Ignoring Opioid Rules has Killer Implications
Hundreds of lives could be saved if often ignored state-mandated guidelines for prescribing addictive opioids were enforced and used more widely.
Currently, the pain treatment guidelines only apply to workers’ compensation cases. But even in those cases, a host of experts agree that the regulations are woefully underutilized.
Dr. Robert Kutzner, an Orange County pain specialist, says if the regulations were used to treat all patients – worker and non-worker alike – the national opioid epidemic would be drastically curtailed.
Other experts agree that too few doctors know about the guidelines, a deadly problem in the midst of what the Centers for Disease Control and Prevention calls a national prescription-drug epidemic.
Consider that more people die from accidental prescription drug overdoses than die in car accidents. Earlier this year, my analysis of coroner records found that the opioid epidemic kills someone in Orange County an average of every two days. Many are teens or middle-age mothers.
Even the head doctor for California’s workers’ compensation acknowledges that physician education is lacking.
The detailed guidelines are drawn up by a panel of health experts for the California Division of Workers’ Compensation.
In the “Medical Treatment Utilization Schedule,” dozens of pages outline detailed procedures for employing short- and long-term opioid treatment.
The regulations themselves actually note: “Physicians are not well trained in diagnosing addiction or treating this condition.”
The regulations include baseline pain assessment, setting goals, first trying non-opioid meds and “assessing the likelihood that the patient could be weaned from opioids.”
But in recent years, treating pain with addictive drugs has become the new normal.
Dr. Richard Thompson is chief medical officer for EK Health Services, a national workers’ comp health company based in San Jose. He says, “There is a disparity from what medication treatment guidelines recommend and what is being prescribed.
“Many of the prescribed treatment regimens are egregiously beyond recommendations.”
Thompson notes, “Opioids – morphine, codeine, and methadone, etc. – are increasingly used to manage non-malignant chronic pain.”
Recent data corroborate Thompson’s point. According to a just-released study by Dr. John Mafi of Harvard Medical School, the use of opioids to treat back pain alone in the last decade has skyrocketed 50 percent.
As early as two years ago, Peggy Sugarman, then working for a law firm and now San Francisco director of Workers’ Compensation, warned that the California Workers’ Compensation Institute found that “one-half of the prescriptions for Schedule II opioids were for minor low back strains and sprains.”
Several factors have come together to create the deadly epidemic. One is that pharmaceutical companies manufacture far more addictive drugs than are used by patients in need of pain medication.
Another factor is that some patients are unable to kick their addiction after receiving opioid treatment. Additionally, some unethical physicians behave more like dealers than doctors and scribble prescriptions for money.
Finally, there are street dealers who sell such drugs as OxyContin and Opana to hard-core addicts. Many are teenagers who became addicted through what is known as “pharm parties,” gatherings in which boys and girls pool pills stolen from parents’ medicine cabinets.
Let’s agree, we also live in a pill-popping culture. Young children watch television advertisements telling us what we supposedly need and why.
A Food and Drug Administration announcement earlier this week that the most powerful opioids must have warning labels is too late and far too little.
With offices in Costa Mesa and Fountain Valley, Kutzner points out that if state regulations were enforced and more widely used, far fewer patients would become addicts, and addictive prescription drugs could more easily be tracked.
What deeply frustrates Kutzner is that armed with the regulations, California could lead the country out of the opioid epidemic.
Worker’s comp Executive Medical Director Dr. Rupali Das acknowledges, “We definitely need to improve physician education regarding the benefits to workers of using these evidence-based medical treatment guidelines.”
Das offers an overview of the regulations, saying the book-length document “provides information explaining whether certain treatments are appropriate, how often the treatment is given, the extent of treatment and the duration.”
She is more cautious than Kutzner in applying the guidelines to non-worker cases and chooses her words carefully, pointing out there hasn’t been a study in California.
Regardless, she says, “Following evidence-based parameters of opioid use would likely reduce avoidable illness and death caused by the inappropriate use of opioids.”
Furthermore, Das states, “Other states with different models for the provision of care for injured workers have shown a decrease in the use of opioids after the institution of stringent opioid use guidelines.”
I reviewed the regulations’ 127 pages on “Chronic Pain Medical Treatment Guidelines.” The document details different types of pain as well as the body’s different pain centers.
It cites specific treatments, both non-opioid and opioid, from aquatic therapy to yoga. And it clearly states the dangers of opioid treatment.
The guidelines warn, “It is important to attempt to identify individuals who have the potential to develop aberrant drug use both prior to the prescribing of opioids and while actively undergoing this treatment.”
Questions to screen for at-risk patients include asking if the person has felt the need to cut down on alcohol or drugs, if others have criticized drinking or drug use and if the patient has felt guilty after such use.
The guidelines also offer steps to avoid opioid abuse including patient contracts, communicating with pharmacists and random urine testing.
Yes, urine testing.
That may seem excessive considering how many people take such opioids as codeine, Percocet and Vicodin. But the document notes, “The prevalence of addictive disorders and/or serious substance misuse in patients with chronic pain may be as high as 30 percent.”
Kutzner follows workers’ comp guidelines and its multipronged approach for treating pain: medication, physical therapy, corrective procedures, psychological treatment.
If a physician simply prescribes opioids, Kutzner maintains, “after a few months, a 25-year-old with a hurt back is physically dependent.”
Dr. Steven Feinberg of Newport Beach echoes Kutzner: “Many physicians do not fully understand the proper role of opioids in the treatment of injured workers, and they do not understand the importance of a biopsychosocial, whole-person approach as promoted in the … Medical Treatment Utilization Schedule.”
If workers’ comp guidelines and their counterpart CURES, which allows physicians to track patients who doctor shop, had more teeth, perhaps we’d make a dent in the opioid epidemic.
It’s a dent that could save someone you know.
David Whiting’s column appears four days a week; email@example.com