) were WC patients. WC patients were younger (47.8 ± 11.2 vs. 57.9 ± 10.4 yr; P < 0.001) and had a lower comorbidity burden (Charlson Comorbidity Index: 1.85 ± 1.30 vs. 3.42 ± 2.07; P < 0.001) than non-WC patients. The distribution of ethnicity differed between WC and non-WC patients (P = 0.002). WC patients incurred longer procedural times (135.2 ± 52.2 vs. 118.9 ± 33.7 min; P < 0.05). However, the estimated blood loss, length of hospital stay, and day of discharge were no different between WC and non-WC patients. Mean oral morphine equivalent consumption did not differ between WC and non-WC patients after adjustment for differences in age, ethnicity, Charlson Comorbidity Index, and procedural time between cohorts.

CONCLUSION

Despite concerns for greater opioid use in the WC population, this analysis demonstrated similar total narcotic consumption between WC and non-WC patients during the immediate postoperative period. Long-term studies are warranted to assess whether this similarity in regard to perioperative narcotic consumption persists beyond the immediate postoperative period.

LEVEL OF EVIDENCE

3.