Psychosocial Issues + Opioids = Poor Outcomes

A recent study on opioid prescriptions in this country is extremely troubling. It showed that more than half the opioids are prescribed for people diagnosed with mental illness — especially depression and anxiety. Since those are among the biggest risk factors for taking opioids, the news should serve as a wake-up call to workers’ compensation payers.

Chronic pain and depression often go hand in hand. In some cases the pain itself leads to depression, while in others the depression is one of the main reasons certain people develop chronic pain. Either way, opioids prescribed to injured workers with depression or anxiety can be a recipe for disaster — or, at least, a greatly increased likelihood of a delayed and poor outcome. The costs to the injured worker and payers alike can be exorbitant.

The Findings
The research, by Dartmouth-Hitchcock Medical Center and the University of Michigan suggests people with mood disorders receive 60 million prescriptions for painkillers every year. They found that among the 38.6 million Americans with mental health disorders, more than seven million, or 18 percent, are prescribed opioids each year. Among adults without mental disorders only 5 percent are likely to be prescribed opioids.

The study did not identify the reasons for so many opioid prescriptions among people with mental health issues. The researchers theorized physicians may be treating their pain, regardless of, or unaware of their mental health diagnoses. Or, they may be prescribing them as a short term fix to address physical symptoms associated with mental health issues, such as headaches or extreme stress. Whatever the reason, the fact that the drugs are so prominent among this population raises myriad concerns for the workers’ compensation industry.

It shows a glaring gap in knowledge among those in the medical profession who are prescribing opioids. Rather than helping people with depression or those with chronic pain who also have depression, opioids can exacerbate both conditions.

Opioids should only be prescribed for chronic pain patients as a last resort and only for the short term — if there are no glaringly apparent risk factors. Depression and anxiety are near the top of that list, since these conditions often make people susceptible to substance abuse and dependency.

Opioids and the Brain
Depression is one of the main side effects of opioids. Patients using them for more than six months have more than a 50-percent greater chance of having a depressive episode, according to research.

Long term use of opioids changes the brain and the way it interacts with the nervous system. It increases the risks that the injured worker will be vulnerable to the negative effects of the drugs — such as depression. Also, the body’s response to opioids can trigger anxiety.

Opioids mimic a natural substance in the body, dopamine. By flooding the brain with this neurotransmitter, the body reacts with depressed breathing, blood pressure and alertness. There is also a sense of euphoria.

The body tries to fight off the depressed effects of the dopamine by releasing noradrenaline, an organic chemical that increases arousal and alertness and produces the fight-flight-freeze response the body needs during times of stress or danger. But the noradrenaline also creates anxiety. So the effect of the opioids is both depression and anxiety.

Also, the euphoric effect of the opioids may lead some injured workers to continue seeking the drugs. The researchers speculate that some physicians may feel empathetic to their patients and refill the prescriptions.

Alternative Treatments
Brief, goal-oriented therapy aimed at psychosocial issues can help injured workers lessen their depression and anxiety, along with their chronic pain. Cognitive behavioral therapy (CBT) is based on the premise that a person’s feelings and behaviors are directly correlated to his thought patterns. Negative thinking affects his feelings and behavior, and can lead to chronic pain.

CBT and other therapies provided by trained psychologists teach injured workers to recognize and replace negative thoughts with positive ones. Changing the way the injured worker thinks can change how he feels and acts, even if his situation does not change.

One simple and highly effective CBT exercise for injured workers with chronic pain and depression involves identifying thoughts and emotions. If the injured worker is telling himself, ‘I can’t cope with this pain,’ we ask him to reframe his thinking to, ‘I can cope with this pain.’

Whether he truly believes what he is saying does not matter. He can trick his brain so it will turn off the fight-flight-or freeze response. Doing so will help him deal with his pain and his depression/anxiety.

Conclusion
Prescribing opioids to an injured worker who has mental health diagnoses has a good chance of making him feel worse, not better. These are powerful drugs that can have a devastating effect on the body, especially those who are already vulnerable to negative feelings.

Instead of medications, payers and providers should look for treatments that don’t cause unnatural changes to the brain — especially therapies such as CBT that have been proven effective for relieving chronic pain and symptoms of mental health conditions.

Integrated Medical Case Solutions (Ascellus) is a national network of Health Providers in Psychology that delivers cognitive behavioral therapy (CBT) for chronic pain, trauma and insomnia across the country for the workers’ compensation industry.

For additional information, contact us at https://theimcsgroup.com, or http://www.cope-with-pain.com. Please join our LinkedIn group, COPE with Pain at https://www.linkedin.com/groups/8540640 .