Rx for addiction? — North Dakota workers’ rate of opioid prescriptions 'consistently higher' than other states

EDITOR'S NOTE: This is a two-part story. Read the companion piece here.

BISMARCK — Richard Landsberger’s job at a dairy required him to repeatedly lift and stack milk crates. Decades of hefting 40-pound milk cases in a refrigerated storeroom took a toll on his body. He has suffered debilitating injuries to both shoulders, both arms, both knees and his back.

After more than a decade of struggling to meet the physical demands of his job, Landsberger, was let go by his Bismarck employer in August because he no longer met the requirements for a job he’d held for 38 years.

To cope with chronic pain from his injuries, Landsberger had had to take narcotic painkillers regularly since 2005 — a pharmaceutical crutch he fears has turned into an addiction.

Landsberger, 59, believes his dependence on narcotics was exacerbated by Workforce Safety and Insurance, the North Dakota workers’ compensation program. He said the agency delayed an evaluation that would have demonstrated the need for lighter work duty, leaving him no choice but to take opioids to keep working.

Also, he said, his routine dosage of opioids was high enough that it masked his pain, making him unaware when he was injuring himself at work, or aggravating old injuries.

“WSI ignored him we feel because he was working — yes, he was working while using opioids, which made his body numb, and I truly believe therefore that he kept getting injured,” said his wife, Marie.

Opioid use by workers covered by WSI has been scrutinized by a series of consultants’ evaluations dating back at least to 2010.

The evaluations concluded that opioid use among workers covered by WSI is “consistently higher” than comparison states, including South Dakota and Minnesota, as a percentage of all paid prescriptions since at least 2010, though the rate has declined in recent years.

As a percentage of all prescriptions dispensed to injured workers covered by WSI, opioids peaked at more than 45 percent in 2012 and 2013, but have since declined to 32.2 percent for the first 11 months of this year, according to WSI figures. Spending for opioids peaked in 2016 at $3.4 million. The number of narcotic prescriptions filled for injured workers topped out at 44,396 in 2012, but fell to 21,506 by 2017.

As a state-run insurance program for injured workers, WSI does not prescribe medicines but has policies and makes decisions to enable or refuse treatments.

“We believe that our efforts to address the overprescribing and abuse of opioid medications has contributed to this (downward) trend,” said WSI Director Bryan Klipfel, “but the overall awareness of this issue and the national exposure concerning proper dosing and duration of opioid medications certainly has had a large influence in prescribing patterns.”

Lawyers who represent injured workers said a common complaint is that workers are offered no alternatives to narcotic painkillers for chronic pain, or pain that persists for three months or more.

“Alternatives like acupuncture are not allowed,” said attorney Stephen Little, who represents Landsberger. “That doesn’t meet WSI’s standard.”

Also, although medical marijuana is now legal in North Dakota for certain conditions, and soon will become available to the public, that option is not available to injured workers covered by workers’ compensation, Little said.

Opioid use has declined in some states that allow medical marijuana, he said.

“So I think there’s some things built into the system that sort of cause this train wreck we’re looking at,” Little said.

Also, he said, workers are not provided behavioral health therapies that can help to reduce opioid use or enable workers to better cope with their chronic pain, a condition with both mental and physical components.

“It’s ridiculous,” Little said. “He’s not being provided an alternative other than suck it up. That only goes so far.”

WSI, which is paying Landsberger wage replacement benefits, is trying to find other work for Landsberger, but he said his injuries and pain level will not enable him to handle even light work that would pay a living wage.

“It is WSI’s role to assist in preparing him to transition and compete in a different role,” Klipfel said in a statement. “Acceptance of this change is neither easy nor is it seamless. It is, however, WSI’s statutory mandate.”

Landsberger has refused morphine — “I know morphine is highly addictive” — and has not gone along with a surgeon’s recommendation to increase his opioid painkiller dosage after he injured his back in 2016, his second back injury.

“So I just lived a miserable life living with pain while I was struggling to work,” he said.

Physical therapy brought no relief, Landsberger said. “It just made the pain worse.”

Because of his multiple injuries, Landsberger’s physical activities are limited. He can no longer do mechanical and carpentry chores around the house, which he used to enjoy, and now takes more than two hours to mow the lawn, a task their children can accomplish in 45 minutes.

Meanwhile, months after he stopped working, Landsberger’s attempts to wean himself from narcotic painkillers have largely failed.

“He has too much pain from too many permanent injuries,” Marie Landsberger said. “He tries his best to use as few (pain pills) as he can. Some days are better than others.”

No medical provider has diagnosed Landsberger with opioid abuse disorder, or expressed concern about his use, Klipfel said. His doses would be considered low according to the consultant’s guidelines, he said.

“Should such a diagnosis arise, obviously an evaluation would follow and a course of treatment would need to be determined," Klipfel said .

Under a state law passed in 2015, WSI is taking steps to restrict opioid use for injured workers. It began limiting immediate-release formulations for the acute phase of therapy, and a consultant’s evaluation this year recommends passing a law limiting the number of days’ supply for opioids dispensed and an upper limit on the daily morphine equivalents allowed.

Since the 2015 law passed, WSI can discontinue payment for opioids, action it has taken for 178 workers. The most common reason was detection of illicit drugs or other non-prescribed opioids in urine, followed by non-detection of prescribed medications, a safeguard against diverting drugs.

“What they ought to be doing is offering alternatives to the pills, to the addictive drugs, instead of looking for ways to cut people off without any alternatives,” Little said.

The Landsbergers have become outspoken critics of what they view as WSI’s overreliance on opioids for chronic pain management and rigidity in dealing with workers who are trying to wean from addictive drugs.

“How many drug addicts are out there because of this agency run by the governor of ND?” Marie Landsberger wrote in a letter to Gov. Doug Burgum and other officials. She has questioned whether Burgum’s dedication to addiction recovery, one of his official priorities, extends to the workers’ compensation program under his jurisdiction.

“The prescriptive rates of opioids are a high concern of WSI,” Klipfel said in his statement.

WSI did not respond to a question, however, about whether it identifies and tracks injured workers who have been diagnosed with opioid abuse disorder.

“While WSI does not prescribe opioids, the governor is aware of several measures WSI has taken to address opioid usage and is supportive of those efforts, including proposed legislation for the upcoming 2019 session,” Mike Nowatzki, the governor’s spokesman, said in a statement.

A pre-filed bill would further restrict opioid prescriptions for injured workers, but does not provide for alternatives, such as behavioral health therapy.

• From 2005 to 2017, opioid prescriptions filled for injured workers peaked in 2012 at 44,396. That figure declined to 21,506 in 2017.
• Narcotic costs peaked in 2016 at $3.4 million. Last year, narcotic costs totaled $2.8 million.
• Injured workers covered by WSI consistently had higher narcotic use, a consultant found. As a percentage of all prescriptions, the narcotic rate in North Dakota in 2012, for instance, was 45.3 percent, compared to 35.5 percent in Minnesota and 35.7 percent in South Dakota. North Dakota's narcotic rate was 32.2 percent for the first 11 months of 2018.