Employee Health Systems - June 2007 Newsletter

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EAP Newsletter - June 2007

In This Issue:

Teenager prescription drug abuse - the doctor's fault?

Study points to mental health issues as leading cost and absence drivers

Coming to grip with phobias

A fight for full disclosure of the possible pain

Teenager prescription drug abuse - the doctor's fault?

Every Thursday evening, I counsel a group of teenagers with serious substance abuse problems. None of the youngsters elected to see me. Typically, they were caught using drugs, or worse, by their parents or a police officer and were then referred to my clinic.

To be sure, all the usual intoxicants - alcohol, marijuana, amphetamines, LSD and cocaine - are involved. But a new type of addiction has crept into the mix, controlled prescription drugs, including potent opiate painkillers, tranquilizers and stimulants used to treat attention deficit disorders.

This is hardly unique to my clinic. Several studies report that since 1992, the number of 12 to 17 year-olds abusing controlled prescription drugs has tripled.

In fact, dabbling with some of the pharmaceutical industry's finest psychoactive compounds constitutes the fastest growing type of drug abuse in the United States, outpacing marijuana abuse by a factor of two. One of my patients, Mary, illustrates this trend all too well. A voracious reader and a talented musician in her high school orchestra, Mary at 16 is also a "garbage head," meaning that she will ingest anything she thinks will give her a high.

Last December, she was taken to the hospital for an overdose of hallucinogenic mushrooms, alcohol, and ketamine, a chemical cousin of angel dust that doctors sometimes use to anesthetize patients and that, more commonly, veterinarians use to sedate large animals.

Lately, she has been playing with one of the strongest opiates and potentially addictive painkillers ever created, Oxycontin. She downs few with a single shot of vodka and calls the combination "the sorority girl's diet cocktail," because it simultaneously allows for a stronger kick of inebriation and far fewer calories than mere alcohol alone.

The most recent Monitoring the Future report, the continuing study of teenage drug use conducted by the University of Michigan and the National Institute of Drug Abuse since 1975, found that 5.5 percent of all high school seniors abused Oxycontin, up from 4 percent in 2002. Oxycontin abuse has increased 26 percent since 2002 among 8th, 9th and 12th graders.

A listing of Food and Drug Administration-approved uses for Oxycontin shows that it is specifically for patients in moderate to severe round-the-clock pain like that in advanced stages of cancer.

So where does this physically robust teenager obtain her pills? Weeks earlier, she had a tonsillectomy, a minor though uncomfortable procedure by any standards. The surgeon wrote a prescription for 80 tablets. Mary spent the next week in a narcotized and medically sanctioned bliss, until her mother confiscated the last 20 tablets.

At medical conferences, I hear colleagues fault parents who abuse and obtain these controlled substances but leave them easily accessible in their unlocked medicine chests where teenagers can help themselves. Other experts fault the Internet, where almost anyone can obtain controlled prescription drugs from offshore pharmacies with a few clicks on a home computer.

The favorite scapegoat is deceptive; addicted patients who the argument goes, "doctor shop" and manipulate the physicians into prescriptions themselves or buy them from drug dealers at exorbitant prices.

None of these targets come close to the real root of the problem. Many doctors are too quick to write prescriptions for these powerful drugs.

The National Center for Addiction and Substance Abuse recently reported that 43.3 percent of all American doctors did not even ask patients about prescription drug abuse when taking histories; 33 percent did not regularly call or obtain records from a patient's previous doctor or from other physicians before writing such prescriptions; 47.0 percent said their patients pressured them into prescribing these drugs; and only 39.1 percent had had any training in recognizing prescription drug abuse and addiction.

Yet from 1992 to 2002, prescriptions written for controlled substances increased more than 150 percent, three times the increase in prescriptions for all other drugs.

The morning after hearing about Mary's Oxycontin holiday, I called her surgeon and asked him whether he had read her medical chart detailing an extensive history of substance abuse, "Why did you prescribe this narcotic bazooka when a BB gun of a painkiller such as acetaminophen might have done the trick? I asked.

Sheepishly, the surgeon replied, "Well, I guess I wasn't thinking."

No one in pain - physical or psychic should suffer. But the fact remains that we doctors still do the bulk of prescribing of the substances. The search for root causes of the epidemic with controlled substance abuse has to include doctors as active participants. A big part of the solution depends on reserving prescriptions for those who need, rather than desire them.

By Howard Markel, M.D.

According to a recent survey of HR professionals and senior managers, mental illness is "the leading cause of indirect costs associated with lost work time." Although both the prevalence and cost of mental health issues in the workplace are viewed as problematic, employers are not effectively grappling with the problem.

The study, "Innerworkings: A Look at Mental Health in Today's Workplace," was conducted by Employee Benefit News in conjunction with The Partnership for Workplace Mental Health and AstraZeneca Pharmaceuticals LP. The study encompassed more than 500 HR-benefits professionals and senior executives representing more than 50 business segments from across the country. This study reveals that mental illness is exacting a high economic toll in the workplace:

* HR-benefits directors say mental illness has far more impact on the indirect costs associated with lost productivity and absenteeism than physical problems.

* Nearly on-third of the survey respondents (31%) believe mental illness has the greatest adverse impact - more than twice the number who blamed back problems (14%) and three times the number identifying substance abuse, asthma/allergies and smoking as the culprits.

Their rankings are supported by other studies showing the cost of mental illness in the workplace. For example, a 2006 study published in the American Journal of Psychiatry showed that a worker with depression averaged 27.2 lost workdays annually due to absence or poor functioning on the job, and an employee with bipolar disorder averaged 65.5 days.

HR managers and employers report that the availability of benefits designed to address mental health issues is high: 90% of the respondents cite mental health insurance coverage, 76% cite employee assistance program (EAP) availability, and 63% have return to work programs for disabled workers.

Despite treatment availability, respondents point to low utilization, citing a variety of factors. Common employee factors hindering utilization are lack of awareness of available help and the stigma and shame associated with mental health issues. In addition, respondents indicated that managers and supervisors may be part of the problem because they often fail to encourage benefit utilization. Fewer than 25% of respondents felt that managers understand the scope of the problems that mental health issues pose, and only 15% of the respondents had training to help managers recognize problems and point employees to help.

The study mirrors much of what we see in treating troubled employees. We strongly believe that line managers are often pivotal in spotting at-risk employees early and directing workers to help before problems are exacerbated. But because good training is often unavailable, supervisors and managers are often ill-equipped to identify and address problems effectively. Particularly when issues appear to be related to non-work matters, supervisors can be reluctant to address problems, either because they don't know how to or because they think it is not their business. Therefore, problems are often ignored until they rise to the level of a crisis. Yet our experience and numerous studies show that early intervention can help to effectively resolve problems. Supervisors should know that they do not need to (and should not attempt to) diagnose or treat personal or psychological problems, but should understand the importance of identifying employees who may be at risk and referring these employees on the HR managers and the benefit programs that can provide help or treatment.

Liberty Mutual recently studied mental health disability claims and issued recommendations for best practices for managing claims involving psychological issues. These include:

The cited article discusses each of these practices in greater depth, and states that employers implementing these practices have cut the number of disability claims related to psychological issues by as much as 10 percent.

By ESI

Goldberg, former associate director for the Center for Corporate Community Relations at Boston College, feared flying. When she had to fly for business, "I would ask people next to me if it was OK if I would grip their arms - I would leave marks," she said. "My colleagues did not want to fly with me. People who were very relaxed, by the end of the flight, would be terrified."

More than 6 million Americans experience specific phobias, or irrational fears, says Jerilyn Ross, director of the Ross Center for Anxiety and Related Disorders in Washington, D.C. Many more experience anxiety disorders such as panic attacks and social phobias.

Some fears are normal, Ross say. It's not surprising that someone might be anxious about flying, especially "when you walk into an airport and they're scanning at every counter," she says.

But sometimes fear can cause problems for employees and employers. Many Americans suffer secret fears of flying, public speaking, heights, elevators, driving on highways or bridges, and other everyday situations.

Often workers manage to avoid these situations on the job. Sometimes, however, this becomes impossible.

Terrie White, special projects assistant in the media library at WGBH in Boston, was expected to fly to a meeting "about five months after 9/11," White says. "I generally don't like flying, but at this particular time, there was no way I would do it."

"With terrorism, there definitely has been a rise in the amount of fear of things like flying and high floors in buildings," says Dr. Srini Pillay, former director of anxiety disorders in the outpatient program at McLean Hospital in Belmont. He's now director of the hospital's panic disorders research program.

But what can - or should - employers do about it? Josh Black, labor and employment lawyer at Bello Black LLP in Boston, says, "An awful lot of clients called in the weeks after Sept. 11 and said, 'My people won't come to work,' or 'They won't fly or go to big cities.' I think that has abated somewhat in the last year, but the issue of mental or emotional disorders like anxiety continues to be a huge issue that human resource (departments) are dealing with."

Liz Hahn, clinical director and vice president of KGA Inc., a national employee assistance program in Framingham, says, "Many of the bigger companies became more flexible about what they required of their employees" after Sept. 11.

"In some companies," she says, "the culture is allowing [workers] to approach their managers with some of [their] limits."

Perhaps because of the rise in fears related to travel and big cities, more workers have become willing to express other long-held anxieties.

"Social anxiety is increasingly reported," Pillay says. Symptoms range "from palpitations at a presentation to being debilitated."

It is, Pillay says, "the third-largest psychological problem in the US today." Both he and Ross say it affects at least 5 million Americans.

Less common, but still seen, he says, are anxieties about driving, often related to fears of being trapped or losing control of a car on icy roads or bridges.

Then there's fear of heights. Even employees who don't work on high floors or at construction sites may find themselves faced, on occasion, with high anxiety.
Some companies, for instance, use team-building exercises in the form of outdoor games, some of which involve rock or tree climbing.

"Height is probably the biggest fear out there," says Logan Westmoreland, past director of operations for Thompson Island Outward Bound Professional in Boston. Westmoreland says participants are encouraged - but not forced - to start slowly and climb as high as 60 feet, although they may stop at any point.

Dr. Daniel Cantor Yalowitz, who founded Project Play Inc., a nonprofit recreational and educational consulting organization, says that, in addition to "challenge by choice," he tries to offer alternatives, such as bandanas for people who fear touching others during exercises that involve holding hands. "People come first, rules are second," he says. Workers who are dealing with a phobia can try changing themselves or their situations. Pillay recommends employee assistance programs as the first step, or private counseling or personal coaches for those reluctant to engage a therapist. Other treatments include cognitive behavior therapy - often used for anxiety about bridges or elevators, for instance - in which a trained therapist helps patients gradually confront their fears.

"Medications can be helpful," Pillay says. "Some can be used just before a presentation - beta blockers to help with social anxiety. There are other medications that people can be on for longer periods of time."

Some workers, however, prefer to change their circumstances. A disinclination to fly, said Patrick Doyle, clinical supervisor of the employee assistance program of Mount Auburn Hospital in Cambridge, "can be a rational, logical concern or preference. The person might simply not want to do it."

Sometimes, Doyle says, managers "say they don't know whether they should mandate" conferences or other business trips, and some struggle with whether they consider it an essential element of the job.

Mike Norton, spokesman for Gillette Co. in Boston, says his company handles these matters on a case-by-case basis and encourages employees who are having difficulties of any kind to seek help from their employee assistance program.

From a legal point of view, Black, the labor and employment lawyer, says, "Those situations sometimes can be a little complicated...Some types of fears - flying, generalized anxiety disorders - if they are severe enough and have enough of an impact on one's life can qualify for protection under the Americans With Disabilities Act or state law." Many companies, he said, require proof.

"Once you've established that a person has a disability," he said, "where the rubber meets the road [in] administering this act, [is] how far does the law or company policy require [a company] to go to help this person?...If you have someone who covers a sales territory that's reasonably small, maybe you can have them drive instead of fly."

Nancy Goldberg still dislikes flying, but will do it. "I had no choice," she says, "but to say 'gotta overcome this...or it's going to affect the entire organization.'" She learned to identify various airplane noises and taught herself breathing and distraction techniques.

"Interestingly enough," she says, "they're very similar to techniques I use to help my clients." Goldberg is now a speech coach with the Speech Improvement Company in Brookline. Part of her work involves helping people conquer an anxiety believed to affect more people than the fear of flying: public speaking.

The dozens of letters, phone calls and e-mail messages I've received since writing my recent columns on total knee replacement and pain management reveal that I struck a chord.

Some readers chastised me for scaring potential patients away from this surgery, which, when healing is completed, can greatly enhance quality of life. But many others praised me for "telling it like it is" about an often painful and difficult recovery that surgeons don't warn patients about.

Clearly I've not been alone in having prolonged, debilitating postoperative pain that was not adequately treated.

Obviously, many people have had total knee replacements without experiencing the kind of pain I suffered.

I knew going into surgery that a friend 10 years my senior had both knees replaced at once, as I did, and was dancing after four weeks. I could not walk down stairs using both legs at nine weeks after surgery despite prompt and intensive physical therapy.

An Ohio man who had both knees replaced at age 77 wrote; "After surgery my pain was very tolerable, and I took minimal pain medication. I now walk everywhere, miles, over hill and dale, all without pain, and I'm hoping to return to the tennis court. I would encourage those who need knee replacement to "go for it," even both knees at the same time."

Since I entered surgery slender and in top physical condition, I expected a similar recovery experience, and my surgeon reinforced that expectation.
Who can explain it? Not me or my surgeon.

To those readers who fear that I unduly frightened some prospective knee replacement candidates away from this life-enhancing surgery, I must say that was neither my intent nor my message.

My message was that whatever procedure a patient faces, full disclosure is imperative. People have a right to know what they encounter, not just what the surgeon hopes will happen.

An orthopedic surgeon called after reading my article to say that he tried to fully inform patients who asked about knee replacement.

As a result, he said, he scares some people off, and the chief of surgery at his hospital has complained that he does not do this operation often enough.

This is outrageous, and just reveals the monetary motives behind much of modern medicine. The patient be damned; just bring in the bucks.

So here's the good news: at 10 weeks post-op, I insisted that the surgeon take another look at me because I was convinced that there was something wrong with my right knee.

The left, the most severely afflicted with arthritis going in, was at last healing nicely, but the right continued to keep me tied to potent painkillers.

As it turned out, I had tendinitis, a seriously inflamed tendon across the outside of the knee cap that was aggravated with every bend of that knee. All it took was a shot of cortisone to bring relief and get the healing process back on track.

I just wish that my weekly complaints of disabling pain in that knee had been acted upon much sooner.

The day after the shot, I was able to walk half a mile each way to my local Y and resume my daily swim.

In just four days I was swimming three-fourths of a mile and feeling almost fully human again.

Yes, I still take medication, but much less than before, and I still have to rest from time to time. But I now anticipate the day when I can resume riding my bicycle and walking around the park, hiking and ice skating with my friends.

Here's what one reader who had total knee replacement wrote: "I wish I had known how incapacitating the recovery period would be so that I could have planned accordingly. It would not have changed my resolve to have the procedure - only my planning for its aftermath."

Is this too much to ask of the medical profession?

I had set aside six weeks to recover and done all my work in advance for that period, only to find that I needed twice the time to return to normal daily activities , including getting to the subway on it and off it.

Another surgeon wrote to me about doctors' fear of legal action over prescribing narcotics. Yes, the government has unfairly attacked some pain management specialists who treat dozens of patients with chronic pain.

Dr. Jennifer P. Schneider, the author of "Living With Chronic Pain," has testified on behalf of such doctors who were unjustly accused of feeding the habits of drug addicts.

This is hardly the case, and a mass uprising by doctors and patients in support of legitimate pain treatment is overdue.

It is also not true that pain patients get hooked on narcotics, craving ever greater does of them. Addicts get hooked; pain patients need increasing doses only when their pain worsens, as often happens to those with advanced cancer.
And as Dr. Laura Lewis Mantell of New York wrote to me, "The use of opioid analgesics (narcotics) need not be avoided out of concerns that addiction will ensue, because the incidence of addiction arising out of postoperative exposure to opioids is negligible. When faced with the kind of pain I experienced, doctors must treat it properly and not act like frightened children when it comes to prescribing narcotics, by far the best drugs for dealing with severe pain.

A narcotic like OxyContin is not abused by pain patients but by drug addicts. I feel no euphoria, just pain relief, and I'm having no problem weaning myself off it now that I am in much less pain.

The American Academy of Pain Medicine, the primary organization for Physicians who treat pain, is alarmed by the interim policy statement issued by the United States Drug Enforcement Agency, which threatens to make it even more difficult than it now is for legitimate physicians to prescribe adequate pain relief for their patients.

Undertreatment of pain is already a public health crisis and the government should act to improve the situation, not make it worse.

Undertreated pain destroys lives. As one young woman put it in an e-mail message: "The effect of pain had an insidious effect on my life, my outlook, my well-being and my relationships in every sphere of my life. Pain is a funny thing. Unless you're the one feeling it, it's basically meaningless."

The time is long overdue to instill empathy, not fear of persecution, into the nation's physicians.