Injured employee? He or she may be at high risk for opioid addiction

'The trap: They feel this is the only treatment that is effective'

An employee's misuse of opioids may go undetected unless there is a positive drug screen, poor job performance, high absenteeism, erratic behavior, an accident or near miss, or an overdose. You may be the only one who can prevent this from happening.

Overuse of opioids for chronic conditions can result in employees becoming addicted or misusing pain medications, according to the American College of Occupational and Environmental Medicine's 2011 Guidelines for the Chronic Use of Opioids. The guidelines were developed by a multidisciplinary expert panel to manage injured workers whose pain hasn't been controlled by more conservative means.

"Opiate medications are widely prescribed for short-term relief of acute work-related strains, sprains, and soft tissue disorders," says Matthew Hughes, MD, MPH, assistant editor-in-chief of the guidelines, and a physician at Rocky Mountain Center for Occupational and Environmental Health in Salt Lake City, UT.

For employees with chronic conditions, there are many treatments that should be considered before opioids, however, including exercise and aerobic activity, topical medications, heat, non-steroidal anti-inflammatory drugs, low-dose tricyclic anti-depressants, select anti-convulsant agents for some disorders, and self-applied palliative modalities such as transcutaneous electrical nerve stimulation.

Beware the trap

Often, opioid medications are extended for chronic use, to treat musculoskeletal conditions such as low back pain, neck pain, shoulder pain, or even arthritis. "Patients may fall into the trap that they feel this is the only treatment that is effective," he says. "Often, these patients have been told they have a certain condition, which they don't entirely understand. They then receive inadequate or ineffective treatments along with the opioid therapy."

Some clinicians may be uninformed about the unproven efficacy, significant side effects and high mortality rates associated with chronic opioid use, and may exhibit prescribing patterns favoring use of these medications.

"Formal medical education has long been deficient in addressing these issues in training programs," he says.

As an occupational health professional, you play an important role in preventing the inappropriate or misuse of opioid medications in the workplace. He recommends these practices:

• When contemplating use of opioids for chronic non-cancer conditions, follow a clear treatment plan.

This should include a comprehensive pre-treatment assessment, identification of contraindications, establishing informed consent after educating the injured worker on the benefits and risks, establishing a written treatment plan with goals and objectives, using an opioid treatment agreement, obtaining specialist referral when indicated, and establishing a follow-up plan.

• Utilize prescription monitoring programs, if available, prior to initiation of and periodically during opioid treatment.

Determine the patient's prior history of prescription opioid use, patterns and frequency of use, and other sources of opioid prescriptions, to identify employees abusing opioids, or at high risk for this.

• Perform periodic drug testing and close follow-up of employees using opioid medications.

"Documented improvement in function, and/or quality of life, should be requisite for continuing opioid therapy," he says.

• Help workers that are abusing or misusing opioid medications for chronic conditions.

These employees may be best served by referrals to specialists with expertise in mental and behavioral health, and to clinicians experienced in pain management with a focus on functional recovery.

"A generic referral to the employers' Employee Assistance Program would likely be suboptimal," he says.

• Remember that there is very limited evidence that opioid therapy is effective for chronic non cancer pain.

"It is therefore only recommended for select patients with moderate or severe pain that significantly affects function or quality of life, and after failure of other non-opioid treatments," he says.


For more information on preventing abuse of opioid therapy, contact:

• Matthew Hughes, MD, MPH, Rocky Mountain Center for Occupational and Environmental Health, Salt Lake City, UT. Phone: (801) 581-4800. E-mail: