Tag Archives: Nancy Grover

How to Help Workers With Low Back Pain

Once an injured worker has low back pain, chances are pretty good he’ll have a recurrence. In fact, new research shows that after an acute episode of LBP, one-third of people will have another episode within a year; and the odds of a recurrence triples after two episodes.

Those statistics are somewhat surprising, given that recurring LBP can be avoided. Gustavo C. Machado and his colleagues at the University of Sydney’s School of Public Health tracked more than 1,000 LBP patients in Australia from 2011-12. Their results were published by the American Physical Therapy Association.

“We know if you do exercise and receive advice you reduce the risk of having a recurrence,” said Machado, lead author of the study. “Some research shows if you do exercise, you reduce your risk of a back pain episode by 35%; and if you do exercise and get some sort of education or information, that risk is reduced by 45%. So it’s a big reduction in risk. “

With LBP one of the most prevalent causes of workers’ compensation claims, the industry could prevent unnecessary pain among workers and save significant dollars for payers by better educating workers on LBP.

LBP

An estimated one-third of workers’ compensation claims involve LBP, with direct costs of more than $14 billion annually. Some 1 in 4 workers with LBP remain out of work for up to six months, increasing the chances of permanent disability.

Workers of any age can experience LBP, though it typically affects those over the age of 40. The reasons for LBP can vary with age.

“With older workers, you see degenerative changes,” said Daniel Sanchez, a physical therapist and VP of Operations for OnSite-Physio, a company that provides PT to injured workers on site. “For younger workers, the LBP tends to be muscular soft tissue in nature. But both degenerative and soft tissue LBP can be recurring.”

See also: The State of Workers’ Compensation  

Acute episodes of LBP last for no more than six weeks, while chronic LBP continues for at least three months. While injured workers with acute LBP should avoid vigorous activity, that does not mean they should be bedridden.

“The first thing initially is to rest, but don’t over rest,” Sanchez explained. “Depending on the severity, maybe a day or two of not overdoing it, but not being laid out in bed all day. Just not doing heavy exercise; no movements that aggravate the pain.”

The simple act of reaching down to pick up something can aggravate the pain. For the first couple of days, injured workers should “take it easy, allowing the body to heal,” Sanchez said.

Machado concurred. “For those patients, the best thing is to remain active. So do not stay in bed, just keep on the move. Try to keep up with routine activities, such as work,” he said. “It’s also very important to receive advice and education about pain, about recurrences.”

The majority of LBP cases resolve within a few weeks. For those that linger, a different regimen is needed.

“A quick fix for LBP does not exist,” Machado said. “The latest research shows taking pills doesn’t help much. Exercise and education seem to be the key for treating back pain, reducing back pain and preventing recurrences. The problem is people are not engaged in exercise.”

Exercises

There are a variety of exercises touted as best for addressing back pain: pilates, yoga and strengthening among others. They are equally effective.

“The more research that comes out, the more it’s clear there is no one exercise that is better,” Machado said. “The best is the one you like to do, they one you’re going to engage in, the one you’re going to stick to.”

A combination of exercises that improve stability, flexibility and strength will increase mobility and range of motion, thereby reducing pain. When muscles are tight and weak, the joints cannot move properly, Sanchez said.

  • Strengthening exercises. The most effective of these, according to Sanchez, are those that target the muscles in the front and back of the spine; the deeper, transverse abdominis that support the spine. Planks are among the most effective and can help the intrinsic, tiny muscles that attach to each vertebrae. These provide postural support which is very important.
  • Flexibility exercises. These, especially to the lower extremities, are extremely important. The lumbopelvic hip complex includes muscles that attach from the lower extremities, such as the hip rotators, hamstrings and hip flexors. Exercises that target these areas can relieve tight hips, which helps relieve chronic LBP.
  • Posture. Practicing sound posture, good body mechanics and lifting habits are also helpful, Sanchez said. Having a neutral spine is the goal.

Future of LBP

The research on LBP should include more robust studies looking at recurrence, Machado said. In the meantime, he and his colleagues are analyzing other aspects of LBP.

“The main one we are looking at is over diagnosis and treatment, because a main issue is that people get lots of X-rays and imaging and that’s usually unnecessary,” Machado said. “Lots of people also get opioids. We know that’s a big problem, especially in the U.S. It is not helpful. There are few benefits and really serious risks for side effects.”

Machado has a trial study starting soon in Sydney. Along with others, he is also looking into technology; specifically, smart phone apps that claim to help back pain.

See also: 25 Axioms Of Medical Care In The Workers Compensation System  

“We found over 69 apps to download. They’re making big promises but have not been tested for effectiveness,” he said. “We are planning to do another study in a few months on a specific app that could be promising… This one recommends a 10-week exercise program, mainly strengthening. The problem is there is no research testing this app as to whether it’s effective in reducing pain.”

For now, Machado hopes the latest study will provide guidance for providers treating patients with LBP. “We didn’t know how common recurrence was; it shows one-third after recovery will have another episode,” he said. “That’s something a clinician can use to educate a patient when they come, to say ‘look, a third of people have a recurrence, so engage in exercise.’ They can use this to educate them now.”

For more information visit https://www.apta.org or http://www.onsite-physio.com.

Potential Key to Tackling Opioid Issues

The use of urine drug testing (UDT) for injured workers raises challenges and questions for workers’ compensation stakeholders. Who should be tested? How many tests are too many? Too few? How often should the tests be performed? And, perhaps most importantly, what — if any — action should be taken in response to test results?

These questions have been brought to the forefront with the rise of opioid-related challenges — the same challenges that led a large workers’ compensation insurer to turn to experts for help.

The carrier saw a significant increase in opioid use among injured workers. Claims adjusters did not have the expertise on their own to aid in the problem.

See also: Opioids Are the Opiates of the Masses

Over the past several years, the insurer has aligned with Optum (its pharmacy benefit manager) and Millennium Health (a health solutions company that specializes in medication monitoring) to create a program that identifies and works with injured workers who are potentially at risk for poor recoveries. The insurer has reported impressive results, with reductions on spending for opioid analgesics and decreases in the number of supply days of the medications. Using the clinical experts and toxicologists of Millennium to help interpret test results has helped the clinical pharmacists at Optum provide recommendations to the adjusters and providers.

Medical treatment guidelines increasingly include UDTs for injured workers who are prescribed opioids; however, the decision of how often to test is largely left to the medical provider’s discretion. Experts say UDT, used in conjunction with other tools, can provide objective information regarding current medication, as well as illicit substance use. The results can help identify injured workers who may be abusing, misusing or diverting prescribed opioids.

“The clinical utility of UDT has been well established and is promoted in several medical guidelines. However, in some segments, there is still an underutilization for various reasons,” said Maria Chianta, director for clinical affairs and managed markets at Millennium Health. “It could be a lack of awareness or a lack of time — it takes time to perform the tests and interpret them.”

(Chianta will lead a discussion at the National Workers’ Compensation and Disability Conference & Expo on Dec. 2 in New Orleans. The discussion will cover the use of UDT in workers’ compensation; explain what led the insurer to enlist the help of its pharmacy benefit manager and Millennium Health; and show the results the company has achieved.)

Non-adherence to guidelines

The latest research from the Workers’ Compensation Research Institute bears out the inconsistent use of UDTs in workers’ compensation. A study of 25 states showed that the percentage of injured workers with longer-term use of opioids receiving drug testing was lower than recommended by treatment guidelines. At the same time, however, the frequency of drug tests was unusually high among the top 5% of injured workers who received opioids on a longer-term basis and had drug testing.

A lack of understanding of what actions to take based on UDT results is perhaps one of the major barriers. “It takes time to walk through those results,” Chianta said. “If you get something unexpected, you have to try to get to the cause of that, which takes time. Some providers may not know the best ways to respond to the test results.”

Follow-up is among the key issues for the effective use of UDT. Depending on the results of the tests, the insurer, for example, may engage the services of a telephonic case manager or conduct a pain management program review.

See also: Urine Drug Testing Must Get Smarter

Another area of confusion over UDTs concerns the types of tests available. “Primarily, there is immunoassay technology and mass spectrometry,” Chianta said. “Immunoassay is a presumptive screening, and mass spectrometry is a definitive or confirmation test.”

Chianta will discuss the types of tests in more detail. Some people on the health plan side may be seeing drug tests coming in and paying for them — and that’s the end of the process. The speakers aim to give session attendees an appreciation of the value of becoming more involved with the outcomes of the tests and follow-up actions that are necessary.

Value of Onsite Physical Therapy

Physical therapy can be one of the biggest cost drivers of a workers’ comp claim. In addition to the treatment itself are the expenses for travel and the employee’s time away from work. Onsite clinics can reduce the expenditures. They are cost-prohibitive for all but the largest companies, but many organizations are starting to turn to an alternative that combines the need for easily accessible PT at a cost comparable to or lower than clinic-based therapy.

Called therapy on demand, onsite PT involves a physical therapist going to the injured worker’s worksite — or home, in some cases — setting up equipment he brings and spending an hour focused solely on a single injured employee. Contrary to what some industry practitioners fear, the logistics are fairly simple.

“All we really needed to provide was a room that looks like a big closet; a room big enough to fit a massage table,” said Sandra Palacio, a claims adjuster at Royal Caribbean International. “We had several meetings before we put this in place. We tested it out for the first week or two, got great feedback and have continued to use it. It’s been a great experience.”

See also: Therapy Charges Are Being Inflated  

Royal Caribbean teamed up with OnSite Physio, a mobile physical medicine company, to treat injuries sustained by the cruise line’s newly hired dancers and actors who train at a Miami-based facility. With the need to keep the entertainers away from work as little as possible, onsite PT has been a natural fit.

“The dance studio is a unique system where they are only here for four to six weeks, so we need to have medical appointments on a fast basis,” Palacio said. “OSP has been great in that they come to us, get the person treated with PT, and injured workers are back doing their normal daily activities within an hour.”

The fact that the workers can stay at their workplace for treatment eliminates the costs for travel and lost work time. Some companies have reported savings of as much as 30% by using onsite PT services. One, Marriott International, will discuss the results it has seen during a session at the National Workers’ Compensation and Disability Conference & Expo, Dec. 2, in New Orleans. (For a reduced registration rate, visit www.onsite-physio.com.)

Focused PT

Among the cost savings reported are fewer PT appointments needed. The one-on-one attention given to each injured worker — often by the same therapist for the duration of the treatment — and being at his workplace allows the therapist to target each patient’s unique problems and job tasks, which can result in quicker recoveries.

“In a clinic, I might work with Mrs. Smith for 10 minutes, then Mr. so-and-so, then Mr. Brown. It’s this constant juggling act while you are in the clinic because, unfortunately, that’s just the model of outpatient PT,” said Daniel Sanchez, a physical medicine expert and a founder and VP of operations for OSP. Working onsite, “there is an ‘aha’ moment, when you realize you can do so much more with this injured worker than you ever could in a clinic. You have that one-on- one time with the patient so we get to really see and put into practice our treatment alongside what it is they do. We can perform therapy that is more meaningful, treatment that is work-related and more transferable to the real world. In a clinic, you have to simulate those things.”

RTW

A key difference between clinic-based PT and onsite is the focus on returning the employee to work. Sanchez makes the analogy of treating an athlete. “If the quarterback for the Jets gets a sprained ankle…what do they have onsite for the injured worker?” he asked. “They have people who specialize and treat them to get them back to their job. They are worried about whether the quarterback can get onto the field and do specific things. All of his treatment is around that.”

That same type of thinking is at play with onsite PT companies such as OSP. One of its clients, for example, is a solid waste disposal company. While the workers in that industry no longer do as much manual labor as they did years ago, workers nevertheless sustain injuries. Repetitive motion injuries to the hand or elbow are typical, as are twisted knees and sprained ankles from getting off a truck improperly.

See also: Employers Solving Healthcare Crisis One Onsite Clinic at a Time  

“If I say, ‘this is a garbage worker,’ and I am in a clinic, I used to think I knew what that meant. Not until I did a ride along and looked at how they are pushing, pulling, spending time sitting in the heat, did I understand what the job entails,” Sanchez said. “In a clinic, I might have that worker going up and down steps. Onsite, I can train him right on that step. It’s the actual piece of equipment he uses, so his treatment is 100% functional. We’re taking the time to really understand what they do and tailor the therapy to it.”

While onsite PT is not necessarily the best option for every injured worker, advocates say it offers many advantages over clinic-based therapy. “I definitely see this as a great benefit to companies that have a lot of workers’ comp claims because they can have the worker at the office, have OSP come and within an hour that worker can be back to work instead of the worker having to leave the job early just because he has to travel early and probably is not able to return that day,” Palacio said.

Gene Testing: Time Is Ripe in Work Comp

Pharmacogenetic testing (PGT) has the potential to help clinicians improve outcomes for injured workers and reduce costs for payers. While research showing the clinical value of PGT continues to grow rapidly, evidence of the return on investment in the workers’ comp space is just beginning to emerge. Practitioners can benefit from the technology without falling victim to the hype of some proponents by becoming better educated about PGT and those providing it.

Because the use of PGT in the workers’ comp population is relatively uncommon, practitioners may find it challenging to realize the true value of the tests. “A few of our customers are trying PGT on select claimants,” said Dianne Tharp, pharmacist and executive clinical liaison for pharmacy benefit manager Healthcare Solutions, an Optum company. “This is a complex area; everything is evolving. It’s relatively new for the industry, and we are all still learning.”

One growing area of interest is in genetic tests that can identify injured workers most at risk for addiction and abuse. However, there are many challenges with such tests, including uncertainty about their predictive performance in clinical settings, which must be overcome before clinicians can use them to help identify whether an injured worker may misuse or abuse a prescribed opioid. While PGT could be a welcome tool, the science is not yet at a level where clinical application is appropriate.

“On the other hand, pharmacogenetic testing for drug response is often more — and in some cases highly — predictive,” said Naissan Hussainzada, senior director of genetics strategy and commercialization at Millennium Health. “For example, certain genetic variations can change how an individual metabolizes some opioid medications. Using this information, clinicians can identify patients at higher risk for medication failure and/or side effects, which may help them make more informed and tailored treatment decisions.”

Injured workers with preexisting conditions or those who develop comorbid conditions post-injury may especially benefit from PGT — as they may be receiving multiple medications that could potentially elevate their risk for drug-drug and gene-drug interactions. PGT information could also help the clinician better understand whether drugs prescribed for comorbid conditions will be effective.

“In the workers’ comp space, PGT could be used to help the clinician optimize medication prescribing and avoid trial and error,” Hussainzada said. “This has the potential to translate to faster recovery, less time away from work and shorter claim duration for the injured worker.”

See also: Genetic Testing: The New Wellness Frontier

Polypharmacy challenges

Multiple medication regimens and comorbid conditions are frequently present in workers who are injured on the job. The inability to work and the presence of pain can result in additional comorbidities, especially depression.

Metabolism can play an important role in how patients respond to medications, particularly antidepressants, opioids, certain anticoagulants and cardiovascular medications. Mental health providers, in fact, were among the first to recognize the value of PGT in guiding medication therapy and dosing.

“Mental health disorders are often assessed subjectively, and drug therapy can be lengthy, unpredictable and suboptimal,” Hussainzada said. “It may take several months to stabilize a patient on an effective antidepressant using trial and error.”

PGT can be especially useful for antidepressants. “There are actionable PGT results with good evidence for the antidepressants,” Tharp said. “That would be an instance where PGT may be useful [among injured workers].”

In addition to antidepressants, Tharp said PGT is also being used to help determine a patient’s ability to properly metabolize warfarin, which is used to prevent blood clots.

Drug-drug interactions

Individuals metabolize medications differently, partly depending on a person’s genetic makeup and partly on clinical factors, such as hepatic (liver) disease, lifestyle factors and administration of other medications. For example, introducing a new medication may change how existing drugs are metabolized, which can change their effectiveness or tolerability. Conversely, an existing medication may have an impact on the metabolism of a new medication.

“There are well-documented drug-drug interactions between opioid analgesics and certain antidepressants,” Hussainzada said. “This is because some antidepressants can inhibit or ‘turn off’ the enzymes responsible for metabolizing opioids. This can lead to the opioid becoming less effective, or in some cases, intolerable or potentially toxic. Making matters more challenging, there are some individuals that carry certain genetic variations that can make them more susceptible to a phenomenon called ‘phenoconversion,’ which can elevate their risk for certain types of drug-drug interactions. For injured workers receiving polypharmacy, PGT may help clinicians identify these higher-risk individuals and help mitigate some of the risks of phenoconversion.”

There are four categories of metabolizer type that correspond to how individuals may metabolize certain medications via hepatic enzymes. Individuals classified as “extensive” metabolizers possess fully functional enzymes and are able to metabolize medications normally. However, some individuals carry genetic variations that lead to reduced or significantly reduced enzyme function, and are classified as “intermediate” or “poor” metabolizers. Finally, some people may have genetic variations that lead to significantly increased enzyme function and are classified as “ultra-rapid” metabolizers. What that means is: Two people taking the same drug at the same dose can have very different responses because of their metabolizer status.

Individuals susceptible to phenoconversion can “switch” metabolism type, for example, from an intermediate or extensive metabolizer to a poor metabolizer. The trigger for these conversions is non-genetic extrinsic factors, such as administering a drug that inhibits the enzyme pathway. Certain metabolizer types are associated with higher risk of phenoconversion and risk of drug-drug interactions.

“Intermediate metabolizers may be at higher risk for phenoconversion compared to normal metabolizers,” Hussainzada said. “However, it can be difficult to identify these patients because they may display normal or typical response to a medication, even if they are metabolizing that drug at a reduced rate. However, if an inhibitor of the drug is added to their regimen, this can shift the individual from intermediate to poor metabolism and lead to medication failure and/or potentially serious side effects.”

For some claimants who take medications for pre-existing conditions, adding a pain medication can increase the risk for drug-drug interactions and phenotypic conversion. “So a claimant who has been taking antidepressants for years is now also prescribed an opioid because of his injury,” Hussainzada said. “If he is an intermediate metabolizer for the opioid, the antidepressant may convert him to a poor metabolizer. This could lead to inadequate pain relief, which may delay recovery and increase risk of poor outcomes.”

In another scenario, an injured worker who is taking opioids for his injury and who later develops depressive symptoms may be treated with concomitant antidepressant therapy. “In this case, the opioid may have been initially effective, but certain opioids would lose analgesic potency once the inhibitor, or antidepressant, is added,” Hussainzada said.

PGT can also help a clinician identify patients who may need to be started with atypical or non-standard doses of certain analgesics. One particular enzyme responsible for the metabolism of a large number of medications is cytochrome P450 2D6, or CYP2D6. Claimants who are reduced metabolizers for the pathway may not respond adequately to a standard dose of oxycodone.

“If you are a CYP2D6 poor metabolizer, standard doses of oxycodone or hydrocodone may not effectively control your pain,” Hussainzada said. “However, without knowing this type of genetic information beforehand, it may appear to the clinician that these individuals are drug-seeking if they continue to ask for higher doses.”

Some poor metabolizers may not get any pain relief, even with very high doses of a medication. Identifying these patients through PGT can lead the clinician to prescribe a different pain medication from the start, something that can be critical to getting an injured worker back to function.

According to a recent position paper from Healthcare Solutions, the rates of comorbidity and polypharmacy are on the rise in workers’ comp and can lead to increased medical costs, delayed returns to work and longer claim durations. Clinical depression is a common comorbidity, and the use of antidepressants is prevalent; however, both are associated with poor recoveries and outcomes.

“For patients taking multiple medications, there may be multiple enzymes that are recruited to metabolize and eliminate these drug combinations from the body,” Hussainzada said. “Some recent data indicates that when you look across multiple enzymes, genetic variation is much more common than when you look at a single enzyme. So for the claimant receiving polypharmacy, it may be even more important to understand how their genetics will contribute to their medication response since it is likely that at least one enzyme system may be variant.”

Clinicians can use PGT information at the beginning of a claim to optimize initial prescribing and dosing of opioids and other medications, which may hasten the recovery time. “In workers’ comp, the data are pretty clear: The faster we can facilitate post-injury recovery and get the claimant back to work, the better their overall prognosis,” Hussainzada said. “Particularly with opioid therapy, we want to use these drugs judicially and effectively.

See also: Urine Drug Testing Must Get Smarter

The future

Researchers and workers’ comp practitioners continue to monitor the clinical evidence for testing in an effort to help clearly identify those injured workers who would benefit most from PGT — in terms of better outcomes and lower costs. For now, there are several types of injured workers who may be good candidates for testing.

“A claimant taking multiple medications from several therapeutic classes, one who has failed several therapies and changing dosages or a patient on ultra-high daily morphine equivalent doses may be a good candidate for PGT,” Healthcare Solutions’ Tharp said.

Ultimately, proponents hope PGT can be a useful tool in getting the right medication at the right dose to each patient. If test interpretations are based on firm clinical evidence, PGT can provide clinicians with a road map for navigating prescribing decisions that can often be complex and subjective. However, providers are advised to become familiar with PGT and, especially, the companies marketing these services.

“Payers, clinicians and patients need to be aware that not all pharmacogenetic testing is equal. Ask questions about the evidence for specific genes and drugs and make sure there are clinical standards in place for how results are interpreted,” Hussainzada advised. “Some tests may not be ready for clinical use, so it’s important to be informed.”

Urine Drug Testing Must Get Smarter

Medical treatment guidelines, such as the American College of Occupational and Environmental Medicine and the Work Loss Data Institute’s Official Disability Guidelines, recommend urine drug testing (UDT) for monitoring injured workers who are prescribed opioids. Yet studies show that few physicians actually order the tests.

There are a variety of concerns about UDT, including its potential overuse, underuse, effectiveness and cost. The guidelines are fairly nonspecific in terms of the frequency and type of testing that are most appropriate for injured workers. The fact is, all UDTs are not created equal and should not be used interchangeably.

Immunoassay tests, for example, are preferred when simply trying to detect the presence or absence of illegal drugs in a person’s system. More sophisticated tests, such as liquid chromatography, may be more suitable for clinical applications. They are far more accurate than immunoassay tests, can identify parent medication and metabolites and can identify specific medications, rather than just drug classes.

The differences in the types of drug testing have important ramifications for patients. For example, inappropriate or insufficient testing can put injured workers at risk for drug overdoses.

“The type of testing clinicians use should depend on the purpose,” said Steve Passik, vice president of Clinical Research and Advocacy for San Diego-based Millennium Health. “The immunoassay test comes from a forensic application and vocational application. In those settings, only the most egregious offenders are meant to be caught.”

Job seekers, workers involved in workplace accidents, and athletes are among those typically subject to forensic tests. For them, immunoassay testing is appropriate and is based on the Mandatory Guidelines for Federal Workplace Drug Testing Programs, developed by the U.S. Department of Health and Human Services.

Because much of UDT today has its roots in forensic applications, the methods and mindsets of simple immunoassay testing are often used in clinical settings. These tests are subject to a high number of false positives; therefore, only positive results are typically sent for confirmatory testing to avoid falsely accusing people of drug use that might have dire consequences, such as job loss.

“This is problematic,” Passik said. “An injured worker who is using drugs and has a false negative result is potentially at risk if the physician uses a forensic mindset and only confirms positive test results. If the injured worker’s pain medications are mixed with whatever drugs he may be abusing, he could suffer an overdose. Or, his addiction could worsen since it is not being detected by the workers’ comp claims administrator.”

Immunoassay tests are generally cheap, fast and readily available. However, they are not designed for, nor are they very effective for, many clinical applications on their own.

“Take a worker who is being prescribed pain medications and is overusing them. The worker runs out of his or her medication and then borrows some from a friend or family member and even further supplements by abusing heroin when these are unavailable,” Passik said. “If his result on an immunoassay test comes back positive for an opioid, this lends a false sense of security that it is, in fact, the prescribed opioid that caused the result. This result is actually a ‘clinical false negative’ for the non-prescribed opioid and heroin. If the clinician has a forensic mindset that sets out simply to catch people but not falsely accuse them, the testing would end there.”

Another example might be seen in the worker prescribed an opioid for pain but also using cocaine who knows not to use it within two to three days of doctors’ visits to avoid testing positive on the immunoassay. The immunoassay test would likely yield a false negative, and testing would, again, end there. “This worker could be quite vulnerable and might even engage in the type of self-deception whereby he convinces himself that he has no drug problem because he can stop in time to produce a negative specimen for cocaine, ”said Passik.

The mixing of cocaine or heroin and prescribed and borrowed pain medications would make the worker susceptible to an overdose and to other drug interactions or to triggering his addiction. But the medical provider in this case would have no idea the person is abusing drugs.

“That’s the rub,” Passik said. “If I were using UDT in a worker’s comp setting, I would have a more flexible policy that allows the provider to use his clinical judgment to determine whether to send either positive or negative results from immunoassay tests to a lab for confirmation testing, or simply skip the immunoassay test and go straight to the lab.”

Immunoassay tests often produce false negative results because of the high cutoff levels that prevent the tests from detecting low levels of medications. They may also fail to detect opioid-like medications such as tramadol and tapentadol, as well as synthetic opioids such as fentanyl and methadone.

False positive results also occur, because certain immunoassay tests are subject to cross-reactivity from other medications and over-the-counter drugs and may produce inaccurate results. And there is a limited specificity for certain medications within a class.

Liquid chromatography tests, on the other hand, enable detection of a much more expansive list of drugs. This is significant, as virtually all injured workers on opioid therapy would be expected to test positive on a drug screening. The liquid chromatography test could detect which opioid was present in the injured worker’s system and at which levels.

In a 2012 study that analyzed results for point-of-care tests using immunoassay in physicians’ offices or labs, Millennium Health found 27% of the test results were incorrectly identified as positive for oxycodone/oxymorphone. The low sensitivity of immunoassay tests can mistakenly identify codeine, morphine or hydrocodone as the same drugs. Similarly, the study results showed the immunoassay tests missed the identification of benzodiazepines in 39% of the results.

One example of clinical chromatography is liquid chromatography tandem mass spectrometry (LC/MS-MS). These tests are far more accurate than immunoassay tests, can identify parent medication and metabolites and identify specific medications, rather than just drug classes.

“Professionals can now accurately test with both great sensitivity and specificity to understand whether patients are taking their prescribed medication, avoiding the use of non-prescribed licit controlled substances and whether or not they are using illicit drugs, which allows for better clinical decision making,” Passik explained. “LC/MS-MS results are now rapidly available to clinicians, allowing for a much greater integration of these results into clinical practice.”

In fact, Passik says much of the growth in the use of LC/MS-MS in recent years is because of the speed with which results can now be obtained, often within 24 hours.

In terms of drug monitoring for injured workers, Passik says immunoassay testing alone does not provide the physician with an accurate basis on which to make good clinical decisions. These tests may be positive for opiates – which, if the person has been prescribed opiates, would be expected.

“In this case, a positive result would need to be sent to the lab to confirm that the opioid detected in the test was solely the medication prescribed and there are no other licit — or illicit — drugs present. The immunoassay positive result by itself doesn’t provide enough information,” Passik said. “However, if the worker is well known to the prescriber and has a long history of UDTs showing he is taking his medications as prescribed, the provider might decide the immunoassay test result will suffice at that point. But, again, it would need to be in the context of appropriate results of UDTs and a clinical exam that do not suggest otherwise.”

Beyond the confusion about the types of UDT, a handful of unscrupulous clinicians are overusing the tests by performing them in their offices or labs they own, regardless of the patient’s risk factors for abuse or overdose. Payers are overcharged by these providers, as they do more testing than is necessary and charge for the initial test, analysis and confirmatory test (because virtually all tests on injured workers receiving opioid therapy would be positive), resulting in three separate bills.

There are also questions surrounding the frequency with which these tests should be performed on a given injured worker. Passik and other experts say the frequency of the tests should be determined by a medical provider based on the injured worker’s risk factors. An injured worker who is depressed, male, a smoker and has a personal or family history of substance abuse would likely warrant more frequent testing than someone with no known risk factors who is fully cooperating with those handling his claims and is eager to do, or is already doing, light duty work. It’s a tough call, and, so far, it is not an exact science.

“If the patient is older and has no history of addiction or other risk factors, you would probably test her a couple of times a year,” Passik said. “But a coal miner in southeastern Kentucky who has been traumatized from an accident, has addiction history in his family, lives in an area where he can make money [by selling the drugs] — that’s a high risk person who likely needs to get tested more often. Most people fall in between, so it’s best to rely on the clinician’s extensive training and individual assessments of their patients and potential risk factors to consider when developing a treatment plan.”

Part of the decision making on the part of medical providers involves figuring out strategies to integrate the two methods of testing, immunoassay and chromatography – “specificity when you need it and the frequency when needed so you can do it in the most cost effective fashion,” Passik said. “The tests should be integrated in a smart way.”

The nature of workplace injuries is such that more testing up front may be required. “Unfortunately, workers’ compensation is heavily loaded with high-risk patients,” Passik said. “They tend to be younger, traumatized because they are injured, and suffer from depression — all of which are risk factors for addiction.”

The best advice for practitioners is to look for thorough documentation from providers, communicate with all parties, especially the injured worker, and become informed on the type and frequency of UDTs performed for each injured worker.