Although the opioid crisis is now recognized as a national priority in both Canada and the United States, the two countries with the highest per capita opioid usage, a feature article in Workers’ Comp Hub Newsletter (summer 2018) highlights the fact that
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.
A study making that association is the Massachusetts Dept of Public Health’s August 2018 report. Based on a statistical analysis of the state death certificates 2011-2015, the report found workers engaged in construction and resource extraction, industries known to have high rates of workplace injury and illness, had an opioid overdose death rate 6 times the average rate for all Massachusetts workers; for female workers, rates were highest in health care support and food preparation & serving sectors. The authors call attention to economic factors contributing to opioid use for pain control and potential addiction following work injury: financial and job insecurity or lack of sick leave benefits may leave a worker with few options other than a return to work while still in pain and before time to heal. This, in turn, may trigger further injury and increased medication intake …
While recommending policy and educational action on unsafe working conditions and appropriate pain management, the report calls also for further research on other occupational and socioeconomic factors contributing to opioid overuse. Some of these have been addressed in the American Journal of Public Health paper “Opioid Crisis: No Easy Fix to its Social and Economic Determinants.” Tracing the course of the opioid crisis since 1990, the authors discuss the role of the pharmaceutical industry, deindustrialization, workplace injury and despair, taking a deeper look at the underlying root causes and structural inequities.
However the public narrative on opioid addiction has been increasingly framed around physician over-prescribing. Law and policy reforms have focused on cutting off or restricting the supply rather than a comprehensive public health approach that includes improved workplace safety. For injured workers, these reforms have placed more limits and tighter control over their medical care while reducing costs for employers, insurers and workers’ compensation systems – and shifting those costs onto the individual worker or the public.
WSIB’s response to the opioid crisis
In 2010 the Ontario government enacted the Narcotics Safety and Awareness Act. On introducing its Narcotics Strategy that same year, the Workplace Safety and Insurance Board (WSIB) reported that 40% more injured workers were being prescribed opioids compared to 10 years ago. Over that same time period, the number of narcotic prescriptions had increased by 100%, with costs rising from $4.4 million to $35 million. Under the new Strategy, prescriptions for short-acting opioids were permitted for a maximum of 12 weeks, with long-acting opioids no longer allowed during this period (with some exceptions such as severe or traumatic injuries); after the 12 weeks of ongoing narcotic use, WSIB clinical staff would review the case for further opioid use.
A recent study evaluating the impact of the WSIB’s graduated opioid management approach found that by delaying the initiation of long-acting opioids for at least 12 weeks, individuals are less likely to escalate to a long-acting opioid at any point in the year following injury. However, the study’s authors were unable to determine the impact on return to work or measure the impact of graduated formularies on other patient outcomes, including quality of life, pain management, and risk of opioid dependence and/or addiction.
An incomplete solution
While the Strategy effectively encourages safer opioid prescribing by physicians (overall daily dosages have decreased, as have the number of injured workers on high-dose opioids), the health care needs of many injured workers with work-related acute or chronic pain remain poorly met. Reports by worker advocates, injured workers groups and healthcare providers – including Bad Medicine (IAVGO) and Prescription Over-ruled (ONIWG/OFL) – document the impact of the WSIB’s reduced spending on healthcare benefits and claims denial: adjudication practices and formularies that exclude an increasing number from drug benefit coverage or non-opioid and and other therapeutic solutions while ignoring the medical opinion of the worker’s treating physician on appropriate treatment.
By capping the Board’s three Programs of Care for musculoskeletal injuries at eight weeks and all too frequently disregarding its own maintenance treatment guidelines for ongoing rehabilitation, the WSIB’s cuts to health care spending leave many workers without the necessary therapy, unable to costs out of their own pocket. Pressured by the Board’s “Better At Work” Strategy for an early return to work, the injured worker often has no choice but to re-enter the workplace in pain and at risk of re-injury. This is a far from the “coordinated program of workplace safety, physical therapy, drug treatment, harm reduction and social and economic supports” needed to help workers with injuries or addiction.
Organizing for change
These structural issues are intimately tied to the Workers’ Comp is a Right campaign, as respect for treating doctors and ending the immense pressure of forced return to work are key campaign components. If the WSIB wants to take steps towards reducing opioid prescriptions, it must do so responsibly, taking into consideration the recommendations from injured workers’ treating doctors. It mus also offer comprehensive and holistic healthcare treatment to help people get safely back on their feet, before they are forced back to work, or “deemed” fit to return to work and cut off benefits.
This is why injured workers across Ontario are organizing for change, to restore integrity to the system, and bring it back to its roots as a system that treats workers with dignity and respect.
- Workers’ Comp Hub. 2018 Aug. “Proscribing Prescriptions or Promoting Public Health? Opioid Treatment in Workers’ Comp.” Newsletter
- Massachusetts. Dept. of Public Health. 2018 Aug. Opioid-related Overdose Deaths in Massachusetts by Industry and Occupation, 2011-2015. Boston: The Dept.
- Lancaster, John & Tarannum Kamlani. 2018 Jul. 12. “Ontario Injured Workers Shut Out of Medical Pot Coverage – Told to Take Opioids Instead.” CBC News Toronto
- Public Health Agency of Canada. 2018 Jun. National Report: Apparent Opioid-related Deaths in Canada. Ottawa
- Furlan, A. et al. 2018 Jun. “A Systematic Review of Strategies to Improve Appropriate Use of Opioids and to Reduce Opioid Use Disorder and Deaths from Prescription Opioids.” Canadian Journal of Pain 2(1): 218-235
- Dasgupta Nabarun, Leo Beletsky & Daniel Ciccarone. 2018 Feb. “Opioid Crisis: No Easy Fix to Its Social and Economic Determinants.” American Journal of Public Health 108(2): 182-186
- Gomes, Tara et al. 2017 Dec. “Impact of a Graduated Approach on Opioid Initiation and Loss of Earnings Following Workplace Injury: A Time Series Analysis.” Journal of Occupational and Environmental Medicine 59(12): 1197-1201
- IAVGO Community Legal Clinic & Antony Singleton. 2017. Bad Medicine: A Report on the WSIB’s Transformation of Its Health Care Spending. Toronto: IAVGO
- Boston University. School of Public Health. 2016 Jul. 25. “Non-fatal Workplace Injuries Raise Mortality Risk.”
- Mojtehezadeh, Sara. 2016 Jun. 10. “WSIB Critics Say Spending Cuts are Devastating Injured Workers.” Toronto Star