Workplace insurers are accustomed to making billions of dollars in payments each year, with the biggest sums going to employees hurt in major accidents, like those mangled by machines or crushed in building collapses.
Now they are dealing with another big and fast-growing cost — payouts to workers with routine injuries who have been treated with strong painkillers, including many who do not return to work for months, if ever.
Workplace insurers spend an estimated $1.4 billion annually on narcotic painkillers, or opioids. But they are also finding that the medications, if used too early in treatment, too frequently or for too long, can drive up associated disability payouts and medical expenses by delaying an employee's return to work.
Workers who received high doses of opioid painkillers to treat injuries like back strain stayed out of work three times longer than those with similar injuries who took lower doses, a 2008 study of claims by the California Workers Compensation Institute found. When medical care and disability payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used than when a narcotic is not used, according to a 2010 analysis by Accident Fund Holdings, an insurer that operates in 18 states.
"What we see is an association between the greater use of opioids and delayed recovery from workplace injuries," said Alex Swedlow, the head of research at the California Workers Compensation Institute.
The use of narcotics to treat occupational injuries is part of a broader problem involving what many experts say is the excessive use of drugs like OxyContin, Percocet and Duragesic. But workplace injuries are drawing particular interest because the drugs are widely prescribed to treat common problems like back pain, even though there is little evidence that they provide long-term benefits.
Between 2001 and 2008, narcotics prescriptions as a share of all drugs used to treat workplace injuries jumped 63 percent, according to insurance industry data. Costs have also soared.
In California, for example, workplace insurers spent $252 million on opioids in 2010, a figure that represented about 30 percent of all prescription costs; in 2002, opioids accounted for 15 percent of drug expenditures.
As a result, states are struggling to find ways to reverse the trend, and some of them have issued new pain treatment guidelines, or are expected to do so soon. These states include New York, Colorado, Texas and Washington. Insurers are also trying to influence how physicians prescribe the drugs.
Doctors in four states — Louisiana, Massachusetts, New York and Pennsylvania — appear to be the biggest prescribers of the drugs for workers' injuries, according to a review of data from 17 states by the Workers Compensation Research Institute, a group in Cambridge, Mass.
Painkiller-related costs are also hitting taxpayers, who underwrite coverage for public employees like police officers and firefighters, experts say. In February, one major underwriter, the American International Group, said that it would no longer sell backup coverage to workplace insurers, citing rising pain treatment expenses as one reason.
There is little question that strong pain medications can help some patients return to work and remain productive. But injured workers who are put on high doses of the drugs can develop chronic pain and face years of difficult treatments. It is not clear how, or if, the drugs are involved in the process, but when pain becomes chronic, the cost of a commonplace injury can equal a crippling one, experts said.
"Some of these claims look like someone who fell down an elevator shaft and had multiple injuries," said Dr. Edward J. Bernacki, the director of the division of occupational and environmental medicine at Johns Hopkins University in Baltimore.
For decades, workers' compensation plans, which vary by state, have been plagued by problems like lengthy legal battles over an injury's financial value. But it is in recent years that opioid painkillers have emerged as a major driver of costs, experts said.
Accident Fund Holdings examined its claims and found that the cost of a typical workplace injury — the sum of an employee's medical expenses and lost wage payments — was about $13,000. But when a worker was prescribed a short-acting painkiller like Percocet, that cost tripled to $39,000 and tripled again to $117,000 when a stronger longer-acting opioid like OxyContin was prescribed, said Jeffrey Austin White, an executive with the insurer, which is based in Lansing, Mich.
In a sense, insurers are experiencing the consequences of their own policies. During the last decade, they readily reimbursed doctors for prescribing painkillers while eliminating payments for treatments that did not rely on drugs, like therapy.
Those policies may "have created a monster," said Dr. Bernyce M. Peplowski, the medical director of the State Compensation Insurance Fund of California, a quasi-public agency.
For patients, such policies had consequences.
Dr. Eugenio Martinez, a physician in the Boston area who specializes in rehabilitative medicine, said one patient, a former waitress who hurt her back five years ago in a fall, recently won a court fight to force her insurer to pay for physical therapy. The insurer had cut off those payments five years ago after a few sessions, and the woman, now disabled, had no option but to take strong painkillers, Dr. Martinez said. "It certainly did not help that she was cut off," he said.
Nationwide, data suggests that a vast majority of narcotic drugs used to treat occupational injuries are prescribed by a tiny percentage of doctors who treat injured workers; in California, for example, that figure is just 3 percent. Also, the bulk of such prescriptions go to a relatively small percentage of injured workers, including those who might be addicted to the drugs or those who sell them, experts said.
Several companies, like Accident Fund Holdings and Liberty Mutual, have set up programs in which pain experts contact doctors identified as high prescribers to discuss their practices. The State Compensation Insurance Fund of California has also instituted a policy that requires approval for a doctor to prescribe an opioid for over 60 days.
Insurers say they are making progress in reducing overuse of the drugs. But their ability to influence physicians is limited because workers' compensation plans can allow employees to see any doctor. So several states have or will soon adopt new pain treatment guidelines for doctors who treat workers.
In New York, one proposal would require a doctor to refer a patient who is not improving to a pain specialist when an opioid dose exceeds a certain level, said Dr. Elain Sobol Berger, the associate medical director of the state's workers' compensation board. Washington State has already adopted such a policy.
Dr. Sobol Berger added that the New York rules, which are expected to be proposed this year, will also emphasize nondrug treatments for pain. "We know that there is a significant problem with the management of chronic pain and the use of opioids," she said.
Some insurers, like the California state fund, have also started paying for alternative approaches like specialized psychotherapy or are trying to get addicted workers into treatment. Other companies are also checking on long-disabled workers.
Mark Kulakowski, a 57-year-old former warehouse worker from Peabody, Mass., injured his back more than three decades ago while lifting a box. He has not worked since 1995. Since his injury, he has taken narcotic painkillers and has had a long list of failed treatments.
Recently, his insurer, Liberty Mutual, sought to have a nurse accompany him to his next doctor's appointment, a suggestion he welcomed if it could lead to taking fewer painkillers.
"It just drains everything out of you," he said.