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October 9, 2006

The Pain Conundrum

Workers comp is about workplace injuries and injuries almost always involve pain. So it's no surprise to see painkillers at the top of the leader board for medicines prescribed in the comp system. The Hartford has published the latest rankings, which is still dominated by powerful and exotic drugs. Oxycontin is still number one, for reasons that defy logic but give rise to serious partying among the talented sales team at Purdue Pharma. (This particular drug comes with plenty of warnings.) The Cox-2 inhibitors (Vioxx and Bextra) have disappeared (for obvious reasons). Here's the entire top seven:
1 Oxycontin
2 Gabapentin (generic neurontin, an anti-seizure med useful in reptitive motion pain)
3 Hydrocodone (generic Oxycontin)
4 Lidoderm (for burns)
5 Celebrex (usually for arthritis pain)
6 Actiq (see below)
7 Oxycodone (another generic version of Oxycontin)

Our colleague Joe Paduda blogged this important issue back on September 27. He questions whether doctors are managing pain or just passing out pills. He is particularly interested in a newcomer to the top 7, Actiq, a powerful new pain reliever developed specifically for cancer patients with severe pain that breaks through their regular narcotic therapy. (As I recall, Oxycontin also began as a drug for terminal cancer patients.) Actiq is an opioid narcotic more powerful than morphine. The medicine comes in the form of a flavored sugar lozenge that dissolves in the mouth while held by an attached handle. Gee, it not only kills the pain, it tastes like candy. Yum! This new favorite comes with a hefty price tag ($1,200 a month), but that's hardly a problem in the comp system, as injured workers are not troubled with a co-pay.

The FDA has some warnings that accompany this latest designer drug. Actiq may be fatal to children. Because Actiq is designed to be dissolved slowly in the mouth, it's not hard to imagine kids trying it out. FDA approved Actiq under special regulations that restrict distribution as defined in a comprehensive risk management plan. Pardon my cynicism, but I wonder just how many injured workers are provided with detailed risk management plans when they receive a script for this drug.

Living with Pain
It's beyond the scope of this blog to tackle the issue of pain medications and why doctors prescribe one drug over another. But the big picture is pretty clear. Doctors treating workplace injuries routinely write scripts for the most powerful drugs available. They appear to move rather quickly toward drugs that were originally designed for the chronic, intense and long-term pain of a terminal illness. Most workplace injuries resolve themselves relatively quickly, so while the initial pain may well be acute, it usually does not - and should not - become chronic. When pain does become chronic in the workers comp system, it is almost always an indication that the employee has not returned to work.

All of this leads us to speculate on the relationship of pain to time: if all the key players (employer, doctor, insurer) focus relentlessly on returning injured employees to work, if we give these employees the opportunity to work through the pain while continuing to function in the workplace, we would probably see a greater reliance on pain drugs at the lower end of the spectrum. In other words, a comp system functioning at optimal levels would have a radically different list of top seven drugs. Needless to say, despite a leveling off of pharma costs, the workers comp system from state to state is not functioning anywhere near these optimal levels.

Posted by Jon Coppelman at 4:14 PM Link to, Comment (1), or E-mail this post

That is very well said; "a comp system functioning at optimal levels would have a radically different list of top seven drugs." That is a very helpful way to look at comp systems; they exist to address a specific problem and so should be looked at in terms of how well they are functioning and how well they are addressing the problem they were created to address - medical treatment and wage replacement for injuries sustained in the course of employment.
If the most powerful chronic pain medications are being over-prescribed in the treatment of work injuries we have to ask two questions: why? and to what effect? A third question I think is relevent here is, if these medications are over-prescribed and actually do damage or cause addition, who is liable? The individual? The doctor? The employer/carrier?
I believe that the doctor should be liable, because carriers generally don't have the legal authority to dictate treatment, especially when attorneys are involved, but they could invest time/money in trying to counter the phenomenon, even through lobbying efforts. Were carriers to do this they would probably be villified in the media for trying to deny treatment that can ease the suffering of truly injured workers, but as you have suggested the cost of not waging that fight might be greater. The question is, who bears the cost? As it is, it is predominantly the injured workers, but carriers do share the financial costs of those consequences as well, through the actual price of these medications, as well as the increased claim costs when an injured worker becomes dependent or generally does not quickly return to work. Those are the cases that become heavily litigated because the attorneys see how poorly off their client is and try to take every penny they can get from the carrier.

Far too often the goal of a work comp claim shifts from a speedy return to work and regular life to that of maximizing the value of the claim. The problem is, those goals are really in fundamental opposition to eachother.

That, I submit, is the true 'problem' with work comp systems.

Posted by: adam at October 10, 2006 2:51 PM
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