Recent Veterans Study Has Important Implications for Workers’ Comp World

Concomitant Benzodiazepine-Opioid Use Increases Risks of Adverse Outcomes

Adding additional strength to the swell of medical research warning us about the dangers of combining opioid and benzodiazepine medications, a recent study published by the International Association for the Study of Pain [see Gressler, Laura E., et al., “Relationship between concomitant benzodiazepine-opioid use and adverse outcomes among US veterans,” Pain, 2018 Mar;159(3):451-459; doi: 10.1097/j.pain.0000000000001111], observes that joining the medications may increase the risk of experiencing an adverse outcome by some 36 percent, when compared to a baseline of nonacute opioid-only use. The study has important implications for the workers’ compensation world since many injured workers share similar symptomatology with injured or wounded veterans.

Societal Backdrop

One would have to have slumbered for several years beneath a rock not to know that the nation is facing a crisis when it comes to opioid abuse. The problems associated with concomitant opioid and benzodiazepine medications are beginning to draw particular attention as well. As noted by these researchers, concurrent opioid-benzodiazepine use doubled among privately insured patients from 2001 and 2013 in the United States. Quoting an earlier study [Quinn PD, Hur K, Chang Z, Krebs EE, Bair MJ, Scott EL, Rickert ME, Gibbons RD, Kroenke K, D’Onofrio BM. Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. PAIN 2017;158:140–8], the researchers warned:

“Opioid prescribing in the United States follows a pattern in which patients who are at the highest risk of adverse outcomes from opioids are more likely to receive long-term opioid therapy. These patients include, in particular, those with substance use disorders and other psychiatric conditions.”

Post-Traumatic Stress Disorder Poses Particular Problems

Within the veteran population, concomitant prescribing of opioid and benzodiazepine medications is most common among patients suffering from PTSD. The researchers observed that rates of such concomitant prescribing increased some 53 percent within VHA facilities from 2003 to 2011.

Earlier Studies Show Potential Danger in Concomitant Use

The researchers acknowledged that several earlier studies had pointed to the dangers of concomitant opioid-benzodiazepine use. They stressed, however, that their objective was to quantify the risk of such concomitant use on a broader set of adverse outcomes (i.e., wound, injuries, death, accidents, etc.) that have previously shown an association with opioid use in veterans living with various mental health disorders.

Large VA Dataset During 2008-2012 Time Period

The researchers’ dataset contained all veterans who filled at least one opioid prescription prescribed by a Veterans Health Administration physician during the years 2008 to 2012. Nonacute opioid use was defined as having opioid prescriptions greater than or equal to 20 days within a 60-day period. Concomitant use was defined as having opioid and benzodiazepine prescriptions that overlapped for at least 7 days. Some patients were excluded from the examination—e.g., those diagnosed with cancer, in hospice, residing in nursing homes or domiciliary, or receiving palliative care—since such patients’ care is not typical of noncancer pain being treated in an outpatient setting. The final sample included 396,141 nonacute opioid-only using veterans and 48,971 concomitant benzodiazepine-opioid users.

Specific Adverse Outcomes

The researchers specifically screened for some specific adverse outcomes:

> Opioid-related accidents and overdoses

> Alcohol and nonopioid drug-related accidents and overdoses

> Self-inflicted injuries

> Violence-related injuries, and

> Wounds/injuries overall.

Study Findings

The researchers found that concomitant receipt of opioids andnzodiazepines increased the risk of experiencing an adverse outcome by approximately 36 percent. In subgroup analyses, the researchers noted that Operation Enduring Freedom (OEF) veterans (i.e., those who served during the relevant time frame in Afghanistan) and Operation Iraqi Freedom (OIF) veterans (i.e., those serving in Iraq) were at a particularly high risk of adverse events following concomitant use of the drugs. The researchers noted that mental health issues, particularly PTSD, have been found to be unusually high within these subgroups of veterans. An important study finding was that the combination of being prescribed opioids while suffering mental health conditions made for significantly negative outcomes.

Limitations of the Study

The researchers noted specific limitations in their study. For example, pharmacy records represented medications dispensed. Such data did not quantify actual use or adherence to dosage. Other possible limitations included:

> Accuracy of diagnoses coding

> Possibility that some non-VHA providers may have filled additional prescriptions for some veterans

> Study did not examine concomitant use of opioids and medicines similar to benzodiazepines (e.g. muscle relaxants and other psychotropic drugs.)

The researchers also stressed that the study’s findings might have limited generalizability because veterans are primarily male and have higher prevalence of pain and mental health conditions than the general population.

Veterans Are Vulnerable Population

The researchers posited that the simultaneous treatment of pain and mental health disorders remains challenging, that merely decreasing the rates of concomitant prescribing would not likely address the true nature of the problem, and that additional efforts were necessary to assist this vulnerable population of Americans.

And vulnerable it is. Veterans receiving both opioids and benzodiazepines account for half of the overdose deaths among veterans during the study period. A separate study found that the adjusted risk for death was almost four times higher in the concomitant prescription group, with the risk increasing as the benzodiazepine dosage increases [see, Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert AS. “Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.” BMJ 2015].

Implications for the Workers’ Compensation World

One of the sad commentaries on life in the 21st century is that injured workers often bear the same sorts of scars as to our wounded servicemen and servicewomen. The joinder of pain and PTSD is not limited to first responders and others, whose work duties approximate the danger and distress faced by soldiers abroad. In recent years we have seen increases in PTSD claims among truck drivers, construction workers—even some types of office workers.

Where a worker suffers both from chronic pain and PTSD, the situation is worse. As pointed out by Gressler and others, clinical studies have repeatedly demonstrated that patients who have both chronic pain and PTSD experience greater pain, distress, and short and long-term disability than patients with either condition alone.

Vicious Cycle

All too often, the injured worker faces a vicious cycle. Pain and loss of work produces anxiety, insomnia, depression, and anger. While concomitant opioid and benzodiazepines use may provide partial relief of pain, that same use often deepens the worker’s feeling of dissociation. And so, the worker withdraws even further. Sleep deprivation and deepening depression often lead to a persistence of the PTSD and an ever-escalation of the opioid/benzodiazepine use. Stronger doses are required just to get the same level of “relief.” The positive reinforcement and satisfaction that often flows from returning to work—at “being productive”—is postponed or forgotten altogether.

In several recent cases, awards of compensation and/or death benefits have been affirmed by appellate courts in spite of the fact that the injured worker violated the dosage instructions provided by his or her physician [See, e.g., Commerce & Indus. Ins. Co. v. Ferguson-Stewart, 2012 Tex. App. LEXIS 4420 (May 10, 2012); Spradling v. Treasurer of State, 415 S.W.3d 126 (Mo. Ct. App. 2013); Brady v. Best Buy Co., 805 S.E.2d 545 (N.C. Ct. App. 2017); See also Larson’s Workers’ Compensation Law, § 38.03].

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