RELATED INJURIES BY JAY AUGSBURGER, M.D. INJURIES BY JAY AUGSBURGER, M.D. ... In 2007, the state...
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OBJECTIVE MEDICAL ASSESSMENTS CORPORATION 800.331.6622 | omacime.com NOVEMBER 2016 OPIOID USE DISORDERS IN WORK RELATED INJURIES BY JAY AUGSBURGER, M.D. However, recommendations have shifted away from opioids to manage chronic pain, based on concerns that there is limited evidence that opioids are effective in treating chronic pain and restoring function, and that there are significant risks of opioid addiction and overdose. In 2014, the Agency for Healthcare Research and Quality completed a review of effectiveness and risks of chronic opioid therapy and concluded that “evidence on long-term opioid therapy for chronic pain is very limited, but suggests an increased risk of serious harm that appears to be dose-dependent.” 2 Safety concerns regarding opioids have been felt most acutely in Washington State, with one study identifying 96 poisonings and 312 opioid-related adverse effects for patients in the workers’ compensation system from 2004-2010. 3 Notably, two-thirds of the poisonings occurred over one year after the original injury. In 2007, the state developed guidelines for prescribing opioids for pain, most recently updated in 2015. 4 The guidelines recommend focusing on non-opioid therapies (including behavioral intervention, physical activity and non-opioid analgesics), screening for comorbid mental health conditions and risk for opioid misuse, only continuing to prescribe opioids if there is “clinically meaningful improvement in function and pain,” and not to exceed 120 mg/ day morphine equivalent doses without pain management consultation. These guidelines have likely contributed to a decrease in the overall prevalence of opioid use and chronic opioid therapy. 5 Opioid addiction is a major concern for patients taking opioids chronically. Defining opioid addiction in this population can be challenging, but a consensus statement from the American Academy of Pain Medicine and American Society of Addiction Medicine listed the main criteria as “impaired control over drug use, compulsive use, continued use despite harm, and craving.” 6 Opioid use disorders are relatively common for patients taking opioids to manage chronic pain, with estimates ranging from 20-26%. 7 Factors increasing a patient’s risk for developing an opioid use disorder include a family history of opioid or other substance use disorders, personal history of substance abuse, age less than 30, and history of depression, bipolar disorder, or other mental health conditions. 8 The Opioid Risk Tool is a freely- available measure that incorporates these risk factors and can be useful to stratify the risk for a patient who might be prescribed opioids. 9 Atluri and Sudarshan identified six criteria placing a patient at risk for inappropriate prescription opioid use: focus on opioids, opioid overuse, other drug use, low functional status, unclear etiology of pain, and exaggeration of pain. 10 The Washington State guidelines provides a list of aberrant behaviors that should prompt further assessment for an opioid use disorder. 11 This list includes several concerns that at times are better explained by uncontrolled pain or depression, such as frequent requests for early refills, claiming lost or stolen prescriptions, and using opioids more frequently or at higher doses than prescribed, as well as several which are highly concerning for addiction, such as buying opioids on the street, stealing or selling drugs, or forging prescriptions. However, clearly not every patient with chronic pain who takes opioids has an opioid use disorder. A common assumption that clinicians make is that a patient who increases his or her dose of opioids over time and continues to complain of uncontrolled pain has opioid addiction. Likewise, clinicians often believe that if a patient is unwilling to cut back or stop taking opioids, either due to worries about worsening pain control or about withdrawal symptoms, that he or she may have opioid Jay Augsburger, M.D. completed his undergraduate studies at Yale University in New Haven, Connecticut and his medical degree at University of Cincinnati College of Medicine, Cincinnati, Ohio. His residency was completed at Oregon Health & Science University, Portland, Oregon. Dr. Augsburger obtained an Addiction Psychiatry Fellowship at the University of Washington, Seattle, Washington. He is certified by the American Board of Psychiatry and Neurology in both Psychiatry and Addiction Psychiatry and maintains a full time practice. He is a Washington State Department of Labor and Industries approved provider. Dr. Augsburger will be available in our Seattle Northgate location on November 2, 12, 16 and 30. ABOUT THE AUTHOR Continued on back page..... Chronic pain is common for patients who have suffered work-related injuries. The management of chronic pain is challenging and complex, and many patients who suffer from chronic pain are prescribed opioids. The rates of opioid prescriptions for chronic non-cancer pain increased significantly in the 1990s and 2000s, to the point that in a sample of Washington workers who had suffered an acute back injury, 42% received opioids in the year following their injury, and 6% received ongoing treatment with opioids. 1
Transcript of RELATED INJURIES BY JAY AUGSBURGER, M.D. INJURIES BY JAY AUGSBURGER, M.D. ... In 2007, the state...
OBJECTIVE MEDICAL ASSESSMENTS CORPORATION800.331.6622 | omacime.com
N OV E M B E R 2 016
OPIOID USE DISORDERS IN WORK RELATED INJURIES BY JAY AUGSBURGER, M.D.
However, recommendations have shifted away from opioids to manage chronic pain, based on concerns that there is limited evidence that opioids are effective in treating chronic pain and restoring function, and that there are significant risks of opioid addiction and overdose. In 2014, the Agency for Healthcare Research and Quality completed a review of effectiveness and risks of chronic opioid therapy and concluded that “evidence on long-term opioid therapy for chronic pain is very limited, but suggests an increased risk of serious harm that appears to be dose-dependent.”2 Safety concerns regarding opioids have been felt most acutely in Washington State, with one study identifying 96 poisonings and 312 opioid-related adverse effects for patients in the workers’ compensation system from 2004-2010.3 Notably, two-thirds of the poisonings occurred over one year after the original injury.
In 2007, the state developed guidelines for prescribing opioids for pain, most recently updated in 2015.4 The guidelines recommend focusing on non-opioid therapies (including behavioral intervention, physical activity and non-opioid analgesics), screening for comorbid mental health conditions and risk for opioid misuse, only continuing to prescribe opioids if there is “clinically meaningful improvement in function and pain,” and not to exceed 120 mg/day morphine equivalent doses without pain management consultation. These guidelines have likely contributed to a decrease in the overall prevalence of opioid use and chronic opioid therapy.5
Opioid addiction is a major concern for patients taking opioids chronically. Defining opioid addiction in this population can be challenging, but a consensus statement from the American Academy of Pain Medicine and American Society of Addiction Medicine listed the main criteria as “impaired control over drug use,
compulsive use, continued use despite harm, and craving.”6 Opioid use disorders are relatively common for patients taking opioids to manage chronic pain, with estimates ranging from 20-26%.7 Factors increasing a patient’s risk for developing an opioid use disorder include a family history of opioid or other substance use disorders, personal history of substance abuse, age less than 30, and history of depression, bipolar disorder, or other mental health conditions.8 The Opioid Risk Tool is a freely-available measure that incorporates these risk factors and can be useful to stratify the risk for a patient who might be prescribed opioids.9 Atluri and Sudarshan identified six criteria placing a patient at risk for inappropriate prescription opioid use: focus on opioids, opioid overuse, other drug use, low functional status, unclear etiology of pain, and exaggeration of pain.10
The Washington State guidelines provides a list of aberrant behaviors that should prompt further assessment for an opioid use disorder.11 This list includes several concerns that at times are better explained by uncontrolled pain or depression, such as frequent requests for early refills, claiming lost or stolen prescriptions, and using opioids more frequently or at higher doses than prescribed, as well as several which are highly concerning for addiction, such as buying opioids on the street, stealing or selling drugs, or forging prescriptions.
However, clearly not every patient with chronic pain who takes opioids has an opioid use disorder. A common assumption that clinicians make is that a patient who increases his or her dose of opioids over time and continues to complain of uncontrolled pain has opioid addiction. Likewise, clinicians often believe that if a patient is unwilling to cut back or stop taking opioids, either due to worries about worsening pain control or about withdrawal symptoms, that he or she may have opioid
Jay Augsburger, M.D. completed his undergraduate studies at Yale University in New Haven, Connecticut and his medical degree at University of Cincinnati College of Medicine, Cincinnati, Ohio. His residency was completed at Oregon Health & Science University, Portland, Oregon. Dr. Augsburger obtained an Addiction Psychiatry Fellowship at the University of Washington, Seattle, Washington. He is certified by the American Board of Psychiatry and Neurology in both Psychiatry and Addiction Psychiatry and maintains a full time practice. He is a Washington State Department of Labor and Industries approved provider.
Dr. Augsburger will be available in our Seattle Northgate location on November 2, 12, 16 and 30.
ABOUT THE AUTHOR
Continued on back page.....
Chronic pain is common for patients who have suffered work-related injuries. The management of chronic pain is challenging and complex, and many patients who suffer from chronic pain are prescribed opioids. The rates of opioid prescriptions for chronic non-cancer pain increased significantly in the 1990s and 2000s, to the point that in a sample of Washington workers who had suffered an acute back injury, 42% received opioids in the year following their injury, and 6% received ongoing treatment with opioids.1
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addiction. It is important to recognize that tolerance and physical dependence on opioids are often distinct from an opioid use disorder; the most recent DSM-5 criteria for opioid use disorders clearly state that tolerance and withdrawal criteria are not met by patients who are taking opioids under appropriate medical supervision.12
Another concern often brought up by clinicians is that a patient’s chronic opioid use is limiting his or her successful engagement in treatment that might hasten his or her return to work; for example, keeping the patient from entering a functional rehabilitation program. Indeed, there is evidence that a prescription for more than 7 days worth of opioids within the first six weeks after a workplace injury is associated with work disability at one year, though it is important to recognize that opioid use disorder was not assessed within this population.13 A patient who has an opioid use disorder (or any substance use disorder) may require addiction treatment before he or she is able to meaningfully engage in vocational rehabilitation.
As a psychiatrist with specialty training in substance use disorders, my role in evaluating a patient with chronic pain and chronic opioid use is to perform a comprehensive psychiatric evaluation, assessing for signs and symptoms of opioid addiction as well as other mental health concerns. Nearly 50% of patients with an opioid use disorder also meet criteria for a mood and/or anxiety disorder.14 A somatic symptom disorder, in which a patient has excessive thoughts, feelings or behaviors related to somatic symptoms, is also common. In many cases, it is difficult to causally link opioid use disorder directly back to an industrial injury, but much easier to directly link the onset of anxiety or depression to the injury. For patients taking chronic opioids, further psychiatric assessment can be a useful tool to provide diagnostic clarification as well as treatment recommendations.
OPIOID USE DISORDERS IN WORK RELATED INJURIES BY JAY AUGSBURGER, M.D.
Continued from front page....
1Franklin GM et al. Opioid use for chronic low back pain: A prospective, population-based study among injured workers in Washington State, 2002-2005. Clin J Pain 2009;25:743-751.
2The effectiveness and risks of long-term opioid treatment of chronic pain. Agency for Healthcare Research and Quality, Evidence Report/Technology Assessment #218, 2014
3Fulton-Kelhoe D, et al. Opioid poisonings and opioid adverse effects in workers in Washington State. American Journal of Industrial Medicine. 2013, 56:1452-1462.
4Interagency guideline on prescribing opioids for pain. Agency Medical Director’s Group, 3rd edition, 2015.
5Garg et al. Changes in opioid prescribing for Washington workers’ compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010. The Journal of Pain, 2013, 12:1620-1628.
6Definitions related to the use of opioids for the treatment of pain, American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine, 2001
7Sehgal N et al. Prescription opioid abuse in chronic pain: A review of opioid abuse predictos and strategies to curb opioid abuse. Pain Physician. 2012, 15:ES67-ES92.
8Turk DC et al. Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clin J Pain. 2008, 6:497-508.
9Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Medicine. 2006, 6:432-442.
10Atluri SL, Sudarshan G. Development of a screening tool to detect the risk of inappropriate prescription opioid use in patients with chronic pain. Pain Physician. 2004, 7(3):333-8.
11Interagency guideline on prescribing opioids for pain. Agency Medical Director’s Group, 3rd edition, 2015.
12Diagnostic and Statistical Manual, 5th edition. 2013, American Psychiatric Association.
13Franklin GM, et al. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine. 2008, 2:199-204.
14Gros DF, et al. Frequency and severity of comorbid mood and anxiety disorders in prescription opioid dependence. The American Journal of Addictions. 2013, 22:261-265.
