The idea of identifying and addressing risk factors for addiction as a means of prevention is not groundbreaking; this concept has existed since at least the 1970s. Unfortunately, there has not been much application of this concept to workers’ compensation where injured employees are routinely prescribed powerful and potentially addictive medications. A TED Talk featuring Johann Hari, "Everything you think you know about addiction is wrong," addressed this issue by questioning the assumption about addiction as a flaw in character or weakness, which has been historically dealt with by intervention – treating withdrawal, punishing, shaming and threatening the individual. He also questioned the more modern approach to addiction as a disease – addiction is the result of chemicals hijacking the brain. Hari concluded that, in order to prevent and treat addiction, we need to take a more holistic approach – one that understands the strong impact social connections and community involvement has on the individual.
In order to understand addiction, we need to also address various psychosocial stressors and view the whole person at risk for addiction rather than simply treat an addict.
Prevention efforts are more effective in reducing overall addiction rates than intervention efforts, which address an unmet need in workers’ compensation. An integrated managed care approach provides the opportunity to support an injured employee early, toward the goal of identifying risk factors for addiction or a previous history of substance abuse. This may be one key to addressing the costly issue of prescription drug addiction in workers’ compensation. The premise that an “ounce of prevention is work a pound of intervention” is clearly at play.
In addition, according to the National Institute on Drug Abuse (NIDA), the prevalence of addiction risk factors (i.e., poor social skills, limited social network, poverty, ready access to drugs) increases the overall individual risk of substance abuse and addiction. Fortunately, there is significant evidence of the benefit of protective factors such as positive social relationships, community resources and family support that reduce the likelihood of addiction. This comes as no surprise as mentally healthy humans have a need for bonding and companionship, especially during times of duress. A workplace injury and the myriad stressors that occur as a result create significant duress.
Here is an example of a workers’ compensation case where early intervention at the time of injury could elicit a positive outcome by addressing and resolving psychosocial issues:
Barry is a 29 year-old data programmer off from work for the past six months after fracturing his wrist in a “slip and fall” at work. He initially sought treatment a few days post injury when he noticed no improvement in pain or swelling. He underwent two surgeries to repair his wrist, and had two courses of physical therapy. To help with the pain of physical therapy, his surgeon prescribed oxycodone, a narcotic medicine. Barry did not call in a workers’ compensation claim until directed by his HR department, when his company paid short-term disability (STD) expired, and he had not returned to work. As a result of reduced income from STD and subsequent expiration, Barry fell behind on his rent, racked up overwhelming credit card debt and ended up faced with eviction. Prior to his accident, he was very involved socially and active in physical fitness activities including softball, rock climbing and mountain biking. His injury and recovery prevented him from engaging in these activities, and his financial difficulties limited his social activities. As a result, he became isolated in his apartment feeling cut off from others. Over time, he found himself using more of the oxycodone just to cope with the pain – even on days he didn’t have physical therapy.
This case leads us to ponder the major role of risk versus protective factors in predicting the likelihood of addiction. By identifying and addressing the risk factors, and encouraging the protective factors, we can provide support to an injured employee early in the workers’ compensation process. The pain of injury, isolation caused by not being able to engage in meaningful work, financial burdens imposed by being off from work, and the lack of an adequate support network may increase the likelihood of addiction. When addiction does occur, providing a positive yet firm process of making the person whole can yield a much better health outcome than treating a “disease.”
Employers should examine their injured employee population and the “off work” status among them. Why do some employees appear to bounce back quickly from an injury and others do not? Why do some claims appear to drag on longer than what would be considered reasonable? The answer may lie in the prevalence of addiction.
Here at Sedgwick, we take a creative approach to understanding and preventing addiction. In addition to our Complex Pharmacy Management and Nurse Case Management services which focus on the medical issues of addiction, we now offer a Strategic Case Management model that includes, among other things, Behavioral Health Services (BHS). The BHS specialist approaches the injured employee as an individual – a whole person with challenges and strengths, risk factors and protective factors. The BHS specialist acts as an advocate and coach to injured employees during their recovery.
BHS resources, when utilized early in a claim, can help injured employees maintain healthy relationships and make decisions necessary to manage their preexisting stressors and those that occur post injury. At the end of the day, the opposite of addiction is a healthy connection.
What are your thoughts on the best practices for Behavioral Health Services? I look forward to continuing our dialogue on this important topic.
Mark Debus, Clinical Behavioral Health Specialist