Imagine a young father of two (Jim) who goes to work one day and sustains a minor back injury. He sees a doctor and is told he can work, but could not lift over 25 pounds. Jim’s employer would not take him back unless he could perform all essential job functions without restrictions. The doctor gives him a few pills to reduce his back pain, but he is unable to easily play with his children or do household chores. Repeat doctor visits end up leading to more pain pills, and then antidepressants to help manage his mood and disappointment. Soon, the pain becomes a daily component of his life. He continues to take the medications and grows more anxious as time goes on. He wonders if he will lose his job. Do his family, friends and co-workers believe he has a condition? His physician had no plausible explanation for his pain. The diagnostic testing and physical examinations were normal, yet Jim still has pain. Should a surgeon be consulted? His doctor is stumped.
Jim’s life becomes very different due to the failure of many systems. The medical community let him down by over-treating his minor injury. He had multiple tests that never amounted to anything. He was sent to specialists who treated the “pain,” and was eventually given more and more medications. Off work for more than a year with essentially a minor back strain, Jim gains weight and is mostly inactive. No one ever spoke to him about healthy lifestyle choices, good nutrition and functioning with pain. Soon, he sits on the couch all day, does not participate in family functions and becomes more disconnected from family and friends. The pills begin to consume his life. He is constantly thinking about when he can take his next dose.
Each day, 22 people in the U.S. die from overdoses due to prescription pain pills or opioids. We know that pain medication and other medications cause great concern from a health and safety perspective once an employee returns to work. Many employers are not aware of the medications workers are taking until there is an accident. These drugs can inhibit sleep patterns, make employees drowsy during the day, impair judgment and lead to addiction. The risks associated with them are too numerous to count. The family dynamic is altered; the injured employee feels isolated and depressed, and is not functioning at optimal levels.
Opioids can be very dangerous when combined with other medications to treat anxiety, depression and sleep disorders, and patients must understand the risks. Physicians rarely take adequate time to explain all the risks, and the dos and don’ts associated with these medications. For example, all pills should be kept in a lock box to prevent others from accessing them. Also, no other medications should be taken with prescriptions unless first discussed with your doctor. Over-the-counter pain medications like acetaminophen or ibuprofen are usually components of prescription pain medications, and high doses can be toxic to the kidneys and liver. Allergy, cold and sleep medications should be avoided as combining them with opioids and anti-anxiety medications can result in overdose or death.
Proper attention should be given to the total morphine equivalent dose (MED) each day. Doctors can become overwhelmed with a patient who has pain and no real diagnosis. There are countless examples of physicians prescribing MEDs exceeding the daily maximum recommended. They often treat the symptoms and forget to treat the person by addressing healthy alternatives, such as exercise programs, smoking cessation and nutritional counseling, and explaining that each pain medication should be treated as a short trial. When the medication does not increase functional abilities or eliminate the pain, it is not working and should be discontinued immediately.
Anti-depressants, anti-anxiety drugs, and managing employees who take them
Stress, depression and anxiety are consistently ranked among the top five causes of time away from work. These conditions are often undiagnosed, under treated, or over treated. Depression in particular is a major contributor to other conditions, such as diabetes, heart disease and muscle strain. It is well documented and known to delay healing in post-operative cases, which extends durations beyond the expected recovery time.
Anti-depressants require close monitoring and management to increase doses, add adjunct medications and ensure optimal therapeutic levels are maintained. Three to nine percent of individuals who sustain an accident or injury have taken or are taking these medications.
Anti-anxiety drugs are commonly prescribed to block pain and can also cause work-related issues. They relieve anxiety by slowing the central nervous system and reducing brain activity, and are used to treat sleeplessness or as a muscle relaxer. They may create unwanted side effects like sleepiness, a sensation of fogginess and a lack of coordination – all of which can make working and driving dangerous or difficult. Anti-anxiety drugs are often associated with and can cause depression, and long term use should be avoided.
Employers need a clear plan of action to manage employees taking these medications. Dependency and addiction are real issues without easy solutions. The best strategies include prevention and monitoring. Best practices for healthcare providers include:
- Completing baseline urine drug screenings (first prescription not given if patient tests positive for opiates or barbiturates)
- Conducting a risk assessment to understand if the patient has any risk of addiction, overdose or dependency
- Signing an opioid agreement – with both provider and patient – prior to the first prescription to ensure the patient understands all health risks and side effects, as well as expectations including not taking other medications, avoiding alcohol and other illicit drugs
- Counting pills and patches on every visit
- Conducting random unannounced drug screenings
- Focusing on function and return to normalcy
- Reducing and eliminating the medications as soon as possible
A large-scale effort is needed to help employees obtain the most appropriate care for their injuries. Education and good communication are the keys to preventing misuse and avoiding addiction and dependency.
Dr. Teresa Bartlett, SVP, Medical Quality