Opioid Paradox: The Drugs Can Cause Pain
Research suggests that the long-term use of opioid pain medications can paradoxically induce or worsen chronic pain instead of relieving it.
It is one more reason to cheer recent report findings that the nationwide rate of opioid consumption may no longer be trending upward, although it has not decreased significantly.
By now, everyone in the workers’ comp industry should know that opioid pain killers are associated with longer claims durations, addiction, and overdose deaths.
But there is also a growing body of research on a phenomena called opioid-induced hyperalgesia that is associated with the long-term use of the pain medications. Marcos A. Iglesias, M.D., medical director for Midwest Employers Casualty Co., discussed this recently at the Risk and Insurance Management Society Inc.’s annual conference.
“A lot of claimants who are on high doses of opiods are still in a lot of pain. A big reason for that is the opioids. Once they are weaned off the opioids, they feel much better and their pain will actually decrease. So ironically, one of the ways to help their pain is to take away their painkiller.” — Marcos A. Iglesias
The condition is also called “paradoxical hyperalgesia” because a patient may experience more pain resulting from their opioid treatment rather than a decrease in pain. The phenomena can encourage dangerous dose escalation as doctors struggle to control a patient’s chronic pain.
It can also be difficult to distinguish whether a patient continues to experience chronic pain because of an increasing dose tolerance or because of opioid-induced hyperalgesia, according to literature on the topic.
The literature also states that opioid-induced hyperalgesia can worsen with increased opioid doses.
Dr. Iglesias said that opioid-induced hyperalgesia is another reason to stop providing the pain medications to certain patients.
“A lot of claimants who are on high doses of opiods are still in a lot of pain,” he said. “A big reason for that is the opioids. Once they are weaned off the opioids, they feel much better and their pain will actually decrease. So ironically, one of the ways to help their pain is to take away their painkiller.”
The good news, though, is that recent workers’ comp drug trend reports produced by pharmacy benefit managers show decreases in the amount of opioids prescribed to workers’ comp claimants.
St. Louis, Mo.-based Express Scripts, for instance, released its 2013 Workers’ Compensation Drug Trend Report in April. The report states that the “per-user-per-year” utilization of opioids decreased 3 percent from 2012 to 2013. Express Scripts attributed the decline to government, payer, and pharmacy benefit manager attention to opioid consumption.
Similarly, a 2014 Workers’ Compensation Drug Trend Report released in April by Westerville, Ohio-based Progressive Medical Inc. and PMSI states that 62.1 percent of injured workers prescribed medications in 2013 used opioids. That was down from 64.2 percent during the prior year.
The decrease is a “true success,” considering opioid consumption had been increasing during past years, said Robert Hall, M.D. and medical director for Progressive Medical and PMSI. But increased accountability and awareness on the part of prescribes as well as improvement in medical quality have helped counter the problem, he added.
“Based on where things were headed [and] what we were seeing across the country, definitely the [growth] trend being stopped and taken in a different direction is a positive,” Dr. Hall said.
Yet the trend in opioid consumption can also be viewed as not having changed much.
Cambridge, Mass.-based Workers Compensation Research Institute recently looked at long-term opioid use in 25 states and compared the 2008/2010 time period to 2010/2012. It found a decrease within 2 percent in most of the states studied, but concluded that change amounted to “little reduction in the prevalence of longer-term opioid use.”