A Healthesystems publication

Fall 2014

Getting Unhooked: Opioid Detoxification Is a Necessary Evil in Workers’ Compensation

The prevalence of opioid prescribing among injured workers opens the door for misuse and abuse of these narcotic analgesics. While prevention is the foremost goal, successful detoxification employing both pharmacologic and psychosocial strategies offers hope to dependent or addicted patients.

Opioids are a dual-edged sword. While they can be used to manage acute pain associated with surgical procedures, medical conditions or severe injury, medical evidence does not support long-term use.1 Chronic use of opioids is often associated with extended disability, poor outcomes, and higher medical costs2,3,4,5 — and yet these powerful pain killers continue to be prescribed. Opioids also offer a significant chance — as high as 30 percent according to some studies — that patients will misuse them.6

Opioids are often prescribed to treat pain associated with workplace injuries, and there is benefit (although limited) in shortterm use to treat acute pain. However, there is a lack of evidence to support their long-term use, and workers’ comp payers often see chronic use of opioids to treat injured workers. In fact, an estimated $1.4 billion is spent annually by workplace insurers on opioids.7 With the high potential for misuse or abuse of opioids — often leading to dependent or addicted patients — and the strong prevalence of these drugs used in workers’ compensation, detoxification sometimes becomes necessary.

Opioid detoxification, or detox, refers to the process in which a patient who is dependent on opioids is slowly withdrawn from the effects of the drug. The process often involves the administration of medication to relieve some withdrawal symptoms given at a certain dose, and then tapered off. It can also involve psychosocial strategies applied in concert with medication.

The path to detox can be avoided altogether by identifying opportunities for early intervention. Patients who develop a tolerance to opioid therapy may be considered at risk for dose escalation, which can then potentially lead to physical dependence or addiction — resulting in the need for detox. Payers, physicians, and PBMs need to be vigilant about looking for early warning signs such as dose increases, irregular refill patterns (for example, the patient refills their opioid prescription on time, but refills their neuropathic agent late or not at all), switching physicians or pharmacies, lost prescriptions, and other behaviors.

IDENTIFICATION AND TREATMENT OF ABERRANT DRUG BEHAVIOR

OPIOID TOLERANCE

Patients who use opioids for extended periods of time may develop physical tolerance to the effects of the drug, requiring a higher dose to maintain the same level of pain relief.8 Once a patient has become tolerant to an opioid, discontinuing the drug may result in withdrawal symptoms. These symptoms vary in intensity depending on several factors and can include: insomnia, anxiety, abdominal pains, sweating, shivering, and craving.9 While unpleasant, opioid withdrawal is not life-threatening. Opioid tolerance is different than dependence and/or addiction. Dependence does not necessarily indicate addiction, however, opioids do have a high potential for addiction.10

OPIOID DEPENDENCE

A patient may become dependent on opioids with chronic use. Dependence refers to a state in which a patient functions normally only in the presence of a drug and when the drug is discontinued, withdrawal symptoms occur.11 Dependence occurs as patients continue taking opioids in an effort to combat the withdrawal symptoms.

OPIOID ADDICTION

Addiction is a chronic and neurobiological disease in which patients sustain long-lasting changes in the brain. Addicted patients use opioids daily to avoid withdrawal symptoms and exhibit compulsive drug-seeking behavior, despite harmful consequences.12, 13

In order to safely remove a dependent or addicted patient from opioid use, detoxification can be employed. For patients who are addicted to opioids, detox may be the first stage of a multi-pronged approach to addiction treatment.

Methadone: Buprenorphine:
Methodose and Dolophine® Suboxone® and Subutex®
Opioid agonist Partial agonist
Interacts with other respiratory depressants Interacts with other respiratory depressants
Detox length: Rapid regimens may last seven to 21 days.
Slow tapering can last up to six months or longer.
Detox length: May be completed within one week through 14 days, or up to several weeks in some cases.
Lower cost than buprenorphine Higher cost than methadone

DETOX 

Detoxification can safely manage the acute withdrawal symptoms of addiction and can increase the chance for long-term addiction treatment success.14 Treatment does not end with detox. In fact, detox itself can include many facets including pharmacological, adjunctive psychosocial, and relapse prevention. In addition, many factors influence the success of a multi-faceted detox program, including the therapeutic alliance between a physician and patient and the establishment of a strong social support network.15

PHARMACOLOGIC DETOX

The Food and Drug Administration (FDA) has approved the use of pharmacotherapy to treat opioid dependence.16 This involves the use of opioid agonists and partial agonists such as methadone or buprenorphine. Determining which medication to use depends on a number of factors such as: severity of dependence; current medication use (including illicit drug or alcohol use); comorbid conditions; and other patient-specific concerns. Methadone, an opioid agonist, produces minimal tolerance and alleviates cravings; it tends to be a better medication to treat patients who are dependent on high doses of opioids.17 Buprenorphine, a partial opioid agonist, activates receptors in the brain to a lesser degree than a full agonist. It also partially works as an antagonist, allowing for a slight opioid effect, which suppresses withdrawal symptoms and cravings. Both of these drugs carry potential for drug-drug interactions, so coordination of patient care is important. Guidelines suggest that when additional medications are necessary, only the minimum effective dose is given.18 Methadone and buprenorphine are both Schedule II controlled substances and patients are typically monitored and guided through detoxification closely.

Duration of detoxification with opioid agonists depends on a number of factors and the medication used; it can take several days to several months, or even years. It is also depends on whether detox occurs in an in-patient or out-patient setting. Patients being treated with methadone can typically remain on the drug therapy for several weeks to three years or longer.19 Using buprenorphine for detoxification is typically faster than methadone and can take days to several weeks.20 With both drugs, patient adherence is crucial in order to achieve success.

Workers’ compensation payers should look for early indicators of drug tolerance and dependence on opioids in order to avoid the hard costs of addiction, such as detoxification, which could involve years of pharmacologic therapy. In addition, early intervention helps payers avoid downstream medical costs that may arise from detox, including the costs to treat symptoms and comorbidities — such as liver damage and respiratory failure.

An integral component to successful detox is the therapeutic alliance between the physician and the patient. The relationship should be positive and supportive so that the prescriber can help motivate the patient to change behavior, as well as gain insight into the social or relationship problems that may be contributing to drug use. Physicians should help patients identify circumstances when they are susceptible to drug misuse and develop healthy coping strategies for the patient to use.21 Since adherence to pharmacologic therapy is crucial, a strong physician/patient alliance can help foster patient “motivation” to engage in therapy and avoid opioid misuse.

THE PATH TO SUCCESSFUL DETOX TREATMENT

ADJUNCT PSYCHOSOCIAL STRATEGIES

Pharmacologic treatment alone can lead to relapse22, so detox should be supplemented with psychosocial strategies in order to ensure the highest chances for overcoming opioid dependence or addiction. It is important for workers’ compensation payers and physicians to take a holistic and patient-centric approach to analyzing each patient and fully understanding all issues, concerns, and possible comorbidities. For example, a psychiatric comorbidity is common in patients who are addicted and if not understood and treated, this can present a barrier to successful detox treatment.23 The goal of psychosocial therapy is to:

Cognitive behavior therapy (CBT). The Fall 2013 issue of RxInformer refers to CBT as an alternative pain management strategy, and in the case of opioid addiction it attempts to change addictive behavior through changes in a patient’s beliefs that serve to support the addiction or by positive motivation to change behavior.25

The level of intensity in which physicians approach individual goals will vary by patient and the ability to modify patient behavior varies, as well.

Some of the more common adjunct psychosocial components added to pharmacologic therapy for the treatment of addiction include:

Cognitive behavior therapy (CBT). The Fall 2013 issue of RxInformer refers to CBT as an alternative pain management strategy, and in the case of opioid addiction it attempts to change addictive behavior through changes in a patient’s beliefs that serve to support the addiction or by positive motivation to change behavior.25

Drug counseling. Counseling aims to support the treatment plan and address psychological issues that may have contributed to or support opioid addiction. It often applies strategies such as patient drug diaries and motivation to encourage successful detox.

Interpersonal therapy. A type of psychological intervention, interpersonal therapy aims to help the patient identify and cope with interpersonal conflicts, grief, loss, and social issues in order to eliminate drug use.26

Social support network. There is anecdotal evidence to suggest that patients who positively engage in social support, such as a peer support group or a 12-step program, experience more success in the detox process.

Family support. Family support helps patients understand the effects that their addiction can have on their relationships. The goal of family support is to foster supportive interactions and reduce conflict.27

While detoxification is not the end goal for any workers’ compensation case, it is, unfortunately, a strategy that occasionally needs to be applied. The nature of workers’ compensation injuries often leads to the first prescription of Vicodin, OxyContin or rapid-release fentanyl products (e.g., Fentora, Subsys) — all opioid formulations with a strong potential for causing abuse or addiction. And in many cases that first prescription turns into refill after refill, most times at escalating doses. Physician education into the appropriate use of opioid therapy to treat short-term acute pain should be ongoing, so that these powerful and addictive drugs are not used incorrectly and prescribed chronically. In cases where drug dependence and addiction develop as a result of long-term use, detoxification remains the answer. The ultimate goal for the welfare of the injured worker and the benefit of the payer and employer is return to work, and successful detoxification employing both pharmacologic and psychosocial strategies can deliver this result.

A Tale of Two Chronic Opioid Users

Cindy K., 35 year old female,
physically dependent on opioids

Cindy K. is a 35-year-old factory employee with chronic neck pain due to the repetitive nature of her manufacturing job. Her physician prescribed hydrocodone to help control pain associated with her musculoskeletal disorder while she underwent physical therapy. Unfortunately, well after her six weeks of physical therapy had ended, Cindy was still being prescribed the opioid painkiller. She didn’t like the mental “fuzziness” that accompanied the use of the medication and tried to quit taking the hydrocodone on her own. She began to experience insomnia and anxiety, and spoke to her physician about these symptoms.

Cindy had become physically dependent on the opioids and was experiencing withdrawal symptoms. Her physician identified the issue and deployed a detoxification strategy in order to wean Cindy from her dependence on hydrocodone by using buprenorphine to taper her opioid dose. The physician developed a treatment plan for Cindy to address her musculoskeletal disorder and included physical therapy and anti-inflammatories.

Paul H., 42 year old male,
addicted to opioids

Paul H. is a 42-year-old postal employee suffering from lower back pain due to an injury he sustained in the workplace. His physician prescribed Percocet to relieve his pain and scheduled an MRI. Based on the results of the scan, his physician prescribed 12 weeks of physical therapy to address a lower-back muscle strain and renewed his prescription for Percocet. Six months later, Paul was still taking Percocet, but he began to notice that the dose was not managing his pain as well as it had been. He began to increase the number of pills he was taking, and eventually ran out of his prescription early. Paul claimed he had lost his pills while traveling and requested an early refill.

During his next office visit, Paul’s physician questioned the early refill request and Paul became agitated and defensive, stating he would find a new doctor who better understood his chronic pain. His physician identified warning signs that Paul may have become addicted to the opioid and recommended detoxification using methadone, CBT, and drug counseling.

 

ABOUT THE ADDICTED

Americans aged 50 to 69 years are the fastest growing population of opioid addicts.

The number of people aged 65 years and over who have at some point abused opioids increased by 34% from 2011 to 2012.

About 24 million Americans — 9.2% of the population — used an illicit drug in 2012, up from 8.1% in 2008.

45% of prescription drug abusers are high school graduates and 30% completed some college.

SOURCE: The Changing Face of Opioid Addiction. Medscape.

 

One Too Many - A personal perspective

By Deborah Conlon, PharmD, BS Pharm, CPh

As a clinical pharmacist, I am well-versed in the hazards of opioid therapy. There are countless statistics relating to adverse events, opioid overdoses and deaths. In fact, I have recited these figures many times when presenting to colleagues regarding the dangers and the hazards of opioid use. However, statistics are just numbers, until one of those numbers becomes the one that is too many. It became very personal the day one of those numbers belonged to me; when it wasn’t just a number, but my loved one. Suddenly, only that one statistic mattered, THE ONE that was one too many for me.

My loved one’s injury, like many of the patients we see, started with a lower back strain at work. After one too many times bending over and she sprained her back. This is where the slippery slope began.

Despite the warning signs and red flags that were present that indicated opioids would be hard for her to withdraw from, the opioid prescribing began. Despite conversations about finding alternatives, the doctors continued to prescribe and even increased the doses. Despite the fact that one prescriber started the medications and a new prescriber entered, they were continued. It became another case of “I didn’t start them, I inherited this patient.”

As the years passed, the doses increased and the side effects increased, but the pain remained and the opioids continued. She was in pain both mentally and physically and chased what she thought was the answer into the bottom of an opioid bottle. Once a vibrant, active, fun-loving woman, she had turned into a depressed, reclusive shell of her former self.

A wake-up call to the severity of the situation came when we received a call about a year ago to report she had been taken by ambulance to the hospital. She was admitted for respiratory failure related to her opioid use. This was when the physician first talked about the need to back down on the opioids because she was having side effects. She had been having multiple side effects for years, signs of hyperalgesia, worsening depression, respiratory difficulties, weight gain, lethargy, difficulty concentrating … but the opioids continued. After the hospitalization for respiratory failure, there was a decrease in dose; however, opioids were continued and eventually the dose surpassed the previous morphine equivalent dose following a joint replacement surgery just six months after her hospitalization.

Detoxification was requested during both hospitalizations, but in California the waiting list is long and difficult to get on, or so we were told. The opioid prescribing continued … we were told they would work on this once she was discharged from the hospital. She never entered a detoxification program.

I was sitting at my desk writing about patient safety concerns related to continued high dose opioid therapy for a back sprain when my phone rang. The call was from a police officer in my loved one’s California town. He stated he was sorry have to tell me this way but he was calling to tell me they had found my family member dead in her home. Her cause of death was ruled accidental opioid overdose. Was it accidental? We will never know. All I know is that she had been given a “loaded gun” of opioids for many years and whether she pulled the “trigger” or it was accidental remains unknown.

For me, the battle against reckless opioid prescribing has become very personal. I am no longer just reciting statistics of opioid deaths; I am living with the anger, pain, and grief involved with one of those statistics. To the local coroner, she is just one of the many faces of countless opioid deaths. For me, it was the face of MY loved one, THE ONE that was ONE TOO MANY.

 

 

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SOURCES

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