Long-Term Opioids Worsen Outcomes After Back Fusions

A new study found that back fusion patients fared significantly worse when receiving long-term opioid therapy.

By: Nancy Grover | September 21, 2015

Long-term opioid therapy for patients who’ve had lumbar fusion for degenerative disk disease may lead to poor outcomes, suggests a new study. Researchers found injured workers prescribed opioids for more than a year after the surgery had lower return-to-work rates, higher medical costs, and more psychiatric comorbidities than those not on chronic opioid therapy (COT).

For the study of more than 1,000 injured workers who had undergone lumbar fusion surgery, researchers from several institutions teamed with workers’ comp administrators. Analysts from Case Western Reserve School of Medicine, the New Hampshire NeuroSpine Institute, and University Hospitals Case Medical Center Department of Orthopedics in Cleveland teamed with officials from the Ohio Bureau of Workers’ Compensation. The study evaluated risk factors among those on chronic opioid therapy compared them with a group that had only a temporary supply of opioids.

“The COT group experienced markedly worse outcomes after fusion,” the study said. “The overall poor outcomes of this study could suggest a more limited role for discogenic fusion among patients receiving workers’ comp.”

Background

The increase in the use of opioids for non-cancer pain has risen significantly in the last decade, the authors noted. The increase has been associated with high rates of substance abuse disorders, hospital admissions, and overdose deaths.

While opioids may be effective for low back pain in the short term, there is little evidence that they are effective long term. There is also evidence that long-term high dose opioids may lead to opioid-induced hyperalgesia, or abnormal pain sensitivity.

“The clinically-distinct workers’ comp population is noted to have high rates of COT and early opioid therapy for acute low back pain in a workers’ comp setting has already been associated with increased disability,” the authors wrote. “Our study investigated opioid analgesic utilization among 1,002 Ohio workers’ comp subjects who underwent lumbar fusion for degenerative disk disease and discogenic low back pain from 1993-2013.”

The study population was divided into two groups. Those receiving opioids more than one year after the initial six-week period following the fusion — 575 patients — were identified as the COT group. The remaining 427 were the temporary opioid group.

Within three years after the fusion surgeries, the COT group received an average of 1,083.4 days of opioids, a 72.3 percent morphine equivalent daily opioid load, and 49 opioid prescriptions, most of which were Schedule II drugs.

Results

The authors noted the COT group’s worse outcomes were “highlighted by an 11.0 percent return-to-work rate and nearly $28,000 higher medical costs paid by the Ohio Bureau of Workers’ Compensation per subject compared to the temporary opioid therapy group.” They also noted “a 43.5 percent overall rate of clinically-diagnosed psychiatric comorbidity — 68.4 percent of which was diagnosed after fusion, a 16.7 percent rate of failed back syndrome, and a 27.7 percent rate of additional lumbar surgery.”

“The overall poor outcomes of this study could suggest a more limited role for discogenic fusion among patients receiving workers’ comp.”

Specifically, three years after the surgery, those in the COT group were out of work an average of 37.3 days more than the other group, had a 27.4 percent lower return-to-work rate, a 20 percent increased rate of new onset psychiatric disorders, 12.7 percent higher rate of failed back syndrome, a 7.4 percent increased rate of total permanent disability payments, and a 16.2 percent higher rate of additional surgery.

Risk Factors

Approximately 32 percent of the workers’ comp population is prescribed opioids, according to the researchers. Those receiving the medications for acute low back pain were found to have higher rates of disability and more surgery, as well as COT.

The authors also identified risk factors associated with COT vs. temporary opioid therapy.

“The strongest predictor of COT after fusion was receiving COT before fusion,” the study said. “Seventy-nine-point-6 percent of subjects on preoperative COT ended up on COT after fusion. Both increasing duration of opioid use and increasing net opioid load within the year before fusion were positively associated with higher rates of postoperative COT.”

The COT group was given opioid analgesics an average 22.4 more days than the temporary opioid therapy group during the year before the fusion surgery. They also filled an average of 1.2 more opioid prescriptions, which the authors said equated to 217.9 additional morphine equivalents and 7.4 morphine equivalent higher daily opioid load than the temporary group.

The chronic opioid group also had an average 76.6 more days out of work before fusion, a 5.9 percent higher rate of psychiatric disorders, a 13.3 percent higher rate of being out of work more than 12 weeks. They also had a 5.4 percent higher rate of psychotherapy utilization, a 10.1 percent increased rate of undergoing discography, a 7.3 percent lower rate of utilizing chiropractic care, a 6.5 percent higher rate of legal representation, and a 3.8 percent higher rate of spondylosis, or spinal degeneration.

Advice

Workers’ comp patients in other states may show different results than what the researchers found in Ohio. Legislative regulations, treatment guidelines, and other factors could generate different findings. Also, differences in preoperative variables between the two groups, as well as “significant differences in surgical methods” could have affected the findings.

However, “the high rates of psychiatric disease after fusion and the strong impact depression had on rates of COT may indicate a possible impact of better screening and treatment for psychiatric disease before lumbar fusion,” the study suggests. “Also, the significantly greater utilization of psychotherapy after fusion among both groups may suggest worsening psychological health after fusion within our study population.”

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected].

How a Carrier Partner Can Help Navigate a Challenging Management and Professional Liability Market

A combination of a choppy economy with increased claims frequency and severity could lead to rate increases in the Management & Professional Liability market.

By: Risk & Insurance | April 3, 2024

Rates in the management & professional liability (M&PL) markets were on the rise from 2020 to early 2023 and are now falling rapidly.

M&PL divisions manage a number of different insurance products including management liability (D&O), professional liability (E&O), employment practices liability (EPL), fiduciary liability policies, cyber, etc. In 2023 and into 2024, a big influence on the marketplace has been the extremely aggressive and softening public company D&O market.

Though these rates have been softening for management liability, that may change over the next few years as companies continue to adjust their business models motivated by economic uncertainty. Layoffs were up nearly 200% last year, Forbes reported, even as other recession indicators, like the inflation rate, improved. A recession could lead to an increased claim activity and force carriers to raise rates.

“Whenever there is a meaningful downturn in the economy, we tend to see claim frequency pop up,” said George Schalick, Jr., senior vice president of the Management and Professional Liability Division at Philadelphia Insurance Companies (PHLY).

With continued fiscal uncertainty, businesses potentially already burdened with pandemic-related claims should seek a carrier with a long history in M&PL products. They will provide much-needed risk management guidance and be better positioned to support their insureds during market fluctuations.

Why Insureds Might See an Uptick in M&PL Claims

George Schalick, Jr., Senior Vice President of the Management and Professional Liability Division, Philadelphia Insurance Companies

The current soft market might come as a bit of a surprise as it does not track with previous underwriting cycles and economic conditions. Afterall, many privately held and non-profit organizations struggled during the early days of the pandemic with shutdowns and rapidly declining revenues. But the Government assistance programs, like the Paycheck Protection Program loans, helped keep many afloat during the tough times.

“During COVID many organizations stopped doing business until they were able to sort out all of the health and safety challenges,” Schalick said. “They were forced to lock down, but then all the government assistance programs allowed them to keep people employed. The increased volume of claims we anticipated we would see coming from the lockdowns and restrictions that were imposed upon businesses in the U.S. didn’t manifest at first.”

“Just because there wasn’t an onslaught of reported claims at the beginning of the pandemic, doesn’t mean the circumstances that would give rise to a claim being reported didn’t occur. Courts and the judicial system were closed or slowed and now that they are back open, we’re starting to see the circumstances that occurred during the COVID lockdowns becoming claims today,” Schalick said. “Litigation is progressing.”

Added to the delayed pandemic litigation is a concern over newer claims that might be filed as the country inches toward an economic downturn. Though a recession was avoided in 2023, experts think a soft dip could occur in 2024, with 76% of economists saying there’s a 50% or less chance of an economic downturn this year — that almost always results in more management liability claims.

“During the Great Recession in 2008, we saw an almost immediate spike in claims because of the economic conditions and the pressure it placed on organizations. They were making personnel changes with significant belt tightening almost immediately.” Schalick said.

What’s in Store for M&PL Policy Rates in 2024?

Despite an uptick in claims and increased economic uncertainty, management liability rates haven’t increased, resulting in market-wide pricing levels that may not meet the increased pressure of rising settlements and jury verdicts.

“Rates are going the other direction and settlement values are not falling,” Schalick said.

The mismatch between rates, claim frequency and severity is, in part, because carriers experiencing the dramatic soft market in the public D&O market are seeking premium gain in the private and non-profit market.

“In the public company market, the rates have been decreasing significantly. The rates were increasing in the private, not-for-profit market, and rightfully so, but there’s a desire to supplement overall mid-size D&O for carriers who also write private not-for-profit, and they see that as an opportunity to aggregate premium,” Schalick said. “So the always competitive landscape in the private, not-for-profit market has dramatically increased in the last 18 to 24 months.”

Still, companies of all sizes and types should be concerned about management liability rates in the future. Legal system abuse is resulting in increases in both the amount of litigation and the size of verdicts plaintiffs are receiving.

Certain areas of the country are particularly vulnerable to this type of legal system abuse. As a result, insureds in these localities are likely to be vulnerable to rate increases.

“The environment is so positive for the plaintiff that forces premium increases so carriers are able to stay in that market long term,” Schalick said.

Why a Tenured Carrier Partner Can Help Insureds Navigate An Uncertain Market

It’s clear that insureds are facing an uncertain M&PL market over the next few years. Fortunately, carriers with a long history in the M&PL space will be there to offer stability.

Philadelphia Insurance Companies has been supporting this market for 35 years. PHLY is committed to offering long-term rate stability, even as economic and claims trends start to push premiums upwards. They have an appetite for all sorts of companies, large and small, for-profit and nonprofit alike.

“We’ve been at this game for a long time and are one of the most tenured underwriters in this space,” Schalick said. “We like to stay very consistent.”

PHLY has worked with both for-profit and non-profit on management liability policies. With dedicated M&PL teams throughout the company’s 13 regions, PHLY provides the support agents and brokers are looking for on behalf of their clients. The teams know their regions well and can respond to local trends. They’re also dedicated to making the renewal process as easy as possible for their partners and policyholders.

“We have real confidence in our results, so we focus a lot on making the renewal experience as painless as possible for all agents and insureds,” Schalick said.

The company is also investing in tools to help insureds avoid losses. Earlier this year, they launched a new online risk management platform, PHLYGateway, which offers resources for insureds on how to create an employee handbook and trainings on issues such as recognizing workplace sexual harassment and discrimination.

If insureds have questions, they can consult a Best Practices Help Line, provided via the platform. That way, they can get on the spot risk management guidance to help them prevent claims.

To learn more, visit: https://www.phly.com/mplDivision/managementLiability/default.aspx.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Philadelphia Insurance Companies. The editorial staff of Risk & Insurance had no role in its preparation.

Opioid Strategies