Opioid-Induced Hyperalgesia
Anytime I discuss medical issues I always clarify that I am in no way a medical physician. Whether it is to a claimant, or an attorney, I can only interpret medical in my own opinion based on training and years of experience in this business. I do also clarify to people that I always try to stay up to date on new medical issues, since they can have a direct application on the handling of workers compensation insurance claims.
There has been some talk of late about a new issue involving opiate medications, coined “Opioid-induced Hyperalgesia” or “OIH” for short. Oftentimes a claims adjuster has a file where a claimant is taking a large amount of opiate medications for pain. Every time the adjuster reviews the medical records, or talks to the claimant, the injured party seems to be in more pain than before, despite the presence or even increased dosage of strong narcotic medications. How is this possible? If Oxycodone is doing nothing for pain control, then what other steps could you take for pain control?
In the past, an adjuster worried about narcotic pain medication causing addiction issues, dependence issues, and increased medication tolerance issues. In addition to that, these medications are costly, and they seem to be prescribed on every claim no matter what the severity. But OIH has raised new concerns about longer-term chronic pain issues and what to do before these claims get out of control.
The Cause of OIH:
The exact cause of why OIH occurs is currently under medical investigation. The leading theory continues to be the excitation of nerves through chemical pathways by certain types of narcotics. Research has shown that some narcotics may have a higher propensity to cause OIH than others. These are mainly known as the “phenanthrene opioid” class of medications, which includes codeine, hydrocodone, oxycodone, and hydromorphone. In patients where OIH could be the culprit, switching to a non-phenanthrene medication such as meperidine or tramadol often times leads to adequate pain relief, much to the surprise to those involved.
In simpler terms, OIH may be caused by the narcotic itself increasing the level of pain that the patient may be experiencing. Almost out of the blue, this medication that is supposed to be used as a pain reliever is actually worsening the pain, thus requiring larger and larger doses of medication for adequate pain relief. As these doses increase, so do the risks for the more well-known issues with pain medication which include central nervous system issues, depression, addiction, drug-seeking behavior, and the risk of overdose. Even more, the financial costs of these medications begin to dominate the claim more than anything else, including wage loss.
What to Watch For:
Some common characteristics of OIH include:
- Worsening pain over time despite increased dosages of opiate narcotics used for pain control.
- Pain that becomes more diffuse in and around the area of injury.
- Sensitivity to touch around the injured area specifically.
- Subjective setbacks in the progression to MMI without diagnostic objective findings.
The Future of OIH
Although this is a newer phenomenon, the study of OIH can change the way physicians diagnose and treat chronic pain cases. To date, if a patient’s pain in not controlled by whatever medication they are taking, it is common to step the dosage up to the next level, and re-evaluate pain at the next doctor appointment. Because increased doses are used, the patient also has increased tolerance for pain medication, and at that point the dose must increase again. But if OIH were to be present early on, but not addressed specifically, then who knows if that medication would have ever helped this person’s pain, no matter what the dose?
There is a large potential for work comp claimants to experience OIH symptoms since narcotic pain relief is often used early on, usually at the first visit to the clinic. When reviewing your comp files, especially those longer-term files where a person has had chronic pain symptoms of an escalating nature without any exacerbation of the injury, those files should be sent for an OIH evaluation by a medical professional.
Summary
I believe it is a safe assumption that OIH could be responsible for a significant percentage of claims dollars spent within the workers compensation system. Cost drivers that can occur if this is not diagnosed will be increased medication costs, medication side-effect management, and addiction treatment. These three issues alone can be responsible for large amounts of money spent on the claim. The ability to identify OIH very early on in the life of a claim can save massive amounts of claim money, and also benefit the claimant who would not have to deal with the strong side effects of the long-term use of these dangerous medications. The ability to identify and treat OIH correctly will lead to better claim outcomes, earlier returns to the workplace post-injury, and an overall decreased burden on the work comp system as a whole.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.
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