The estimable Gary Franklin MD, Medical Director of Washington Labor and Industry, weighed in with passion and precision at CWCI; Gary’s message was simple and straightforward:
Workers injured on the job get worse and worse and worse, unlike people with the same injured hurt outside employment. Why? They become chronic pain patients. Preventing the transition from acute and sub-acute pain management to chronic pain and the inevitable disability that accompanies chronic pain is critical; that is “secondary prevention.”
Causes of disability and more specifically causes of the decade-long increase in the duration of disability include the:
- use of harmful treatments including spinal surgery (especially lumbar fusion) and opioids
- creeping diagnoses that seem to evolve as claims age
- severely damaging effects of bad providers
A key data point – a case-mix adjusted study indicates patients getting opioids for more than 7 days double their risk of disability for a year.
The takeaway is if patients receiving opioids are not showing improvements in pain and functionality, the treatment should be modified – and not with an increase in opioids.
L&I is working diligently to address the issue of secondary and tertiary disability with an eye towards intervening and re-directing claims before they head too far down the disability “curve”. There are a relatively few docs who are “bad” (perhaps some may be the high IMR filers noted in a previous post).
And that work is paying off; among L&I’s claimants, the percentage of workers receiving opioids 6-12 weeks from injury has decreased from 4.9% in 2012 to 1.1% in Q4 2013.
In contrast, a recent study by PBM Express Scripts indicated that fully have of all patients taking drugs for more than 90 days will still be on opioids in three years.
If anything Dr Franklin is even more passionate, and more compelling, when speaking about lumbar fusion and the disasters associated therewith. Fully 64% of those getting lumbar fusion are disabled 2 years out, with many of those on SSDI. What’s scarier is California’s outcomes for spinal fusion surgery are significantly and categorically worse.
WA has been able to reduce the percentage of workers who end up on SSDI via their COHE program; clearly their focus on appropriate medical care has been the leading factor.
What does this mean for you?
Crappy medical care by crappy docs looking to make money off the easily-abused workers comp system leads to unnecessary disability, hugely damaged people and families, unknown but certainly very high societal costs.
Yes! Thanks for posting such an important topic in work comp, Joe. There’s compelling research that demonstrates that what we providers say (and the non-verbal body language we use) can feed a chronic pain pattern. Sounds cliched, but early, quality intervention is key for these IWs.
Spinal fusion is not the only treatment for back injuries. When calledior, disc replacement is performed in medical facilities outside the US, amd at lower cost than fusions.
Please do not suggest that disc replacement is better. The science overwhelmingly disagrees with you. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989192/
A biopsychosocial problem is not treated by plates, screws, and plastic.
Thanks for the article, Joe. Would you by chance be able to provide sources/cites for any of the studies mentioned by Dr. Franklin? Particularly the case-mix adjusted study regarding extended opioid use?
John, that reference might be to: Franklin, G.M., Stover, B.D., Turner, J.A., Fulton-Kehoe, D., and Wickizer, T.M., Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976), 2008. 33(2): p. 199-204.