Pezzano Mickey & Bornstein, LLP September 2018

SEPT 2018

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Perspectives PMB

The History of the Opioid Crisis PAIN MANAGEMENT AND ADDICTION ISSUES IN WORKERS’ COMPENSATION

I recently read the book “Dreamland” by Sam Quinones, an investigative reporter who tracked the roots of the opioid crisis in America. I was interested in the subject because I have unfortunately seen several of my clients develop devastating addictions due to pain caused by work injuries. The title of the book comes from the town of Portsmouth, Ohio, where residents flocked to a huge swimming pool named Dreamland, which served as the communal center of the once-vibrant town. The idyllic pool closed when industry left the town, but another type of dreamland took its place — in the form of a “pill mill.” The author researched the evolving attitudes of the medical community, which struggled to balance the need to alleviate patient pain against the risk of addiction. Before the advent of prescription painkillers, patients often suffered horribly without medication, even post-surgery, due to the fear of addiction. In the 1980s, Dr. Hershel Jick studied hospital records to determine the percentage of hospital patients treated with narcotics who became dependent on the drugs. He advised the New England Journal of Medicine of his findings in a one-paragraph letter to the editor, writing that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” For decades, this simple letter has been twisted, misquoted, and misrepresented by the pharmaceutical industry to persuade the medical community that their fear of narcotics was overblown. Purdue Pharma, the manufacturer of OxyContin, began to use the letter in their marketing plan to convince doctors that it was safe to prescribe such narcotics to people suffering from chronic pain on a long-term basis. Physicians were lectured that it was cruel to turn away those who suffered from chronic pain when they could be treated with “non-addictive” miracle painkillers, such as OxyContin. The theory peddled by the pharmaceutical industry was that the patient’s pain would “soak up” the euphoric effects of the drug, reducing the likelihood of addiction. In his book, Quinones details the cycle of how patients with relatively minor injuries could become hooked on opioids after a short period of time. These patients found out the hard way that terrible withdrawal symptoms occurred when the medication was stopped. Pain clinics started popping up all over the Midwest to meet the growing demand, and an underground economy was born. To feed their addiction, patients often visited multiple clinics to stock up on opioids and sold the extra pills to support their habit.

Some patients, unable to get their prescriptions refilled and desperate to relieve the withdrawal symptoms, learned of a cheaper alternative which would provide them with a similar high: heroin. The illegal drug known as “black tar heroin” made its way into the heartland of America from Mexico around the same time that our country experienced a proliferation of pain clinics. In his book, Quinones explains how traffickers of black tar heroin soon found a new group of customers in chronic pain patients. This poison was marketed as the “Happy Meal of dope” — fast, cheap, and convenient. Dealers hung around pain clinics and offered special discounts for first- time users, leaving their customers with phone numbers to call anytime they needed a refill. I have unfortunately watched several of my own workers’ compensation clients go down this distructive path. Physicians must no doubt perform a difficult balancing act — to alleviate pain while avoiding addiction to medication. Sometimes the bureaucratic red tape of the workers’ compensation system makes this balancing act even more challenging. Some insurance carriers try to avoid surgery at all costs, at times unwittingly leading doctors to prescribe narcotics for patient pain instead of surgically addressing injuries that cannot be cured with conservative measures. It is not uncommon for a patient to wait months for surgery while attorneys are litigating the issue of whether a procedure is necessary and related to a work injury. During that time, patients are often sustained by pain medication. Of course, after surgery, the pain medication continues to address the acute pain caused by the surgical procedure. In short, the delays experienced by workers’ compensation claimants often result in unnecessarily extending the amount of time a patient is on narcotic medication, increasing the risk of addiction. On the flip side, most carriers will not authorize alternative medical treatments, such as chiropractic care and acupuncture, which could at least temporarily ease the pain of a traumatic injury while the body is healed over time. How many injured workers could have avoided surgery and opioids altogether if such alternative treatments were available? For example, one of my clients, whom I will call John, injured his lower back at work. He dutifully followed the recommendations of the workers’ compensation physician, who performed a lumbar fusion. The fusion

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