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Summer 2018 Newsletter

Edited by Jim Ellenberger

This month we report on the opioid epidemic, focusing on the connections between workplace injuries and painkiller dependency and highlighting how failures in the workers' comp system exacerbate addictive opioid use. We also analyze recent public health and workers' comp legislation, considering which regulative policies present pro-worker solutions and which are mere smokescreens for industry-driven attacks on workers' rights.

– Jim Ellenberger

Prescription Proscriptions or Public Health? Opioid Treatment in Workers’ Comp

The nation’s opioid crisis has reached epidemic proportions. More than 2 million people in the United States are now addicted to opioids or heroin, and in 2017 alone, 64,000 Americans died from drug overdoses—more than from car crashes or guns, more than died from AIDS at its peak, and more Americans than were killed in the Vietnam and Iraq Wars combined. Opioid addiction has helped put the nation’s life expectancy on track to fall for a third straight year, a backward slide virtually without precedent in the developed world. If things don’t improve, 650,000 more people could die of opioid or heroin overdoses in the next ten years. And it’s not just those who die who suffer: addiction is devastating entire families and communities.

Decades in the making, the opioid crisis is finally beginning to be taken seriously as a national priority: the House passed a set of 57 opioid bills in June, and the Senate is expected to follow suit. Yet far too little attention has been paid to the connection between opioids, dangerous jobs and workers’ compensation, despite research showing disproportionately high overdose fatality rates in occupations with the highest injury rates. This deficit has created space in which the pharmaceutical, workers’ compensation insurance, and employers’ industries are capitalizing on the opioid crisis to chase profits by, yet again, pushing anti-worker legislation that is reshaping states’ workers’ comp systems. In this latest round of reforms, states are adopting statutes and regulations that further limit and tighten control over workers’ medical care rather than addressing worker safety and opioid addiction with the comprehensive, worker-centered public health approach the epidemic demands.
 
Workplace hazards and Big Pharma drive chronic pain and addiction
 
Workers in many industries contend with heavy lifting, repetitive motion, sedentary postures, and other stressors that can lead to musculoskeletal problems, back injuries and chronic pain. Left untreated, chronic pain can be extremely debilitating, affecting not just people’s work, but also their home lives, their financial stability and their physical and mental health.
 
“When sustained over years, on-the-job injuries can give rise to chronically painful conditions, potentially resulting in a downward spiral of disability and poverty,” write public health scholars Nabarun Dasgupta, Leo Beletsky and Daniel Ciccarone in a paper in the American Journal of Public Health.

Workers suffering from painful injuries often have few options. As the Massachusetts Coalition for Occupational Safety and Health (MassCOSH) explains, “inadequate workers compensation systems and the fear of losing their job leads people to return to work before they are healed and to work in pain, depending on painkillers to get through their day, leading to addiction and overdose.” 

This occurs, of course, in a context in which workers are systematically disempowered in the workplace and the economy. Workers often don’t have the power to fix the unsafe working conditions that cause their injuries, nor to make work and life adjustments that would allow them to manage their pain and return to health. It is exacerbated too by the fragmentation and biases of workers’ comp and the rest of the medical system, which tend to individualize and medicalize pain rather than facilitating prevention and supporting comprehensive occupational, physical, and mental health treatment—strategies that often need to include not only doctors and patients, but also a workers’ employer, co-workers, and family members.

In this context, the immediate pain relief offered by a pill can be the quickest, easiest solution for workers, doctors and employers alike. In the 1990s, drug reps began touting opioids as ‘miracle drugs’ for pain. They targeted much of their marketing at doctors serving patients with painful black lung disease in West Virginia and Kentucky, claiming that their extended-release formulas were less habit forming. By the end of the decade, pills were a staple prescription for back pain and other common workplace injuries across the country.

As we now know, the low risk of addiction claimed by drug companies was wildly understated. When prescribed unchecked over the long term, opioids can be highly addictive. By 2015, reported the CDC, enough opioids were prescribed each year to medicate every adult in the country around the clock for three weeks. 

Opioid addiction extends far beyond injured workers, but as National COSH’s opiate working group found in a recent investigation, workers in dangerous industries continue to face a particularly high danger. Workers in construction and other occupations with the highest injury rates have higher opioid overdose fatality rates, and many of those who die from overdoses previously suffered a work injury. A 2015 study in the International Journal of Drug Policy reached the same finding.
 
Lobbying for false solutions
 
Since around 2000, increasing addiction and overdoses across the country have attracted public attention, including the attention of insurance companies and employers’ associations. Seeking to cut the cost of prescriptions and the potential role of addiction in driving long-term disability, these industries are pushing states to take action.
 
Over the last ten years state legislatures and the federal government have responded to lobbying by enacting new legislation to rein in opioid prescriptions. In 2011, for example, Texas introduced a closed formulary that requires workers’ comp insurers and self-insured employers to preauthorize workers’ prescriptions. That same year, Florida shut down “pill mills”—doctors’ offices dispensing large amounts of opioids—by banning physician dispensing of drugs. In 2012, Kentucky required providers to use its prescription drug monitoring program (PDMP) to monitor patients’ prescriptions across doctors and pharmacies before writing any opioid prescriptions for patients.
 
Such measures to cut off the supply of opioids would seem to make sense, but in practice most states have choked off prescriptions without doing much of anything to address the root causes of pain and addiction and without providing patients who are already suffering from drug dependency with effective treatments.
  
Drug formularies set what Dasgupta, Beletsky and Ciccarone describe as “arbitrary targets” that do not work for “patients who do not conform to clinically arbitrary expectations.” And as Beletsky explains in the Huffington Post, PDMPs are a tool that can do more harm than good if they’re employed in the wrong way. Too often when a patient is flagged for having too many prescriptions, their doctor’s only option is to withhold the prescription, “fire” the patient or call the police.

When tools like drug formularies and PDMPs are used to cut off medication or criminalize a patient rather than triggering a coordinated program of drug treatment, harm reduction, and social and economic supports, they do not help people avoid the use of painkillers or break an already existing cycle of addiction. Indeed, they push patients out of the healthcare system and into the black market.

There is a long history of blame, punishment, and criminalization of addiction in the U.S., especially for poor people of color. The crack epidemic of the 1980s and 1990s, which largely affected poor and working-class Black communities, was met with brutally punitive policing, prosecution and prison sentencing. Powder cocaine was also widely used at the time, but because it was more prevalent in wealthier White communities, officials took a far more lenient approach. Similarly, heroin addiction, which has historically been associated with poor people and people of color, has always been treated far more harshly than addiction to prescription pills, which is frequently associated with celebrity overdoses and media tropes like painkiller-addicted soccer moms. Only as the perceived prevalence of heroin use among White people has increased have we begun to see a shift from criminalization toward a public health approach. We must still move much farther away from criminalizing addiction—by granting legal immunity to drug users who report an overdose, for example—but we can only do so by directly contending with the historic and ongoing racial and class bias of the criminalization of addiction.

Rather than pushing people out of the healthcare system, monitoring and regulation of opioid prescriptions must be matched with comprehensive medical treatment and social supports to address patients’ pain and provide for their economic and psychological wellbeing. Unfortunately, in most states these industry-driven proposals have in practice ignored the environmental causes of addiction, been warped by profit incentives, and suffered from narrow, ideologically constrained thinking.
   
Pennsylvania, the latest state to become a battleground for such legislation, serves as an apt example of how this can play out. A recent bill proposing workers’ comp drug formularies (SB 936) sparked a heated debate, with the state’s unions, democrats, and medical and legal professionals warning that supporters’ promises of opioid prevention were nothing but a smokescreen for slipping past far-reaching attacks on injured workers’ medical and legal rights. As Lisa Benzie, president of the state trial lawyers group, explains, the bill’s overly broad wording threatened to give insurance companies decision-making powers that could limit treatment for injured workers beyond their drug regimens. Like many worker groups and advocates, the Pittsburgh firefighters union warned that the bill would take injured workers’ treatment “out of the hands of doctors and giv[e] the decision making power to insurance companies.” While democratic Governor Tom Wolf vetoed the bill at the end of April, it represents a legislative strategy being pushed more widely by the workers’ comp insurance industry, which continues to make opioid regulation a priority front for its lobbying efforts.
 
A worker-centered public health approach to safety, pain, and addiction prevention and treatment

An effective approach to preventing opioid addiction among workers must begin by preventing the root causes of injuries and pain that lead to addiction. As MassCOSH emphasizes in its 2018 Dying for Work report, safe, healthy workplaces and appropriate, comprehensive, and timely treatment of workplace injuries are essential to reducing injured workers’ reliance on painkillers. 

Worker education is also an important factor. Building off research into the relationship between work injuries and opioid use, conducted with Cora Roelofs, ScD at the Center for Promotion of Health in the New England Workplace, the organization is working to pilot a peer-training model for educating workers about painkillers, addiction and how to advocate for proper medical treatment and work accommodations. They also emphasize that destigmatizing addiction, providing accessible recovery services, and re-evaluating punitive workplace drug testing are crucial steps to help workers recover from opioid dependency.

When it comes to promoting effective evidence-based pain treatment, Washington State’s workers’ comp system provides a strong model. Washington’s Department of Labor, which runs the state’s public workers’ comp system, has worked in collaboration with other agencies to establish treatment guidelines for physicians and cross-agency prescription monitoring that guide doctors toward prescribing comprehensive pain management treatment and evidence-based addiction treatment rather than denying patients care.

Washington developed its approach in response to a 500% increase in opioid prescribing in less than a decade’s span. Its safe dosing guidelines, introduced in 2007 and updated in 2015, offer separate guidance to prevent addiction among patients receiving new prescriptions and to provide comprehensive treatment to patients already dependent on opioids. In 2010, Washington added a good Samaritan law designed to help combat the risk of overdose for individuals suffering from addiction. The law both gives legal immunity for drug possession to anyone seeking medical aid for an overdose and allows naloxone, an opioid antidote, to be prescribed preventatively to at risk individuals or those who may witness an overdose. 

By targeting opioid use at multiple stages and emphasizing care and treatment rather than criminal consequences for addicted individuals, Washington has effectively reversed opioid prescription and overdose rates. This success extends into the state’s workers’ comp system, which saw significant decreases in the number of injured workers prescribed opioids or treated for opioid dependency, according to findings from a Journal of Pain study.

While there is a clear public health consensus around the need for prevention and evidence-based treatment of opioid addiction, pro-worker solutions can only be widely implemented if labor, public health advocates, and their allies work together to prioritize workplace health and safety and timely, adequate care in workers' comp. To conduct needed research on this challenge and build strategies for worker-focused solutions, National COSH has established an opiate workgroup comprised of community, academic and labor health and safety activists. The group is in the process of building collaborations between National COSH's affiliates and university or state partners to investigate the connections between vulnerable workforces, occupational injury, and opioid dependency. The group will host a webinar on September 20 from 2-3 pm, where you can learn more and find out how to get involved.

Events

Workplace Injury and Opioid Addiction: Getting to the Root of the Problem — a webinar hosted by National COSH
Thursday, September 20, 2018; 2-3pm

In this webinar we will look at current data and research that makes the link between workplace injury and opioid use to understand the “state of the issue” and where and how to intervene to prevent addiction and overdose.  Speakers will also discuss a worker-justice framework to this problem and, through case studies and current research, innovative solutions including training and peer-led models.  
Join by computer or call in at (669) 224-3412, passcode: 128431613
 

Save the Date: National Conference on Worker Safety and Health
December 4-6, 2018
Maritime Conference Center, Linthicum Heights, MD 

Register Now!


Resources: more on the opioid crisis

Origins, Impact and Solutions

Opioid crisis: no easy fix to its social and economic determinants

A public health approach to drug policy

Inside a killer drug epidemic: A look at America's opioid crisis

The opioid epidemic, explained

How to stop the deadliest drug overdose crisis in American history

Pharma's culpability

Politics of pain: Drugmakers fought state opioid limits amid crisis

The family that built an empire of pain

Racial and Class Disparities in Treatment of Addiction:

Opioid addiction knows no color but its treatment does

Cashing in on despair

Prescription Monitoring

As heroin deaths skyrocket prescription monitoring programs may do more harm

CDC prescription guidelines 

News Roundup
 

Trump’s Labor Department has failed to reappoint an Obama-era committee that helped federal nuclear workers get compensation for work-related illnesses stemming from toxic exposure. The lapse in the advisory board of scientists, doctors, and worker advocates that defended injured workers’ rights against deliberate delays and complications in the DoL’s Energy Employees Occupational Illness Compensation Program is “concerning and potentially hazardous to the health and livelihood of workers,” said New Mexico’s Democratic Senator Tom Udall. 
 

Tesla Motors has falsified its safety records, leaving numerous incidents off the books according to a new investigative report from Reveal. The electric car manufacturer has a record of consistent health and safety violations and worker abuses, often sending injured employees back to work without proper treatment and telling them their pain is not work-related. 
 

5,190 people were killed on the job in 2016 and over 50,000 died from occupational diseases, shows AFL-CIO’s annual “Death on the Job” report, adding that worker safety is under a grave threat from the Trump administration’s deregulatory policies, which include delaying or throwing out regulations on workplace violence, infectious diseases, and silica in mining and combustible dust, and making costs the primary factor in adopting new protections. 

Visit us at www.workerscomphub.org! We invite you to suggest events and actions for inclusion on the website or share resources and tools. If you have a perspective or story that you would like to share, please contact us at info@workerscomphub.org.
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