Chronic pain fuels opioid epidemic

Pain. Artist: Harrygouvas, via Greek Wikipedia. Creative Commons

Pain. Artist: Harrygouvas, via Greek Wikipedia. Creative Commons

PENNEY KOME: OVER EASY
January, 2017

Of all the stories I’ve seen about the prescription opioid epidemic, only a few touch briefly and lightly on the major factor driving all the prescriptions — chronic pain — before they skip on to recommend better patient and physician education.

“For 20 years, doctors have prescribed opioids — drugs such as oxycodone, hydromorphone, fentanyl and others — liberally for chronic pain, one of the most common problems we see.” wrote David Juurlink, head of the University of Toronto’ pharmacology department, in a Globe and Mail op-ed piece.

“Chronic pain not caused by cancer is among the most prevalent and debilitating medical conditions,” said a New England Journal of Medicine (NEJM) article, “but also among the most controversial and complex to manage.”

“Chronic pain is a major public health problem,” said an article from the U.S. National Institutes of Health, “which is associated with devastating consequences to patients and families, a high rate of health-care utilization, and huge society costs related to lost work productivity. The existing treatments for chronic pain are unable to address the problem and better therapies are urgently needed. The need for these therapies is the backdrop for the expanding use of opioid drugs.”

Chronic pain is not a given, it’s a catastrophe

Let’s define chronic pain as constant, incessant, stabbing, aching, throbbing, agonizing sensations that people live with day in and day out, with no hope they’ll ever get better. Between three and four out of every 10 Americans meet each day painfully. “More than 30 per cent of Americans have some form of acute or chronic pain,” says the NEJM. “Among older adults, the prevalence of chronic pain is more than 40 per cent.”

Here, for me, is where most reports start to lose perspective. The NIHI article continues, “Given the prevalence of chronic pain and its often disabling effects, it is not surprising that opioid analgesics are now the most commonly prescribed class of medications in the United States.” I take issue with practically every clause in this sentence.

First of all, having 40 per cent of the population in chronic pain is not a given, it’s a catastrophe. In Canada, the rate is half that — one in five adults, or 20 per cent, according to the Canadian Pain Society. European data is similar.

Second, prescribing opioids was not a natural or even logical result of these pain levels. A lot of medical people now regret that health care adopted a “fifth vital sign” policy during the 1990s, apparently as a result of military hospital concerns about veterans’ pain being undertreated. Administrators required any nurse who checked a patient’s four vital signs (pulse, temperature, heart rate and breathing rate), also to take “the fifth vital sign” and ask the patient to assess their pain. This well-intended practice almost inevitably led to more pain medication prescriptions. But that’s not how opioid prescriptions became standard medical practice in the U.S. Third, the American Journal of Public Health reports that one aggressive and deceitful company led the way in promoting opioids as safe for long-term use. Purdue Pharma introduced OxyContin during “a
period of liberalization” in prescribing narcotics, with highly profitable but socially disastrous results. Purdue also pioneered marketing directly to doctors, with paid trips and personal pitches.

“When Purdue Pharma introduced OxyContin in 1996, it was aggressively marketed and highly promoted. Sales grew from $48 million in 1996 to almost $1.1 billion in 2000. The high availability of OxyContin correlated with increased abuse, diversion, and addiction, and by 2004 OxyContin had become a leading drug of abuse in the United States.”

In a 2007 court settlement, Purdue agreed to pay the U.S. government a $160 million fine for fraudulently claiming that OxyContin was “abuse resistant,” because it was a time-released medication.

Finally, let’s get back to the chronic pain. In Canada, the main causes of chronic pain are shingles, surgery and fibromyaglia. In the U.S., causes include chronic respiratory issues, mental and substance abuse disorders and neurological disorders. Two of the main five causes are back pain and “musculoskeletal injuries” a term that usually includes conditions such as frozen shoulder, tendinitis, and yes, carpal tunnel syndrome.

The American Journal of Public Health article says chronic pain patients’ numbers started to increase during the 1980s. Doctors started prescribing opioids in the 1990s.

“Productivity” boosts come at a cost

Lest we forget, the 1980s introduced the computer revolution. As a freelance writer, I bought my first computer in 1982, a KayPro64, in a buying co-op with a group of other writers. About the same time, newsrooms all around the world introduced computers according to the best technical advice. By 1992, hundreds and thousands of journalists were reporting intense arm or shoulder pain, or losing the use of their hands.

“Work-related injuries, long the plague of those who do heavy manual labor, have become a scourge among white-collar workers, too,” Jane E. Brody reported in the New York Times in 1982. “Experts say hundreds of thousands of office workers are being disabled each year in an epidemic of motion-related damage to the hands and arms that is costing the nation many billions of dollars annually.”

The 80s also brought in deregulation, union-busting and constant pressure to increase “productivity.” “Productivity” in the business sense means increasing the value added by each employee’s work. In theory, employers can do this by providing mechanical aids, such as offering carts instead of expecting workers to carry loads on their backs.

In the digital age, though, increasing “productivity” usually means speeding up, adding more work or reducing wages and employment expenses. Thus we have supermarket scanners and cashiers wearing wrist braces.

A cashier with a scanner is more “productive” because one job replaces two other jobs, the bagger and the inventory clerk. However, the job’s design is inherently injurious, starting with the constant wrist-flip to push products over the scanner. One study calculated that a cashier who also bagged products, lifted an average of 11,000 pounds a day over the counter to customers. If the cashier walks around the counter to hand you a bag, she’s not being lazy — she’s probably nursing an aching elbow. These days supermarkets are hiring baggers again and installing self-serve cash desks.

Although white-collar workers suffered computer injuries, by far the majority of those affected by RSIs were (and still are) blue-collar factory workers and pink-collar service workers. Affected workers suffer excruciating back pain, red hot elbow pain, frozen shoulders that howl at the slightest attempt to reach out, wrists that throb and hands that tingle and often simply stop working. One radio reporter filed a story about how, suddenly, on a major expressway, her right hand couldn’t grip her steering wheel or steer her car.

Workers’ compensation costs skyrocketed in major urban states. In the U.S., statistics from the Occupational Safety and Health Administration (OSHA) and the Bureau of Labour Statistics (BLS) showed injury rates climbing and health costs soaring. Three per cent of lost time claims — due to repetitive motion injuries — cost 30 per cent of the compensation paid.

RSIs have proved difficult to treat, partly because they develop slowly, and mainly because — after treatment for injuries — most injured workers go back to the same jobs. Fixing the patient usually involves fixing the workplace, and that’s a very difficult project to sell in most workplaces if only one person is injured. Doctors have searched since the 1990s for cures, or at least pain relief. They were ready for a miracle cure.

As more and more workers were injured by repetitive motion, and filed complaints, unions like the (US) AFL-CIO negotiated for ergonomic improvements to their workplaces. Some employers recognized that inefficient workplaces caused the workers’ injuries.

Employers as different as Red Wing Shoes, Lilydaly poultry packers and General Motors brought in ergonomics experts, asked their workers to identify awkward spots and suggest solutions, and redesigned their workplaces to fit their workers, not the other way around. They quickly proved that working together with workers and installing ergonomic equipment more than repaid their investment, especially compared to the cost of one lifetime disability claim.

Most employers, however, balked. They balked at the investment, they balked at inviting in ergonomic consultants, and most of all they balked at sitting around a table taking advice from shop floor workers. Unless a limb swelled up like a balloon, they accused injured workers of malingering. They were already practicing Milton Friedman’s economics, which puts workers on the “liability” side of the spreadsheet, rather than seeing workers’ skills as assets.

As OSHA prepared ergonomics regulations that would have provided guidelines for confused US employers, a new cottage industry sprang up in opposition. Eugene Scalia, son of Supreme Court Justice Antonin Scalia, became known as “Mr Anti-Ergonomics.” He addressed employers’ conventions with scary stories about ergonomics costs and workers in charge of their companies. He crusaded against ergonomics rules not only at OSHA, but in Washington and other states that already included ergonomics in workers’ health and safety regulations. Since then, the Wall Street Journal reports, he has moved on to defending big banks against government regulation aimed at protecting consumers.

OSHA never was able to announce an ergonomics standard for industry, let alone offices. For office ergonomics, U.S. experts rely on the Canadian Standards Association (CSA) guidelines.

Worse, the George W. Bush administration solved the problem by banning any mention of RSIs. He ordered OSHA and BLS to stop tracking repetitive strain injuries (which they called MSDs, MusculoSkeletal Disorders), as they had been doing since 1970, when Richard Nixon signed OSHA into being. The rancour endures. In 2011, U.S. Chamber of Commerce opposition prevented reinstatement of an MSD column on the event-based OSHA incident report.

The Bureau of Labor Statistics, though, somehow continued to gather and report statistics, which are pretty consistent with 1990s figures.

For 2014, the BLS reported that MSDs accounted for nearly a third (32%) of all injury and illness cases. Women accounted for nearly four in 10 (39%) cases of days-away-from-work; they suffered more falls, intentional violence, and repetitive motion.

Gender is another factor — in both the 1990s MSD epidemic and the 2016 opioid epidemic, especially the drug poisoning deaths. Middle-aged women are over-represented in both groups, especially fatalities, which affect more white women. As I wrote last April, the US has to be the only place in the industrialized world to see an increase in mortality rates for mid-life white women.

In the 1990s, many medical articles dismissed any claim that linked workplace duties to invisible symptoms like pain — calling patients “hysterical” because complaints came mainly from women employees. Never mind that the women were doing intensely repetitive jobs while working at desks designed to fit men. Doctors diagnosed their pain as psychogenic, more related to unhappiness at home than to too-tall workstations.

Some of the current medical community discussion about opioid patients closely echoes that rhetoric. For example, the Cleveland Medical Clinic article about patients who use opioids states, “Risk factors are biologic, sociologic, psychological, and
environmental. It [opioid use] is more common in those with depression, anxiety, and substance-use disorders. Pain-associated disability is also more common in those from lower socioeconomic strata and in those who dislike their work or feel underpaid and unsupported at work.”

Let me play devil’s advocate here and suggest that most people with disabilities are already struggling to pay their bills, and to find honest jobs with decent wages. Moreover, people get injured at low-paid jobs because the jobs tend to involve heavy-duty,
labour-intensive work, whether the workers be hauling logs or laundry. Low-wage jobs also tend to be unprotected jobs, precarious work, outside labour legislation because they’re “independent contractors” or part-time workers at two or three jobs.

Most of all, low-wage jobs tend to be repetitive: hoeing vegetables, carrying trays, completing forms, cleaning bathrooms…workers do the same exact thing, over and over. Anybody stuck doing the same action over and over is liable to develop aches and pains. Just clicking a mouse with your forefinger all day can be enough to cause forearm tendinitis. Yet the endless push for productivity encourages employers to break jobs down into the simplest tasks, and have each worker do only one task, so the employer doesn’t have to pay for a skilled worker who can perform the entire task.

Prescribing opioids for soft tissue injuries, even for back pain, may seem like overkill. But that’s what happened. Sam Quinone’s book about the opiate crisis, Dreamland, begins with the story of Carol Wagner, whose “handsome, college-educated” son Chad developed carpal tunnel syndrome (an extreme aching wrist). His doctor prescribed OxyContin. Chad became addicted. The drug became his life. “He lost home and family,” writes Quinone, “and five years later he lay dead of an overdose in a Cincinnati half-way house.”

In 2011, the American Chronic Pain Association produced a 30-second TV public service announcement warning that pain prescriptions were killing people — their legitimate users and others. The ACPA newsletter explained that, while opiates “can make the difference between disability and the ability to function at a more normal level,” most patients received little or no information about how dangerous they were. Hence, the TV spot, with advice about how to keep the medicine safe.

Last on the list of concerns (such as safe storage, not sharing, and keeping close track of doses), the ACPA reported that half of those using opioids legitimately were worried about addiction — 19 per cent very worried, and 34 per cent somewhat worried. The ACPA’s executive director offered reassurances that the risks of addiction when opiates are used legitimately under a professional’s care are “modest.”

A 2016 paper in the Journal of Chronic Pain seems to indicate that specifically RSI patients received opioid prescriptions early and often. The authors searched five medical databases for a year’s worth of studies about opioids and MSDs (Musculoskeletal Disorders, another name for RSIs) and found five historical cohort studies — five groups of comparable people — who filed Workers’ Compensation claims and who received opioid prescriptions within the first 12 weeks. Instead of ordering physiotherapy, the doctors gave RSI patients something that stopped the pain, and sent them back to work. This is like short-circuiting your car’s low-oil light instead of topping up your oil. It’s a recipe for burn-out. In four out of five cohorts, early opioid prescriptions were associated with much longer disability.

The good news is that the entire medical establishment seems to be working on finding other ways to deal with chronic pain. In addition to a wider range of nerve prescriptions (eg, Lyrica), doctors are working with other disciplines such as physiotherapists, chiropractors, massage therapists, and acupuncturists. They’re prescribing pain-relieving ointments like diclofenac and sending patients to radiologists for steroid injections to their painful spot. Some doctors still look to surgery for remedies in severe cases.

The bad news is that the U.S. and (apart from Ontario and BC) most provinces in Canada still don’t have workplace regulations to protect workers from RSIs. Although the fentanyl crisis has spread far beyond the patients who received the early opioid prescriptions, we’d be fools to let it overshadow the workplace factor.

MSDs (RSIs) accounted for one-third of U.S. workplace injuries in 2015, according to the U.S. Bureau of Labour Statistics, and probably about half of lost-time days. Jobs at highest risk were laborers and freight, stock, and material movers; nursing assistants; and heavy and tractor-trailer truck drivers (14,900). Nursing assistants often have lift patients. Workers who sustained strains, sprains or tears (the MSD descriptor) required longer to heal than other kinds of injuries.

Behind the opioid menace is another, less visible threat. RSIs exact a heavy financial and human toll in the workplace. Yet the chronic pain of RSIs is more easily prevented than cured. While employers may save a few short-term dollars by ignoring RSI-caused worker turnover, while Workers’ Comp may have saved a few dollars by encouraging doctors to dope injured workers so they could function a little longer, the rising toll of opioid deaths shows who bears the real costs: society.

Varying the work throughout the work day, fitting the job to the worker, taking frequent breaks — ergonomics techniques involve common-sense measures to protect workers’ health. While artists and athletes suffer RSIs, they consciously take risks for the sake of their passion. Assembly line workers and office workers usually just want to earn a living. They have every right to expect that their employer provides a safe workplace and job description that won’t injure them while they do their duties — that won’t leave them facing years of constant chronic pain.

Until the U.S. enacts ergonomics regulations to make workplaces safer, the American chronic pain problem is only going to increase. Awful as they are, opioid fatalities also signal a deeper problem.

Copyright Penney Kome 2017

Contact:  komeca AT yahoo.com

Read more F&O columns by Penney Kome here

 

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Penney KomePenney Kome is co-editor of Peace: A Dream Unfolding (Sierra Club Books 1986), with a foreward by the Nobel-winning presidents of International Physicians for Prevention of Nuclear War.

Read her bio on Facts and Opinions.

Contact:  komeca AT yahoo.com

 

 

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