Posts Tagged ‘addiction’

Opioids: the Gateway to Heroin

Wednesday, February 12th, 2014

The surprising overdose death of acclaimed actor Philip Seymour Hoffman has put a spotlight on a national epidemic: prescription drug abuse. In workers’ comp, prescription drugs have been an area of great concern for a number of years; so too in the public health and policy arena. But has the message — and the necessary education — filtered to the general public? It would seem not: According to the CDC, prescription painkiller overdoses nearly quadrupled in the decade from 1999 to 2008.
This past week, the New York Times framed the new reality: Prescription Painkillers Seen as a Gateway to Heroin

“Dr. Jason Jerry, an addiction specialist at the Cleveland Clinic’s Alcohol and Drug Recovery Center, estimates that half of the 200 or so heroin addicts the clinic sees every month started on prescription opiates.

“Often it’s a legitimate prescription, but next thing they know, they’re obtaining the pills illicitly,” Dr. Jerry said.

In many parts of the country, heroin is much cheaper than prescription opiates. “So people eventually say, ‘Why am I paying $1 per milligram for oxy when for a tenth of the price I can get an equivalent dose of heroin?’ ” Dr. Jerry said.

In many parts of the country, heroin is much cheaper than prescription opiates. “So people eventually say, ‘Why am I paying $1 per milligram for oxy when for a tenth of the price I can get an equivalent dose of heroin?’ ” Dr. Jerry said.”

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Oklahoma: One state’s experience
The investigative journalism non-profit Oklahoma Watch recently published a report on the state’s addiction: As Drug Deaths Rise, Millions of Narcotic Prescriptions Filled
According to this report, Once occupying the ignominious position of first in the list of states with prescription drug abuse, Oklahoma is now #8 on the list. In 2012, 844 Oklahomans were killed by overdoses, eclipsing the year’s 708 traffic fatalities. The state has a real-time Prescription Monitoring Program that is reported to be one of the best in the nation, but doctors are not required by law to check the database before prescribing controlled dangerous substances. There was an average of 68 prescriptions per patient.
Oklahoma is also seeing a steep rise in heroin use, echoing the concept and experience that opioids are the gateway drug.

“Hal Vorse, a physician who treats habitual drug users and teaches new doctors about addiction at the University of Oklahoma Health Sciences Center, said he’s seen the phenomenon in his own practice.

“We’re seeing a big surge in heroin, and 85 percent of those people started on prescription opiates,” said Vorse. “The cost of their addiction got so high that they switched to heroin because it’s cheaper.”

Vorse said the price on the street for OxyContin has risen to $1 to $1.50 per milligram. Addicts typically use 200 to 300 milligrams per day, he said. “They find out they can get an equivalent dose of heroin for a third of what it costs for Oxys,” Vorse said.”

On the Workers Comp front
Meanwhile, in workers’ comp’s battle against opioids, Joe Paduda says that Opioid guidelines are about to get a whole lot better with the anticipated upcoming release of guidelines by ACOEM. He’s has a sneak peek and finds them to be “comprehensive, extremely well-researched and well-documented, and desperately needed.”
But he also points out that more progress is needed: Why don’t workers’ comp payers have pharmacists on staff?.

“I’m only aware of three major work comp insurers (Travelers, BWC-Ohio, Washington L&I) that have pharmacists on staff; the North Dakota State Fund does as well.

With pharmacy costs accounting for somewhere around 15% of total medical spend, that seems like a “miss”. Yes, pharmacy costs have been flat in recent years, but the impact of drugs on work comp claim duration and the medical and indemnity expense associated with long-term drug use is quite significant.

by-state
Resources:
The National Conference of State Legislatures offers an overview of state laws
CDC on the Drug Overdose issue
Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
Prescription Drug Overdose: State Laws

Derek Boogaard: A Bully and His Demons

Tuesday, June 5th, 2012

Derek Boogaard was a hockey player. Well, sort of. He didn’t score goals (only 3 in 6 years) and he spent a lot of time in the penalty box (589 minutes). He was an enforcer: at 6’8″ he was a ferocious and much-feared brawler.
As we learn in a New York Times article, he was also addicted to pain medications. While still playing hockey in 2008-2009, he received at least 25 prescriptions for opioids from ten doctors, a total of 600+ pills: eight team doctors of the Wild (his team at the time), an oral surgeon in Minneapolis and a doctor from another NHL team.
In 2010, he was signed by the New York Rangers for $6.5 million, despite his by then well-documented drug problems – he was an active participant in the NHL’s substance abuse program. While playing for the Rangers, a team dentist wrote five prescriptions for hydrocodone; another team doctor wrote 10 prescriptions for Ambien.
Occupation-related Pain
There is not much question that Boogaard suffered from pain. Here is just a small segment of his pain-filled saga, from the final few months of his career: In October 2010, a punch from a Toronto player broke a three-tooth bridge in his mouth. A couple of days later, he hurt his hand while punching a Boston player. In November he had his nose broken by an Edmonton player. In December he suffered a concussion in a fight with an Ottowa player. He never played hockey again.
In the months following his retirement, he exhibited erratic behavior and wild mood swings. He acquired numerous prescriptions from current and former doctors. In May of 2011 he signed himself out of a rehab facility, spent a night drinking with friends, and died of an overdose in his Minneapolis apartment. He was 28 years old.
Privilege Has Its Pain
The article quotes Dr. Jane Ballantyne, a pain expert from the University of Washington: “A single course of opiates might be O.K. for normal people who only get injured once in a blue moon, but when injuries are frequent, it can easily turn into chronic treatment instead of just acute treatement. And athletes are at high risk of developing addiction because of their risk-taking personalities.” She adds: “the tendency is to overtreat” because team doctors want to help athletes return to competition.” [At LynchRyan, we are strong proponents of prompt return to work, but only where there is no risk of re-injury. There is no such thing as modified duty on ice.]
Boogaard was a fan favorite wherever he played. In hockey, fighting is “part of the game.” But his sad saga is primarily a story of brain injury and addiction. As a professional athlete, Boogaard had virtually unlimited access to drugs, through doctors who, for the most part, did not bother to document their treatment plans or monitor their patient.
It should come as no surprise that an autopsy revealed that Boogaard had chronic traumatic encephalopathy C.T.E., a brain disease caused by repeated blows to the head.Thus he is linked in death to the growing number of football players who suffered the same fate, the result of frequent concussions.
Official Response Speak
As a lifelong student of language and rhetoric, I cannot miss an opportunity to quote some of the official responses to Boogaard’s death:
The NHL: “Based on what we know, Derek Boogaard at all times received medical treatment, care and counseling that was deemed appropriate for the specifics of his situation.”
The Minnesota Wild: “The Wild treated Derek’s medical status in accordance with the NHL/NHLPA Substance Abuse and Behavioral Health Program as we do with all our players.”
The NY Rangers: “We are confident that the medical professionals who treated Derek acted in a professional and responsible manner and in accordance with their best medical judgment. They took extraordinary steps to coordinate the medication prescribed for him with the professionals in charge of the NHL-NHLPA Substance Abuse and Behavioral Health Program.”
Not exactly heartfelt or compassionate, just the voices of powerful corporations, protecting their interests, their brands and their proverbial asses. As for Derek Boogaard and his misguided career on ice, RIP for the man who knew no peace.

Overdosing on Drugs: Compensable in Tennessee, Denied in Ohio

Monday, December 12th, 2011

Today we examine two court cases that trouble the dreams of claims adjusters: workers with severe injuries whose use of pain medication leads to their deaths. In one case, the accidental overdose is deemed compensable; in the other, the claim is denied. The devil, of course, is in the details.
Compensable Death In Tennessee
In November 2008, Charles Kilburn was severely injured in an auto accident while in the course and scope of employment. Fractures to his back and neck resulted in permanent total disability. Following surgeries, he still experienced severe pain. A pain specialist prescribed oxycodone. Fourteen months after the accident, Kilburn died of an accidental overdose. His widow filed for death benefits.
Kilburn’s employer believed that the death was the result of negligence, which would break the chain of causality with the original injury. Kilburn had ignored his doctor’s cautions to limit his intake of oxycontin to a specific maximum dose. The Supreme Court of Tennessee determined that the severe pain experienced by Kilburn might result in diminished faculties, which in turn might lead to taking more medicine than was prescribed. In their view, the chain of causality remained intact at Kilburn’s death and thus his widow was entitled to benefits.
Denial in Ohio
In Parker v Honda of America, the initial circumstances are similar, but the apparent “diminished faculties” lead to a very different result. John Parker suffered a severe back injury at work in 1988. He was prescribed OxyContin in March 1999. He eventually became addicted to the drug, along with cocaine, percocet and heroin. In March of 2006 he was found dead, a syringe in his arm, a spoon with a lethal dose of melted OxyContin at his side. In this case, the Ohio Court of Appeals found that his melting and injecting the drug, combined with his documented abuse of street drugs, broke the chain of causation linking the death to the workplace injury.
The court rejected his widow’s argument that the drug abuse was the result of a “severe disturbance of mind” and thus unintentional. It’s worth noting that if Parker had deliberately overdosed as an explicit act of suicide, the death may have been deemed compensable. But because the overdose was an acccident, workers comp benefits were denied.
The Big (and Not-So-Pretty) Picture
Pain is a constant factor in work-related injuries. The control of pain is a complex and widely misunderstood aspect of claims management. Because we live in a culture that relies heavily on powerful medications to control pain, and because the prescribing of these powerful drugs is neither well managed nor well monitored, we will see more and more cases of drug overdoses wending their way through the workers comp system. Some cases will be compensable, others will not. One thing is certain: the challenges of managing these situations will continue to haunt key players in the comp system: the doctors who prescribe the drugs, the adjusters who authorize bill payment, the families who suffer the consequences of loved ones in severe discomfort, and above all, the injured workers, whose every waking moment is compromised and consumed by a pain that just won’t go away.

Opioid Abuse in Florida: Who Controls Controlled Substances?

Monday, December 5th, 2011

Florida is famous for at least three things: citrus fruit, sunshine and pain pills. The citrus and sunshine are pretty much permanent, but it appears that the easy dispensing of opioids may be coming to an end. HB 7095, the state’s new law regulating opioid distribution, bans doctor dispensing of drugs and subjects pharmacies to inspection of prescription records. The state is determined to put an end to its reputation as the pill mall of America.
Now CVS, the giant pharmacy concern with over 700 stores in Florida, has stepped into the breach. They have notified a small number of doctors that they will no longer honor their prescriptions for opioids. CVS has analyzed prescription data and determined that these doctors are over-prescribing. As with so many issues involving insurance coverage, the data goes into a black box and a determination comes out the far end. What happens in the box remains a mystery. Our esteemed colleague, Joe Paduda, has strongly endorsed the CVS effort at his Managed Care Matters blog.
Feeling the Pain
It should come as no surprise that a key stakeholder in the use of opioids, the Florida Academy of Pain Medicine, is crying foul. The academy points out that the criteria for blackballing doctors is unknown and that doctors – and only doctors – should be allowed to determine who needs pain killers and for how long. As Jeffrey Zipper, chair of the Academy’s Medical Affairs committee puts it, “I don’t want to be subject to the scrutiny of CVS.”
Given the immense dimensions of the prescription drug problem in Florida, it’s clear that some doctors have long been abusing their power to prescribe medications. They need scrutiny and they need to be sanctioned. While CVS and other pharmacies are a key part of the distribution network, their leverage in this area is somewhat limited. To begin with, other pharmacies may choose to pick up the rejected business: we’re talking big bucks. In addition, CVS at some point will have to disclose the criteria used for rejecting the prescriptions written by certain doctors. Once this happens, doctors may attempt to manipulate their prescription practices to avoid detection and sanction.
In attempting to get its arms around this formidable problem, the State of Florida has reframed the question about who controls controlled substances. While it’s apparent that doctors no longer have sole discretion in the area, it remains to be seen how effective and how equitable the control exerted by pharmacies can be. The Insider will monitor with great interest this important experiment in substance abuse control.

Annals of Health: Why Smokers Cannot Quit

Monday, September 28th, 2009

In all of our discussions about controlling the cost of workers comp, we continually come up against two lifestyle issues that have a direct impact on costs: obesity and smoking. Let’s leave obesity for another day and focus on smoking.
According to a compelling article by Stephen Smith in the Boston Globe, 70 percent of smokers want to stop, but fewer than 10 percent will succeed each year. For non-smokers, this might appear to be a matter of will. But that is both condescending and a gross over-simplification.

Nicotine, the primary addictive agent in tobacco, steals into the brain, setting on fire circuitry that regulates our sense of pleasure [emphasis added]. At the same time, cigarettes acquire a sort of social permanence in smokers’ lives – a way to start the day, to end a meal, to celebrate good times, to muddle through bad times.

Smith uses a rather terrifying analogy to describe how nicotine enters the brain:

Smoking is a uniquely efficient manner of delivering an addictive substance to the brain. “That’s why crack cocaine is so much more addictive than regular cocaine,” said Dr. Nancy Rigotti, chief of Massachusetts General Hospital’s tobacco treatment center. “Cigarettes are kind of like the crack cocaine of nicotine.”

Inhaled nicotine from a cigarette arrives in the brain in 10 seconds. There, it attaches to an especially pivotal region of neurons, those cobweb-like structures that govern our physical and mental actions.

Nicotine, said Dr. Jonathan Winickoff, a tobacco control researcher at Mass. General, “stimulates the same area that get stimulated when you have a wonderful gourmet meal or when you have sexual intercourse. It lights up that part of the brain, which is the rewards center. It drives human behavior. It’s powerful stuff.”

Hmm. Similar to gourmet meals and love making. No wonder people have trouble walking away from the habit, despite the known and often dire consequences of continuing to smoke. It would take powerful medicine indeed to counteract nicotine’s overwhelming appeal.
If there is good news in all of this, it is that a combination of drug therapy and counseling increase the chances of success.

“The data are very clear that you can double your chances if you use a medication if it’s appropriate for you, and you can triple your chances if you use a medication and counseling,” said Thomas Glynn, director of cancer science and trends at the American Cancer Society.

The medicine cabinet now includes seven first-line treatments, anchored by five forms of nicotine replacement. Regardless of the delivery system, the goal is to stave off the withdrawal symptoms and cravings that bedevil so many people who want to quit.

Finally, perseverence is key. You just have to keep at it.

“It takes smokers seven to 11 quit attempts to quit for good,” said Lois Keithly, director of the Massachusetts Tobacco Control Program. “We need to get the message out that if you make a quit attempt and you relapse, you don’t give up.”

Smoking Out Smokers
It will be interesting to see if the nation’s pending experiment with universal health care attempts to tackle the issue of smoking. Will smokers be charged higher premiums? (With a significant portion of smokers qualifying for premium subsidies, such penalties may prove difficult to enforce.) Will the new insurance rules mandate coverage for smoke cessation programs, including the full range of pharmacology options plus counseling? On the one hand, the success rates are low, so smokers are likely to keep smoking; on the other hand, any and all successes project to future cost savings.
Let there be no doubt about how hard it is to give up cigarettes. After all, we have the image of our president: a self-possessed, calm and extremely bright (American born!) man sneaking out of the White House for secretive puffs. Good luck to him and to all smokers who strive valiantly to give up this nasty habit once and for all.

“Crackberry” Addicts: One More Email for the Road…

Monday, October 2nd, 2006

It’s only Monday, so it might be too early in the week for this. But the Insider is committed to keeping our readers informed on the latest developments in risk and human resource management. Today, we confront the physical, emotional and legal time bomb of BlackBerry addiction.
We first tracked the health implications of using tiny keyboards in our “BlackBerry Thumb” posting in February of last year. Well, repetitive motion is certainly a potential problem, but that may prove to be the least of the worries for employers who hand out these devices. We now find that the seductive technology embodied in PDAs is leading workers into hospitals, mental health facilities and courtrooms.”Crackberry” devices are addictive. Workers find themselves unable to put the little contraptions down. By connecting workers 24/7 to their jobs, employers suddenly find themselves on the hook for unanticipated liabilities.
The Independent out of Great Britain tells us of Nada Kakabadse (now that’s a splendid name!), a professor at England’s Northampton Business School. The good professor warns British employers that they could face multi-million-pound legal actions from BlackBerry-addicted staff on a similar scale as class law-suits taken against tobacco companies. That’s a pretty big scale, indeed! Research by the University of Northampton has revealed that one-third of BlackBerry users showed signs of addictive behaviour similar to an alcoholic being unable to pass a pub without a drink. “Just one more email for the road…”
Textbook symptoms
The report found that some BlackBerry users displayed textbook addictive symptoms – denial, withdrawal and antisocial behaviour – and that time with their families was being taken up with BlackBerry-checking, even at the dinner table.
As a result, Professor Kakabadse notes that employers are being sued for failing in their duty of care to staff and in following health and safety guidelines. In one case in the US, a female business consultant claimed that her marriage fell apart because she was constantly checking messages. She ended up losing custody of her children and sued her employer for damages. [Note to our lawyer readers: I have no citations for this and the subsequent cases.]
Written Policies
“Enlightened companies that issue BlackBerrys as standard like pen and paper should also have policies on how to use them, so that people can use technology in a way that doesn’t have an addictive side,” said Professor Kakabadse. So perhaps your written policy should require that the device be turned off during dinner, during any interactions with spouse and children, during love making for sure and at bedtime. [Just how such a policy would be enforced is beyond the scope of this posting.] One Chicago hotel has even offered to lock up your Blackberry, so you can enjoy your stay unencumbered and unconnected.
The Independent article cites another recent case, where a woman sued after putting cleaning fluid on her baby’s nappy instead of baby oil because she was distracted by her BlackBerry. [We sympathize with this poor working mom for making such a common mistake in the nursery. No question, it’s her employer’s fault.]
One study reveals that nine out of every 10 users have a compulsive need to check for messages and that nearly half experience long-term negative consequences associated with carrying a BlackBerry. A survey of business workers by researchers at the Sloan School of Management at Massachusetts Institute of Technology in the US found that employees were constantly tired because they were waking up in the middle of the night to check or send messages. One interviewee likened the sense of potential gain from staying in touch with work to “pulling the lever of a slot machine”.
24/7 = Always at Work
A professor at Rutgers’s School of Business, Gayle Porter, predicts in a soon-to-be-published study that disgruntled workers who feel they are unable to turn off their personal digital assistants and mobile telephones will begin suing their employers for their technology addictions — and that such lawsuits could potentially cost corporate America hundreds of millions of dollars.
“If companies develop a culture in which people are expected to be available 24 hours a day, then they should be prepared for the physical and psychological consequences,” Mrs. Porter said. “Addicts exhibit extreme behavior and have no control over themselves. So a corporation handing someone a BlackBerry on his first day of work could be seen as enabling, even accelerating, a serious addiction to technology.”
Be Forewarned
The trends are clear, the dangers incontrovertible. Uncontrolled use of Blackberry-type devices can lead to physical, mental and social debilitation. Someone is bound to announce the development of a new 12 step program for Crackberry addicts. The road to recovery will begin with the assertion that “I am an addict.” Meanwhile, employers should develop comprehensive written warnings to accompany the provision of any PDAs. These guidelines should set clear parameters for appropriate Blackberry use. With half the marriages in this country already ending in divorce, employers need to avoid any possible inference that work – and work-provided equipment – is a significant cause of marital discord. In the ever-expanding definition of risk management, this is one area where increased vigilance – and a few disclaimers – are definitely in order.

Alcoholism and Work: The Devil’s Brew

Tuesday, July 26th, 2005

We begin today’s blog not in the workplace, but in the home. The family basement, to be exact. According to the Detroit Free Press, Merle Rydesky wrapped a chain around his 57-year-old alcoholic brother’s neck, binding the other end to a bedpost in the basement. He padlocked the chain, pocketed the only key and left for work. His was trying to keep his younger brother sober, he said, in hopes of getting him into a treatment program. His brother had to stay sober for five days before he could be admitted to a detox program.
About four hours later, James Rydesky was found dead in his Dearborn MI home, choked to death by the chain wrapped over a basement banister, his body hanging in a semi-seated position. His elderly mother found the body.
The most surprising part of this story is that Merle Rydesky is a well-respected doctor who chaired the emergency medicine unit at Providence Hospital in Southfield for 20 years. He obviously did not specialize in substance abuse! Rydesky was spared any prison time by pleading guilty to involuntary manslaughter.
Rydesky’s dubious approach to detoxifying his brother raises a number of interesting issues related to drunkeness. We’ve been here before — in the high profile cases where employers are confronted with employees who drink. We recently profiled the case of Thomas Wellinger, who may qualify for the Guinness Book of Records for his blood alcohol content of .43. Driving in a drunken stupor, he wiped out a mother and her two sons — but as is so often the case in these tragedies, he himself survived and now faces serious criminal charges.
And in Newsday here’s yet another affluent individual whose driving has destroyed the lives of others and brought his own life to the verge of prison. This time it’s a well known trial attorney named Keith Kalmus. Prosecutors say Kalmus was driving at 85 mph in a 30 mph zone, lost control of his Ford Explorer and swerved into the eastbound lane, colliding with a Subaru sedan. The collision killed Belgian visitor Eva Bertuccioli-Krapfenbauer, 65, and critically injured her sister, Margot Krapfenbauer of Austria, and her son Claudio Bertuccioli and his wife, Rebecca McMillin, both of Brooklyn.
Alcoholism as Disability
There is little question that alcoholism is a life-threatening condition. What makes it unusual is that the threat is not just to the alcoholic, but encompasses immediate family members (just ask Dr. Rydesky) and innocent bystanders as well. It is considered an illness, but unlike most illnesses, theoretically the alcoholic can sober up at any time. This is one illness from which you can walk away when you are ready.
Under the ADA, recovered alcoholics are considered individuals with a disability and as such are protected from discrimination. However, the ADA draws the line at active drinking. Once employees “fall off the wagon,” they are no longer protected by the ADA. (Some state disability laws, however, expect employers to take proactive steps to help the relapsed employees enter a treatment program.) When employees have a drinking problem, employers are faced with a lot of uncertainty — up to a point. As soon as the drinking endangers the employee and or others, employers are expected to take decisive action.
Responding to Impaired Employees
We’ve been tracking the Wellinger case from the perspective of liability: who will pay the price for Wellinger’s appalling performance behind the wheel? His lawyers have taken steps to protect his assets, putting a valuable vacation home into a trust — and thereby out of the reach of his victims’ family. The search continues for the party or parties who provided the alcohol to fuel his astonishing blood alcohol level. Was it a package store? A bar? Most important for our purposes, what did the employer know about his impaired state? Did they allow him to drive off drunk, without taking appropriate action to protect the general public? If the employer had any knowledge of his drunken state, they will assume at least some of the liability for his actions, because they failed to notify the police of the immanent danger.
We encourage employers to have written policies to ensure a drug and alcohol free workplace. Most do. The problem is in the execution. How do you enforce the policy? How do you balance the privacy concerns of the employee with the obligation to provide a safe workplace? Most important, how should you respond when you become aware of a potential danger? Let’s say you take what you think is appropriate action because someone has a history of alcoholism and you think they look impaired, but it turns out you are wrong. They are perfectly sober. If you are not very careful, your “action” may be an act of discrimination. On the other hand, you have a popular employee who has four alcoholic drinks at lunch, but you take no action, because he’s such a good guy. He drives off and wreaks havoc on the road — and because you had knowledge of the drinking, you are liable for your failure to take action. Talk about being between a rock and a hard place!
These situations do not arise in a vacuum. I was struck in the Wellinger story about the months preceding the accident. He had gone through a painful divorce. Evidently, he was very distraught by the breakup. He was a good employee going through a rough time. I wonder what the employer did to support him during his troubled divorce. I wonder if they encouraged him to get help. I have no idea whether his drinking prior to the divorce was a problem, but he clearly began drinking more and more heavily after the divorce, building a remarkable tolerance that enabled him to reach nearly impossible blood alcohol levels. Did his supervisor look the other way? Did co-workers feel too embarrassed to question him? Did they simply hope the problem would go away? The truly sad part is that their failure to intervene probably contributed not only to the deaths of three innocent people, but to the end of Wellinger’s career as well.
Communicate!
If there is a single answer to these problematic situations, it’s keeping the lines of communication open. Management requires open eyes and, to the degree possible, open hearts. There are unthreatening ways of initiating a dialogue with troubled employees. It’s not easy, but considering the devastating tales in today’s blog, it’s well worth the effort.