Treating OUD as a Chronic Disease Produces Best Outcomes, Expert Says

Sarasota, FL (WorkersCompensation.com) – Despite the decrease in prescription-related opioid overdoses in recent years, there are still many injured workers with opioid use disorder (OUD). The good news is they can recover, no matter how far along the continuum they are. 

Stakeholders who understand the risk factors and the symptoms and employ harm-reduction strategies and appropriate treatment options can be successful in helping these workers reduce or even eliminate their use of unnecessary medications. What’s important is to meet the injured worker where he is and deal with the underlying pain.

“As we think about our work comp patients, across our continuum and  those that have been on opioids or other medications for long periods of time, the complexity of weaning off of those medications or tapering down, hopefully getting off of them completely, and figuring out how we’re going to treat that chronic pain, that non-malignant non-terminal chronic pain, in those situations,” said Tron Emptage, chief Clinical Officer for Optum, “I think understanding all  these different aspects are really important to our understanding of just what’s going on with that patient, even if it’s not an illicit issue or opioid use issue, just that chronic use issue.”

Emptage recently joined an OUD expert from Ohio State University for an in-depth webinar on how to manage these injured workers for best outcomes.

The Terminology

One of the first lessons needed to appropriately treat injured workers negatively affected by opioids or other medications is to know what their situation is. For example, patients who tolerate various medications are not necessarily dependent on them; likewise, those who have a dependence are not necessarily addicted.

Having a tolerance means the person must take additional doses and/or the same dose over a shorter time span to get the same relief. Dependence refers to the state where the body adjusts its normal functioning around having the medication, so stopping it abruptly can produce unpleasant physical symptoms, such as patients who take SSRIs for depression.

A patient with OUD has “a problematic pattern of use that causes impairment or distress,” explained Kelsey K. Schmul, assistant professor of Clinical Pharmacy at OSU’s College of Pharmacy. “It occurs when attempts to cut down or control opioid use are unsuccessful or when use results in social problems and a failure to fulfill obligations at work, school and/or home.”

Risk Factors

Focusing on injured workers who are likely to develop OUD early in a claim is invaluable to mitigating the problem – or preventing it in the first place. Among the telltale risk factors are:

• Genetics, which researchers say play a key role
• Untreated psychiatric disorders
• Environmental and life experiences, such as early life trauma, stress, adverse childhood experiences, and easy access to opioids
• Past or current substance misuse

“As our case managers, our adjusters, as we’re thinking about those items … in those early-on interview times, when we are gathering information about the claim … there are opportunities to learn and activity listen,” Emptage said. “I think that will help point out these items for us … in some of those injuries where we know it’s going to go beyond that initial injury.”

A Chronic Disease

Treating an injured worker with OUD is most successful when it is supportive, rather than punitive. For example, relapse is a signal that resumed, modified or new treatment is needed, and/or increased support. It is common and expected in patients with OUD.

“OUD has been recognized as a chronic, relapsing disease of the brain,” Schmul said. “We need to treat it like other diseases that are chronic that have common relapses; we see that in other chronic diseases such as hypertension, high blood pressure, or asthma. These are always super well controlled. Sometimes we need more education, we need more resources and support for these patients to get to their goal. We see the same things with OUD.”

Harm reduction strategies can be employed to reduce some of the problems associated with OUD. Harm reduction principles should recognize that drug use is a part of society, produce evidence-based interventions to reduce harm, approach the patient in a non-coercive non-judgmental way, and provide services along a continuum.

An example of a harm reduction strategy is overdose prevention, through the use of Naloxone distribution, and fentanyl testing strips to use on a batch of drugs to ensure they are not laced with the deadly synthetic opioid. Syringe access programs is another strategy, where clean needles are provided to those injecting drugs to prevent transmission of HIV, hepatitis or other conditions.

Recovery

One strategy that can actually help someone recover from OUD is urine drug screening (UDT). Historically, it’s been used as a method of punishment for someone not meeting the goals of a program. But it can be used in a positive way.

“What the current guidelines really say is that UDT should be used as a tool for supporting recovery rather than a method of punishment,” Schmul said. “It should be used in combination with a patient’s self-reported information of substance abuse, so if the UDT results don’t match what the patient is saying we should definitely send it for confirmation testing. It also provides an opportunity to engage with the patient about their treatments when discrepancies do exist and talk about their goals.”

Providers should explain to injured workers that UDT can help them meet their recovery goals, she said. Unexpected results may lead to increased levels of care, changes in doses of medications, or increased patient education.

Medication assisted treatment is among the typical treatments for patients with OUD. This is sometimes done along with therapy. “The most recent data shows medications alone can actually be just as effective as medicine in combination with behavioral therapy,” Schmul said. “So we should offer the therapy support to those patients who want it, but if somebody doesn’t want to engage in that it should not be a reason to withhold medicine form them.”

Several medications are typically used to help aid OUD recovery. Each has varying pros and cons.

A question frequently asked is, how long should this particular treatment last. The answer depends on how well it is working.

“Similar to other chronic diseases where we have people on medications sometimes for life, these medications might need to be used long term. Years. For life, potentially,” Schmul said. “And as long as it’s still providing benefits I think it’s reasonable to keep them on it.”

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