Alternative pain management treatments should be considered: Experts
News stories of late have been filled with alarming stories concerning opioid addiction and overdoses. Misuse of the prescription and non-prescription drugs has led to an epidemic in Canada and the United States.
That’s having an impact on employers. In looking at the prescription of opioids to treat acute musculoskeletal disorders (MSDs), a Canadian review of five studies has found a link to longer duration of time on disability.
“There’s certainly an indication that there’s a relationship between the two, that people who use opioids or higher doses of opioids tend to have prolonged work disability,” said Nancy Carnide, a post-doctoral fellow at the Institute for Work and Health (IWH) in Toronto, who led the review.
“But (it’s not clear) whether opioids are actually causing the work disability or whether it’s something else… We’re sort of saying there is no clear-cut causal relationship between opioids and workplace disability but, having said that, none of the studies have demonstrated that opioids prevent work disability or help in any way, and we know that there are significant risks of serious harm associated with opioids.”
“And RCTs (randomized control trials), in terms of pain and general function, really don’t demonstrate that opioids are effective, so clinicians should obviously continue to be cautious if they’re ever going to provide opioids.”
The results are not surprising, according to Aaron Thompson, medical director of occupational disease at the Workplace Safety and Insurance Board (WSIB).
“When somebody’s on opioids, because of the resulting impairment, it can become a principle barrier to return to work and we know a delayed return to work results in ever-increasing disability duration, and the extent to which use of opioids delays return to work, that’s going to worsen the prognosis for the worker and the outcomes are going to be worse.”
The IWH report is similar to previous research both from McMaster University and the WSIB, said Jason Busse co-director of the Michael G. DeGroote Centre for Medicinal Cannabis Research at McMaster University in Hamilton, which led a team that released guidelines in 2017 advising physicians to reduce their prescribing of opioid medication to patients with chronic non-cancer pain.
“This is observational study, so we can’t say it’s a causal association, but certainly it’s a very strong observation from the kind of data that we do have to work with, and suggests that compensation boards such as WSIB may want to look very seriously at trying to reduce the number of patients that are prescribed opioids for their acute lower back pain complaints, and make available other types of modalities and interventions,” he said.
When physicians are prescribing these analgesics, they need to also have plan for deprescribing, said Busse.
“It’s easy to write that script but you need to have a plan for how you’re going to help wean people off them as well. Because what we want to try to prevent in most cases is that initial acute prescription going on to become prolonged use.”
The IWH review raises questions that are important for all the different stakeholders, said Marc White, president and CEO of the Work Wellness and Disability Prevention Institute in Vancouver.
“It’s really important for clinicians to know the answer, but it’s also important for workers’ comp boards, human resources professionals who are responsible for absence management, labour representatives, workers and other stakeholders that are concerned about prolonged work absence.”
Why the epidemic?
Given their limited effectiveness, and definite risks, how did opioids come to be so popular?
For one, pharmaceutical companies have aggressively marketed the substance and promoted it as being less addictive than morphine. At the same time, there was a push to manage pain more effectively, said Carnide.
“It was just a culmination of this desire to manage pain and then we’re hearing from pharmaceutical companies: ‘Hey, we have this great product that will be effective and won’t cause harm’... unfortunately, that led to what we have now.”
North America uses 80 per cent of all opioids produced in the world, said Andrea Furlan, physician and scientist at the IWH.
“We know that opioids are the strongest painkillers that exist. They’re highly effective, anyone who has acute pain and needs some painkillers knows that you take the pill and the pain is probably 100 per cent relieved,” she said. “They are powerful, they are very effective, they’re quick, they’re cheap.”
But several years ago, there was a push to help people who suffer from chronic pain, which affects one in five adults, and one in three older adults. And lower back pain is the number one cause of work disability, followed by neck pain, said Furlan.
“People started to think: ‘Well, we have these powerful drugs and we know they work, why don’t we give them for chronic pain?’ and that’s when the disaster started… the problem is people have chronic pain, so they will (have) chronic pain forever. So if you start someone with chronic pain on an opioid prescription, you are giving this for the rest of their life, and then the body develops a tolerance, and to get the same effect, you need to increase the dose; and the higher the dose, the more effect on the brain and the body. And we know nine to 10 per cent of people who are exposed to drugs every day will develop an addiction,” she said.
“The crisis we have is well-intentioned doctors wanting to help those patients to overcome their disability chose the easy route and, of course, the pharma industry was fuelling this by telling doctors the addiction was less than one per cent.”
The medical system is primarily geared to pharmacological solutions, said White.
“We’ve created a medical system that tends to rely a lot on pharmacological activity, and then we have drug companies that promise the world… there is good research that opioid use can be useful for some people in early stages of pain, like most surgical pain, that type of thing, but there’s also issues of opioids substance abuse and impact on work outcomes.”
The odds of an employee’s return to full employment drop to 50-50 after six months of absence, according to 2006 guidelines from the American College of Occupational and Environmental Medicine: “Even less encouraging is the finding that the odds of a worker ever returning to work drop 50 per cent by just the 12th week. The current practice of focusing disability management effort on those who are already out of work rarely succeeds.”
In all of the discussions around opioid use and working populations, it’s important to remember the alternatives, said Carnide.
“(Pain) has to be managed properly,” she said. “A lot of workers’ comp organizations are introducing policies to reduce opioids — which I certainly understand the impetus behind — but there needs to be consideration for what else can workers be offered to ensure their pain is managed properly.”
This means making sure there’s appropriate access to treatments such as physiotherapy and chiropractic, said Carnide.
“Some workers find that there are barriers to accessing those alternative measures or there’s delays in accessing them, and really when we think about it… insurance tends to pay most of your prescription medicine, but you tend to have quite a limit on visits to a physio, chiro, to a massage therapist, and so often people then say, ‘Well, I have no choice, I have to choose some sort of medication.’”
There’s good research that cognitive behavioural therapy or physiological intervention can be as effective or more effective for certain people, said White, “and improving coping skills are things that can be learned.”
“The biggest culprit is this over-reliance on pharmaceutical solutions and, in that way, there are opportunities for companies and HR to ensure that you have a good employee assistance program, and that those services are utilized,” he said.
Medical marijuana also holds some potential, said Busse.
“There is interest right now in terms of further exploring the potential role of medicinal cannabis for treatment of chronic pain, and there’s at least some limited evidence to suggest co-prescription of medicinal cannabis may allow some patients to reduce the amount of opioids they’re taking.”
Anti-inflammatories such as acetaminophen are also possible alternatives, along with spinal manipulative therapy, and some physical therapy modalities, he said. Followup by physicians is also important, along with prescribing for shorter periods of time to better track patients.
Mindful prescribing has also become more popular, with greater alignment to guidelines, along with more information provided by pharmacies, said June Duesberry-Porter, director and chief nursing officer at the WSIB.
“There’s an increased awareness all around that way, so what we have also seen is an enhanced clinical rationale for the prescription of opioids with workers.”
There’s also been a campaign to stimulate conversations between physicians and their patients around what is appropriate care, and judicious use of health care, said Thompson.
“It limits risk by cutting down on unnecessary diagnostics and unnecessary treatments, and focusing the care.”
There’s growing appreciation for thinking about the non-pharmacologic modalities for pain management, and the psychological approach for that pain, he said.
“Some of the best pain management practitioners say that basically the old system — where you try and treat the pain medically first and then when that fails, start thinking about the psychological aspects of pain — that traditional way of thinking needs to be reversed, where the two need to be combined to adequately address the pain early in the course to optimize outcomes.”