Drug Dangers Beyond Opioids
Opioids are not the only prescription drugs fueling injured worker addiction and overdose deaths.
Workers’ compensation payers are growing increasingly aware that sedative hypnotics and anti-anxiety tranquilizers called benzodiazepines are habit-forming drugs commonly prescribed for chronic pain sufferers, often in dangerous combinations with addictive opioid narcotics.
“There are extreme dangers with mixing these types of products with opioids,” said Brian Carpenter, a registered pharmacist and director of product at Healthcare Solutions, an Optum company.
The dangers include addiction and death, familiar fates met by chronic pain sufferers introduced to polypharmaceutical regimens of drugs that are neither recommended in combinations nor for long term use.
Hypnotics are sleeping pills, such as Ambien used to treat insomnia. They are among the most prescribed pharmaceuticals in workers’ compensation, according to several drug trend reports.
Chronic pain often prevents sufferers from sleeping at night, especially when the pain-relief effects of opioids taken during the day wane. That drives the prescribing of hypnotics.
Opioid consumption can also contribute to sleeplessness, making some patients agitated, Carpenter said.
About 60 percent to 70 percent of the chronic pain patients he sees suffer from sleep problems, said Michael Coupland, a psychologist at IMCS Group, which provides chronic-pain management services.
“It’s the combination of the pain and the medications they are taking for the pain,” Coupland explained. “So when they report that to their medical doctor the medical doctor often gives them a hypnotic and just throws more drugs at it instead of getting to the core problem.”
Taking as few as 18 Ambien a year alone increases the likelihood of death fourfold, said David Randolph, an occupational physician. Combining the hypnotics or benzodiazapines with opioids synergistically increases their toxicity level and increases the risk of death by more than 330 percent, he added.
“It’s not the dose or the duration that leads to the death, it is simply the drug combination,” said Randolph, who also holds a Ph.D. and researches chronic pain issues.
” … the medical doctor often gives them a hypnotic and just throws more drugs at it instead of getting to the core problem.” — Michael Coupland, psychologist, IMCS Group
Yet long-term, daily consumption of the drug combinations is common enough that he witnesses almost daily.
A common scenario involves pain suffers prescribed opioids. Weeks later when they complain of difficulties getting out of bed their doctor prescribes an amphetamine to make them more alert, Randolph said.
Then they feel anxious, so the doctor prescribes Xanax and Ambien to help with sleep, he continued.
“This is a practice pattern I see all the time,” Randolph said. “Just this past week I saw another death associated with this polypharmacy.”
The Danger of Euphoria
Benzodiazepines, or benzos, such as Valium and Xanax for treating anxiety are also commonly prescribed to patients consuming opioids.
Various forms of benzos and hypnotics are similar in structure to each other and closely related, Carpenter said.
Benzodiazepines, muscle relaxers and opioids in combination are often abused for the high they create, Carpenter said.
One reason benzos are prevalent in workers comp is they have synergistic impact when combined with opioids, enhancing the drugs’ euphoric qualities, Carpenter said. An injured worker may not initially seek that euphoria, but once introduced they may grow to desire it.
The synergy created when combining benzos and opioids, however, also boosts the potential for addiction beyond each drug’s individual capacity to become habit forming, Randolph said.
Healthcare Solutions workers’ comp claims data shows that most doctors are managing their patients well by following safe practices regarding opioid and benzodiazepine prescriptions, Carpenter said.
But the inappropriate mixture is often seen among costly chronic pain cases that drag on without resolution.
Researchers reporting in the July 2014 issue of Journal of Occupational and Environmental Medicine reviewed 11,394 lost-time claims filed in Louisiana between 1999 and 2002. They observed that despite medical guidelines advising against prescribing benzos in combination with opioids, the practice frequently occurs.
They found that adding benzos to an opioid regimen prolongs claims durations and when the two are prescribed together claims costs are three times higher than when benzodiazepines alone are prescribed. Costs are also 50 percent higher when benzodiazepines are combined with long-acting opioids than when opioids alone are prescribed.
The concomitant use of benzodiazepines and opioids has not been well studied, including within workers’ comp, the researchers stated in their report. The studies that do exist show the combinations are connected to increased risk of addiction and death, they said.
“I don’t think I ever admit a work comp patient who is not on a habit forming sedative.” — Mel Pohl, medical director, Las Vegas Recovery Center
Discussions about death and addiction associated with opioids spread across the workers’ comp landscape before the narcotic pain relievers became a nationwide concern. The inappropriate prescribing of benzos and hypnotics, though, has not reached a similar level of attention.
“I don’t know that people are as aware of the potential dangers of benzodiazepines and sedatives as they are of the dangers of opioids,” said Mel Pohl, an M.D. and medical director at the Las Vegas Recovery Center, which treats addiction, including the abuse of opioids and other substances among workers’ comp chronic pain sufferers.
Yet “I don’t think I ever admit a work comp patient who is not on a habit forming sedative,” Pohl added.
But awareness about the abuse of benzos and hypnotics may be growing, as drug and claims costs push payers to learn more about addressing the underlying problems, such as sleep problems, that drive prescribing of the drugs.
A workers’ comp insurer, for instance, recently asked him to adopt a cognitive behavioral therapy program for treating chronic-pain claimants whose consumption of hypnotic sleep medications “seems to go on and on,” amid increasing costs, Coupland said.
“A lot of these people have been on hypnotics (and opioids) for longer than they should be,” said the insurer who asked not to be identified.
Increased discussion about drugs prescribed concurrently with opioids is also occurring as workers’ comp claims payers are increasingly agreeing to fund detox programs for injured workers who have grown dependent on opioid narcotics.
“If you are addressing opioid dependence, in my opinion, you have to address benzo and sedative dependence,” Pohl said. “To just take people off opioids and leave them on their sedatives and anti anxiety drugs is not good care.”