Every day there is a discussion in the news about the “opioid crisis” going on in the United States. What is an “opioid crisis” and why is this such a big deal right now? What impact does the “opioid crisis” have on the workers’ compensation system?
First, let’s identify the type of drugs we are talking about. Opioids are strong painkiller drugs that include both legal drugs like morphine, oxycodone, or hydrocodone prescribed by doctors for acute or chronic pain, as well as illegal drugs like heroin or illicitly made fentanyl. The way these drugs work is by binding to receptors in the brain to disrupt the pain signals sent from the body. Opioids also activate the reward center of the brain and signal an increase in dopamine production. This flood of dopamine creates a feeling of euphoria or a “high”. As a result, opioids are addicting, and those who become dependent on opioids may experience withdrawal symptoms when they stop taking the pills. Dependence usually indicates the user is developing an increasing tolerance of the drug’s effects, which means opioid users need to take increasingly larger doses of the medication to experience the same effect. Due to sedative effects on the part of the brain which regulates breathing, opioids in ever higher doses present the potential for respiratory failure and death.
In 1970, the United States had approximately 3000 deaths from opioids. This number had only climbed to about 5000 deaths by 1988. However, in 2016, opioids are cited as being responsible for over 42,000 deaths in the United States, about 115 per day. The International Narcotics Control Board reported that in 2015, Americans represented about 99.7% of the world's hydrocodone consumption. Drug overdose, mostly accidental, is now the number one killer of Americans under the age of 50 years. This rapid increase in the use of opioids and the related deaths has come to be known as the “opioid crisis”.
Why is this happening? Many experts propose the opioid epidemic is a result of the ever growing economic inequality in the United States. The theory is that the lack of higher paying jobs for the working middle class leads to increased drug (and alcohol abuse) to cope with the stress of not being able to support one’s self and/or family. The increased number of opioid related deaths in such economically depressed areas as Appalachia and the Rust Belt from 1999 - 2015 does suggest a close connection with economic despair.
However, a closer look at the demographics of overdose deaths over time shows there is likely more to this story. Christopher Ruhm with the University of Virginia argues that the supply of opioids is a more significant cause of the current crisis than simply economic decline. Ruhm’s proposition is supported by the fact that opioid pain relievers are the most prescribed (some argue over-prescribed) class of medications in the United States. In the late 1990s, around 100 million Americans were estimated to be affected by chronic pain. This led to a push by pharmaceutical companies to expand the use of painkilling opioids. As of 2016, more than 289 million prescriptions were written for opioid drugs per year with the most commonly prescribed opioids being oxycodone (OxyContin and Percocet) and hydrocodone (Vicodin and Lortab/Norco).
And, its not just the volume of opioids that has increased. The potency of these drugs has also gone up. Fentanyl, a newer synthetic opioid painkiller, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin with only 2 mg becoming a lethal dose. It is pure white, odorless and flavorless with a potency strong enough that police and first responders helping overdose victims have themselves overdosed by simply touching or inhaling a small amount. As a result, the DEA has recommended that officers not field test drugs if fentanyl is suspected, but instead collect and send samples to a laboratory for analysis. According to the DEA, "Exposure via inhalation or skin absorption can be deadly.”
In looking at the potential causes of the opioid crisis, it should not be overlooked that the structure of our health insurance system in the U.S., especially our workers’ compensation insurance has traditionally favored prescribing drugs for chronic pain over other more expensive or alternative type therapies such as chiropractic, acupuncture, massage therapy, or marijuana based drugs. An estimated 75% of opioid abusers started their opioid use by taking legitimate prescriptions.
In light of this “opioid crisis”, injured workers and doctors have to constantly be cognizant of the fine line between taking painkillers to cope with an injury and the dependence and addiction that can develop from these drugs. Many work injuries, both acute and chronic, warrant the use of strong painkillers. The goal should continue to be to help these injured workers with opioid drugs. However, as the Center for Disease Control (CDC) instructs, doctors should prescribe opioids for chronic pain only where all other options have been exhausted. If this edict is to be followed, injured workers are going to have to be willing to try something other than just taking a pill. Doctors are going to have to make peace with chiropractors and alternative medicine ideas to educate themselves on other possible treatment plans. And, workers’ compensation carriers are going to have to be willing to authorize these alternative treatment plans even when the initial cost seems higher than an opioid or perhaps even somewhat experimental. If we are not willing to follow the CDC advice, the true cost to injured workers (and families) can be death by overdose.
Kimberly J. Syfrett
Attorney at Law