Early Opioid Prescriptions for Work-Related Musculoskeletal Disorders of the Low Back: Understanding Dispensing Patterns, Their Determinants, and Their Impact on Work Disability

Opioids are prescribed early for low back pain (LBP), despite little evidence supporting this practice. The dissertation objective was to understand factors associated with early opioid provision after a LBP workersâ compensation claim and their relationship with work disability. A systematic review (Manuscript 1) found evidence of a positive association between early opioids and prolonged work disability for musculoskeletal disorders, but internal validity was jeopardized by exposure measurement and confounding biases. Informed by review findings, an historical cohort study was conducted of workersâ compensation claimants with LBP using dispensing data on LBP-indicated drug classes: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and skeletal muscle relaxants (SMRs). Opioids, NSAIDs, and SMRs were dispensed to 19.7%, 21.2%, and 6.3% of claimants, respectively, one year pre-injury, and 39.0%, 50.2%, and 28.4% one year post-injury (Manuscript 2). Dispensing was stable pre-injury, increased within eight weeks post-injury, and declined thereafter, although not to pre-injury levels. A small subgroup demonstrated prolonged dispensing, suggesting delayed recovery. Claimant factors associated with early post-injury dispensing included pre-injury days supplied with the three drug classes, prior adjuvant medication dispenses, diagnosis, prior health care, age, sex, and occupation (Manuscript 3). Prescriber sex, birth year, and specialty were associated with drug class(es) at first prescription and the prescriber accounted for 25-36% of outcome variability. Examining the relationship between these drug classes dispensed within eight weeks post- injury and wage replacement benefits after eight weeks (Manuscript 4) revealed claimants receiving opioids, particularly with NSAIDs and/or SMRs, were more likely to receive benefits compared to NSAIDs/SMRs only. Strong and weak opioid combinations and days supply for all classes were positively associated with receiving benefits. There is evidence of increased opioid, NSAID, and SMR dispensing within eight weeks of a LBP claim. Early dispensing is multifactorial and prescribers play a role in dispensing variation. Early opioids compared to NSAIDs/SMRs appear to confer a greater risk of work disability. Methodological strengths include capturing pre-injury factors and all prescriptions and partially addressing confounding by indication/severity. However, residual confounding remains concerning. Consideration of severity, prescriber, and system/workplace measures is needed to advance understanding of opioid use for LBP and work disability.Ph.D.2019-12-19 00:00:0

Cannabis use among workers with work-related injuries and illnesses: results from a cross-sectional study of workers’ compensation claimants in Ontario, Canada

Objectives Little is known about how workers use cannabis following a work-related injury/illness, including whether they receive clinical guidance. The objective was to compare characteristics of workers using and not using cannabis after a work-related injury/illness and describe use patterns.Design Cross-sectional study.Setting and participants Workers who experienced a work-related physical injury/illness resulting in one or more days of lost time compensated by the workers’ compensation authority in Ontario, Canada (n=1196).Methods Participants were interviewed 18 or 36 months after their injury/illness. Participants were asked about their past-year cannabis use, including whether use was for the treatment of their work-related condition. Sociodemographic, work and health characteristics were compared across cannabis groups: no past-year use; use for the work-related condition; use unrelated to the work-related condition. Cannabis use reasons, patterns, perceived impact and healthcare provider engagement were described.Results In total, 27.4% of the sample reported using cannabis (14.1% for their work-related condition). Workers using cannabis for their condition were less likely to be working (58.0%) and more likely to have quite a bit/extreme pain interference (48.5%), psychological distress (26.0%) and sleep problems most/all the time (62.1%) compared with those not using cannabis (74.3%, 26.3%, 12.0% and 38.0%, respectively) and those using cannabis for other reasons (74.2%, 19.5%, 12.0% and 37.1%, respectively) (all p<0.0001). No significant differences were observed in medical authorisations for use among those using cannabis for their condition (20.4%) or unrelated to their condition (15.7%) (p=0.3021). Healthcare provider guidance was more common among those using cannabis for their condition (32.7%) compared with those using for other reasons (17.1%) (p=0.0024); however, two-thirds of this group did not receive guidance.Conclusions Cannabis may be used to manage the consequences of work-related injuries/illnesses, yet most do not receive clinical guidance. It is important that healthcare providers speak with injured workers about their cannabis use

Course of Depressive Symptoms Following a Workplace Injury: A 12-Month Follow-Up Update.

Introduction To estimate the prevalence, incidence and course of depressive symptoms, their relationship with return-to-work, and prevalence of depression diagnosis/treatment 12 months following a lost-time workplace musculoskeletal injury. Methods In a prospective cohort study, 332 workers' compensation claimants with a back or upper extremity musculoskeletal disorder completed interviews at 1, 6 and 12 months post-injury. Participants self-reported they had not received a depression diagnosis 1 year pre-injury. Cutoff of 16 on the CES-D defined a high level of depressive symptoms. Self-reported data on depression diagnosis and treatment and work status since injury were collected. Results Cumulative incidence of high depressive symptom levels over 12 months was 50.3 % (95 % CI 44.9-55.7 %). At 12 months, 24.7 % (95 % CI 20.1-29.3 %) of workers exhibited high levels. Over 12 months, 49.7 % (95 % CI 44.3-55.1 %) had low levels at all 3 interviews, 14.5 % (95 % CI 10.7-18.2 %) had persistently high levels, and 25.6 % (95 % CI 20.9-30.3 %) demonstrated improvements. Among workers with low baseline levels, incidence of high levels at 12 months was 6.0 % (95 % CI 2.7-9.3 %). For workers with high baseline levels, 36.1 % (95 % CI 27.9-44.3 %) exhibited persistent high symptoms at 6 and 12 months, while 38.4 % (95 % CI 30.1-46.6 %) experienced low levels at 6 and 12 months. Problematic RTW outcomes were common among workers with a poor depressive symptom course. Among workers with persistent high symptoms, 18.8 % (95 % CI 7.7-29.8 %) self-reported receiving a depression diagnosis by 12 months and 29.2 % (95 % CI 16.3-42.0 %) were receiving treatment at 12 months. Conclusions Depressive symptoms are common in the first year following a lost-time musculoskeletal injury and a poor depressive symptom course is associated with problematic RTW outcomes 12 months post-injury. While symptoms appear to improve over time, the first 6 months appear to be important in establishing future symptom levels and may represent a window of opportunity for early screening

Course of Depressive Symptoms Following a Workplace Injury: A 12-Month Follow-Up Update.

Introduction To estimate the prevalence, incidence and course of depressive symptoms, their relationship with return-to-work, and prevalence of depression diagnosis/treatment 12 months following a lost-time workplace musculoskeletal injury. Methods In a prospective cohort study, 332 workers' compensation claimants with a back or upper extremity musculoskeletal disorder completed interviews at 1, 6 and 12 months post-injury. Participants self-reported they had not received a depression diagnosis 1 year pre-injury. Cutoff of 16 on the CES-D defined a high level of depressive symptoms. Self-reported data on depression diagnosis and treatment and work status since injury were collected. Results Cumulative incidence of high depressive symptom levels over 12 months was 50.3 % (95 % CI 44.9-55.7 %). At 12 months, 24.7 % (95 % CI 20.1-29.3 %) of workers exhibited high levels. Over 12 months, 49.7 % (95 % CI 44.3-55.1 %) had low levels at all 3 interviews, 14.5 % (95 % CI 10.7-18.2 %) had persistently high levels, and 25.6 % (95 % CI 20.9-30.3 %) demonstrated improvements. Among workers with low baseline levels, incidence of high levels at 12 months was 6.0 % (95 % CI 2.7-9.3 %). For workers with high baseline levels, 36.1 % (95 % CI 27.9-44.3 %) exhibited persistent high symptoms at 6 and 12 months, while 38.4 % (95 % CI 30.1-46.6 %) experienced low levels at 6 and 12 months. Problematic RTW outcomes were common among workers with a poor depressive symptom course. Among workers with persistent high symptoms, 18.8 % (95 % CI 7.7-29.8 %) self-reported receiving a depression diagnosis by 12 months and 29.2 % (95 % CI 16.3-42.0 %) were receiving treatment at 12 months. Conclusions Depressive symptoms are common in the first year following a lost-time musculoskeletal injury and a poor depressive symptom course is associated with problematic RTW outcomes 12 months post-injury. While symptoms appear to improve over time, the first 6 months appear to be important in establishing future symptom levels and may represent a window of opportunity for early screening

Systematic review of intervention practices for depression in the workplace

Design Systematic Review. Objective To determine which intervention approaches to manage depression in the workplace have been successful and yielded value for employers in developed economies. Data Sources We searched MEDLINE, EMBASE, CINAHL, Central, PsycINFO, and Business Source Premier up to June 2010 using search terms in four broad areas: work setting, depression, intervention, and work outcomes. Study Selection Two independent reviewers selected potential articles that met the following criteria: working age individuals with mild or moderate depression; interventions or programs that were workplace-based or could be implemented and/or facilitated by the employer; inclusion of a comparator group in the analysis; outcomes of prevention, management, and recurrences of work disability or sickness absence, and work functioning. Methods Two reviewers independently reviewed each article for quality and extracted data using standardised forms. Following guidelines from the GRADE Working Group, the quality of evidence addressing each outcome was graded as high, moderate, low, or very low on the basis of six criteria: study design, risk of bias, consistency, generalisability, data precision, and economic benefit. Using this information and following Cochrane Collaboration guidelines, the findings for each intervention were summarised and key messages were developed. Results We identified ten randomised trials and two non-randomised studies from various countries and jurisdictions that evaluated a wide range of intervention practices. The evidence was graded as "very low" for all outcomes identified. Therefore, no intervention could be recommended. Conclusions To date, there is insufficient quality of evidence to determine which interventions are effective and yield value to manage depression in the workplace