A recent TED Talk that emphasized the importance of psychosocial over pharmacological interventions for opioid addiction reminds me of an important debate that impacts our injured workers. The debate is about treating opioid addiction, specifically the place of opioid maintenance treatment (OMT)—providing chronic prescription opioids to replace other opioids.

One argument often used to support the use of OMT today is based on the belief that addiction is largely a biological condition mediated by the brain and that addicts “need “continued chronic opioids to become stable. Some of this argument is bolstered by functional MRI data that allows us to see what parts of the brain interact in addictions and in other behaviors. However, seeing what parts of the brain are active does not mean that targeting the brain with a pharmacological solution is better than targeting it with psychosocial interventions.

Of course, our healthcare environment is vulnerable to quick fixes that promise a simple solution in a bottle. We bristle at any intervention that requires more complex follow-up or less wieldy coordination or additional steps.

How does any of this apply to workers’ compensation? First, there is the prescription opioid problem which is alive and well, though we are making some gains due to mitigation strategies. But is the use of chronic prescription opioids the answer for those who become medically dependent? How about the injured worker with a prior addiction history? Second, workers’ compensation claims organizations are vulnerable to solutions that result in unmet promises because they naturally seek the simple one-stop, and apparently less costly, “get it done” solutions desired by high volume operations. But it can be dangerous to conflate the concepts used to treat heroin addicts with practices for meeting the needs of a more diverse workers’ compensation population.

Opioid Addiction Versus Dependence

There is ongoing debate about the ideal strategies to treat opioid addiction and dependence. It is vital to not confuse the discussion about opioid addiction and that about injured workers who have become medically dependent on prescription opioids. For the purposes of this blog post, addiction refers to the person who is addicted to illicit opioids (such as heroin) or prescription opioids (often not prescribed to them).

The hallmarks of “addiction” (the 4 Cs) have traditionally been defined as loss of control of use of the drug, continued use despite harmful consequences, craving for the drug, and compulsion to use or seek the drug. Though some injured workers on long-term and/or high dose opioids may manifest these behaviors, most do not. But just as important, many do not show obvious benefit from the drugs and will often present with significant side effects which may include aberrant use.

Physical dependence develops commonly when on long-term opioids. Often, higher and higher doses are required to avoid dreadful withdrawal symptoms between doses. Thus, opioid doses may escalate due to drug seeking behaviors similar an addicted person. Clearly there is some overlap, but the reason to differentiate these populations is so we do not commit a previously well injured worker to life-long opioid dependence perpetuated by opioid maintenance therapy.

Opioid Maintenance or Not?

The controversy here relates to the best way to treat opioid addiction. In recent years, we have seen a resurgence of pharmaceutical approaches to treating addiction (e.g. Suboxone, Subutex, Buprenorphine, and Methadone) over non-pharmacological approaches. Local and federal agencies have discussed the need for access to treatment, which often included opioid maintenance therapy (OMT). Some studies have shown that maintenance therapy can effectively treat addiction, yet so can abstinence and ongoing psychosocial treatments. Of course OMT is attractive to those who want to deliver a “quick fix,” simple solution, and give a prescription. What’s overlooked is the relapse rate on OMT. More important, OMT is not an addiction cure. In fact, most OMTs deliver very high doses of opioids; they maintain the addiction so that people do not have to seek opioids by illegal means.

In the mid-1960s, methadone programs began popping up to provide heroin addicts a safer alternative. Safer was defined as not having to share needles and less criminal behavior to acquire money to buy heroin. The comprehensive program helped keep people sober, but not abstinent since methadone is a powerful opioid. In fact, a whole subculture developed around methadone abuse.

More recent pharmaceutical innovations, namely buprenorphine—including products such as Buprenorphine Suboxone and Subutex, Zubsolv and Bunavail, to name a few—are becoming increasingly popular, mainly because buprenorphine has a ceiling effect and is reputed to be less likely to lead to overdose. But many buprenorphine solutions do not have an exuberant psychosocial support structure around them.

A colleague of mine notes that most of his Suboxone patients become more stable, if for no other reason than they do not have to seek prescription medications or illicit opioids via nefarious means. All the time spent drug-seeking is now freed up to live one’s life, and perhaps return to work. Of course, there are still those who abuse drugs and who do not benefit from the stability of receiving a prescription supply. The methadone experience suggests that OMT helps decrease the criminal behaviors, but recent studies on that are mixed.

Unfortunately, all of these products have high morphine equivalence. For example, a common regimen for Suboxone—8 mg tablets 2 times per day—can deliver a morphine equivalent daily dose (MEDD) of 320-800 mg. For someone who is dependent on 160 mg per day of oxycodone (80 mg BID), for example, this represents a significant increase in opioid dose from their MEDD of 240 mg. Buprenorphine has a ceiling effect, so at yet higher doses, there is a decrease in MEDD. Methadone delivers a powerful dose, as well. Someone on 40 mg of methadone per day would have a MEDD of 320 mg. Thus, an injured worker on opioid maintenance therapy would still be at risk for all the potential short- and long-term side effects of chronic opioids.

Alternatives to Opioid Maintenance Therapy

The point here is that opioid maintenance therapy does not cure addiction, it sustains it. Committing injured workers who have prescription opioid dependence (essentially a physical need to prevent withdrawal syndrome) to a potential lifelong dependence on opioids with the risk of opioid-induced side effects (e.g. hypogonadism, impairments of immunity, osteoporosis, addiction, hyperalgesia, and cognitive impairment) is not often an effective treatment.

Despite the need for simple, automatic and inexpensive claims solutions, these cases require thoughtful strategies that incorporate the goals of good long-term health and consequently a manageable claim tail. There are alternatives to OMT including counselling, chronic pain management programs, and abstinence programs.

Most injured workers are not addicts and were not previously addicts. Though some of them would meet the criteria of addiction, or severe opioid use disorder (DSM V) and may benefit from OMT, the majority would benefit more from putting this episode of opioid dependence behind them completely. OMT is a real commitment both financially and medically, and for that reason is not a simple solution.

About the Author

Steven M. Moskowitz, MD, is the Senior Medical Director and supervisor of Paradigm Outcome’s complex pain program. Dr. Moskowitz is a specialist in physical medicine and rehabilitation with clinical expertise in complex musculoskeletal and neurologic rehabilitation including spinal cord injury, multiple sclerosis and chronic pain.