The Pain Conundrum

October 9th, 2006 by

Workers comp is about workplace injuries and injuries almost always involve pain. So it’s no surprise to see painkillers at the top of the leader board for medicines prescribed in the comp system. The Hartford has published the latest rankings, which is still dominated by powerful and exotic drugs. Oxycontin is still number one, for reasons that defy logic but give rise to serious partying among the talented sales team at Purdue Pharma. (This particular drug comes with plenty of warnings.) The Cox-2 inhibitors (Vioxx and Bextra) have disappeared (for obvious reasons). Here’s the entire top seven:
1 Oxycontin
2 Gabapentin (generic neurontin, an anti-seizure med useful in reptitive motion pain)
3 Hydrocodone (generic Oxycontin)
4 Lidoderm (for burns)
5 Celebrex (usually for arthritis pain)
6 Actiq (see below)
7 Oxycodone (another generic version of Oxycontin)
Our colleague Joe Paduda blogged this important issue back on September 27. He questions whether doctors are managing pain or just passing out pills. He is particularly interested in a newcomer to the top 7, Actiq, a powerful new pain reliever developed specifically for cancer patients with severe pain that breaks through their regular narcotic therapy. (As I recall, Oxycontin also began as a drug for terminal cancer patients.) Actiq is an opioid narcotic more powerful than morphine. The medicine comes in the form of a flavored sugar lozenge that dissolves in the mouth while held by an attached handle. Gee, it not only kills the pain, it tastes like candy. Yum! This new favorite comes with a hefty price tag ($1,200 a month), but that’s hardly a problem in the comp system, as injured workers are not troubled with a co-pay.
The FDA has some warnings that accompany this latest designer drug. Actiq may be fatal to children. Because Actiq is designed to be dissolved slowly in the mouth, it’s not hard to imagine kids trying it out. FDA approved Actiq under special regulations that restrict distribution as defined in a comprehensive risk management plan. Pardon my cynicism, but I wonder just how many injured workers are provided with detailed risk management plans when they receive a script for this drug.
Living with Pain
It’s beyond the scope of this blog to tackle the issue of pain medications and why doctors prescribe one drug over another. But the big picture is pretty clear. Doctors treating workplace injuries routinely write scripts for the most powerful drugs available. They appear to move rather quickly toward drugs that were originally designed for the chronic, intense and long-term pain of a terminal illness. Most workplace injuries resolve themselves relatively quickly, so while the initial pain may well be acute, it usually does not – and should not – become chronic. When pain does become chronic in the workers comp system, it is almost always an indication that the employee has not returned to work.
All of this leads us to speculate on the relationship of pain to time: if all the key players (employer, doctor, insurer) focus relentlessly on returning injured employees to work, if we give these employees the opportunity to work through the pain while continuing to function in the workplace, we would probably see a greater reliance on pain drugs at the lower end of the spectrum. In other words, a comp system functioning at optimal levels would have a radically different list of top seven drugs. Needless to say, despite a leveling off of pharma costs, the workers comp system from state to state is not functioning anywhere near these optimal levels.