A Closer Look at Comorbidities

Comorbid conditions in workers’ compensation and auto no-fault can create a trifecta of negative outcomes and aggravate an already difficult situation for an injured individual. In Part one of our series on comorbidities, we will define what they are and describe the three ways comorbidities can make a bad situation worse.

Comorbidity and Injured Individuals: when the egg is first, the chicken follows

In medicine, comorbidity is defined as the presence of one or more additional conditions co-occurring with a primary condition. Relating to workers’ compensation and auto no-fault, when a person has a preexisting pathological process or processes, that individual may be predisposed to injury, treatment may be complicated, and duration of therapy extended.

THE POTENTIAL IMPACT OF A COMORBIDITY

Longer recovery and disability duration

This confounding of the injury may be somewhat intuitive since signs and symptoms of disease, both physical and mental, can negatively affect the injured individual's structure and function, and contribute to distress, dysfunction and pain on its own. The relationship between comorbidity and injury has been studied and codified. For example, people with diabetes and foot ulcers1 have an increased risk of falls and subsequent fractures. You can also see the impact of comorbidity on a forearm fracture recovery:

It’s no secret there’s a close connection between mental health and overall physical health. For this reason, injuries can lead to a number of unexpected outcomes such as depression, sleep-related disorders and anxiety disorders. And the likelihood of developing depression increases as the severity of pain strengthens. One study demonstrated that injured workers were 45% more likely to suffer from depression than non-injured workers.¹

These problems can cause devastating consequences disrupting overall quality of life and straining relationships that often protect against these disorders in the first place. In addition, comorbid mental health disorders in an injured individual can result in a longer duration of treatment and increased cost burden.²

For example, an injured worker with a lumbar sprain and disc involvement is typically out of work 30 days, add in comorbid depression and the missed time from work nearly doubles to 53 days.³

Inability to work can worsen psychological symptoms

Work provides an individual with a structured sense of self, identity and purpose in life. When physical injury prevents a person from being able to function in this capacity, the worker’s psyche is often impacted negatively. Physical pain from these injuries can limit a worker’s ability to do their job, as well as normal activities of daily life, often requiring medication, such as opiates. Over time, these medications can become addictive, leading to higher rates of opioid use disorders.

Persons with a substance abuse disorder miss between 15-29 days per year of work.⁴ It is estimated that healthcare costs are three times higher for persons who abuse opioids.⁵

The impact of depression on health outcomes

Physical pain, as well as prolonged periods of time away from work, can often lead to signs and symptoms of depression, such as decreased interest in pleasurable activities, decreased appetite, impaired sleep, feelings of guilt and, in extreme cases, thoughts of suicide. These symptoms often go unnoticed as they can sometimes be confused with pain syndromes.⁶ Coexisting depression is two times more likely when an individual is in pain.

A traumatic injury with associated pain has a typical return to work period of 45 days. However, if depression is a comorbidity, the anticipated return to work time increases to 83 days.

Research also shows significantly greater costs associated with treatment of depression.

A 2016 study estimated the annual cost of treatment of major depression was $6,787. Add in the cost of an injury with medical leave and costs escalated to $13,929.⁷

Trauma from injuries can intensify mental health issues

For some injured individuals, the actual injury can be a traumatic experience. Over time, the original trauma can trigger sleep impairment, anxiety, flashbacks and nightmares, and lead to post-traumatic stress disorder.

Early intervention has proven to improve outcomes

Early recognition of these conditions and applying prompt treatment with appropriate medications (antidepressant medication, sedatives, and anxiolytics), as well as therapeutic modalities such as cognitive behavioral therapy, can have a very positive impact and increase the probability of a successful return to work.

As noted in a 2010 study, any treatment, regardless of type, improved pain scores, reduced depression severity and improved social functioning.⁸

Sources:

1. Asfaw A, Souza K. Incidence and cost of depression after occupational injury. Journal of Occupational and Environmental Medicine. 2012, 54(9) 1086-1091.
2. Kim: Depression as a psychosocial consequence of occupational injury in the US working population: findings from medical expenditure panel survey. BMC Public Health 2013, 13:303.
3. Official Disability Guidelines. Comorbidity Calculator. Available on subscription: https://www.mcg.com/odg. Accessed Oct 11, 19.
4. Centers for Disease Control and Prevention. NiOSH launhes a new framework to tackle opioid crisis in the workplace. https://www.cdc.gov/media/releases/2018/p0831-NIOSH-opioid.html Accessed Oct 11, 2019.
5. McCormick V. The rise of workplace opioid abuse. Clan Lab, Health and Safety Training May 2019. https://www.nesglobal.net/the-rise-of-workplace-opioid-abuse Accessed Oct 11,2019
6. Cosio, David, et al. “The Association Between Depressive Disorder and Chronic Pain.” Practical Pain Management, 2017, www.practicalpainmanagement.com/pain/other/co-morbidities/association-between-depressive-disorder-chronic-pain.
7. Goldberg R, Steury S. Depression in the workplace: costs and barriers to treatment. Psychiatric Services Online. https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.52.12.1639 Accessed October 11, 2019.
8. Teh CF, Zaslavasky A, Reynolds CF et al. Effect of depression treatment on chronic pain outcomes. Psychosom Med. 2010 72(1):61-67/

Injuries can often lead to comorbidity and complications that can lengthen the duration of treatment, delay return to work and increase costs. Hypertension, or high blood pressure, was the most prevalent comorbid condition in workers’ compensation according to a study published in 2012, and its frequency and costs have increased.¹

• Diagnoses of comorbid hypertension tripled from 2000 to 2009.¹
• Costs doubled compared to similar workers’ comp claims without comorbid hypertension.¹

Hypertension is defined as a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher based on an average of at least two elevated blood pressure readings on two separate occasions.² This problem impacts nearly one in every three adults in the United States ― approximately 75 million people.³ And if left untreated, hypertension can lead to severe complications such as stroke, heart attacks, heart failure and kidney disease.

Injuries can contribute to hypertension

Injured individuals may be more likely to develop hypertension as a comorbidity, especially older adults. Lack of activity or mobility, stress, and poor diet management due to income reduction are likely contributing factors.

Hypertension can complicate the treatment of an injured person

• Chronic hypertension can harden arteries, thereby reducing the flow of oxygen and nutrients to a wounded area and delaying healing.⁴
• Uncontrolled high blood pressure among injured individuals requiring surgery and general anesthesia can potentially halt, interfere and delay needed treatment.⁴
• Certain prescription medications used to treat an injured person can contribute to elevated blood pressure, such as: corticosteroids, non-steroidal anti-inflammatory drugs and antidepressants.⁴

Careful oversight of prescribed hypertension medications is critical to avoid adverse side effects

Some medications used for treating hypertension have potential to interact with medications commonly seen in workers’ compensation or auto claims.

Co-administered medication issue

Amlodipine, a medication routinely prescribed for high blood pressure, is classified as a calcium channel blocker and can increase the effects of an opioid, such as methadone, when used concurrently. When both medications are used together, there is an increased risk for respiratory depression and sedation because amlodipine can increase methadone exposure in the body.^5,6

A solution to the co-administration of these medications is to reduce the dose of methadone or use an alternative antihypertensive medication.⁶

NSAID concerns

Similarly, NSAIDs (non-steroidal anti-inflammatory drugs) can interact with a class of antihypertensive medications known as Angiotensin-converting enzyme inhibitors (ACE inhibitors). NSAIDs can weaken the antihypertensive effects of ACE inhibitors and can cause severe renal damage in older adults when used concurrently.^5,6

Certain NSAIDs, such as indomethacin, naproxen and piroxicam have a greater impact on elevating blood pressure in the presence of ACE inhibitors, whereas NSAIDs like sulindac and nabumetone have a lesser impact.^5,6

Generally, NSAIDs should be avoided in older adults. But if simultaneous use is needed, blood pressure and renal function should be monitored throughout treatment. Clinicians can consider alternative pain treatment modalities if significant risk from the drug-drug interaction is present.

Early recognition of hypertension and a full clinical picture of the claimant can improve outcomes

Although many risk factors that contribute to developing hypertension are beyond control, prevention, early identification and holistic management can vastly benefit claimants and outcomes.

• Lifestyle modifications, including diet and exercise, can reduce a systolic blood pressure by approximately 4 to 11 mm Hg.
• Reducing salt intake, a diet rich in fruits, vegetables and whole grains, and decreasing alcohol consumption are beneficial ways to improve blood pressure control.
• Encouraging blood pressure self-monitoring can improve self-awareness and aid in treating and managing hypertension.
• Initiating blood pressure-lowering medications with favorable side effect profiles can be instrumental where medication intervention is warranted.^7,8,9

Conclusion
Treatment of comorbid high blood pressure in an injured person requires a holistic view of the case and a multidisciplinary approach to treat and manage the comorbidity.

Hypertension often is not recognized because there are generally no signs or symptoms. Early identification and consistent screening and monitoring of high blood pressure allow for the best possible outcome.

Sources:

1. https://www.ncci.com/Articles/Pages/II_research-brief-comorbidities-in-workers-compensation-2012.pdf
2. https://www.ahajournals.org/doi/10.1161/HYP.0000000000000066
3. https://www.cdc.gov/bloodpressure/index.htm
4. https://labor.mo.gov/sites/labor/files/2017_DWC_Conf_Cormorbidities_Injured_Melander.pdf
5. https://www.eshonline.org/esh-content/uploads/2014/12/17_Newsletter-Interactions-Between-Antihypertensive-Agents-and-Other-Drugs.pdf
6. http://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=350&sec=moninte&t=0
7. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_497445.pdf
8. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_497445.pdf
9. https://www.heart.org/-/media/files/health-topics/high-blood-pressure/tylenol-hbp/aha19_tylenolbroch_web2.pdf?la=en&hash=C9F6152CC02E8C5A47F88C997C0664466DD540E7

Respiratory health is an important but often overlooked component of a person’s overall health and well-being. Respiratory issues can not only worsen an injured person’s prognosis but can increase the risk of adverse health effects in some working environments.

Chronic respiratory disease is a major health issue and can exacerbate injuries

As of 2017, it was the fourth leading cause of death in the United States.¹

• 22.5 million U.S. adults have asthma
• 16.3 million U.S. adults have chronic obstructive pulmonary disease (COPD)
• 33.2 million U.S. adults have other diagnosed chronic lung conditions²

Hazardous working conditions can contribute to respiratory diseases

Jobs such as mining, working in machine shops, firefighting, farming, cleaning and construction may expose workers to respiratory irritation from aerosolized particulates.³ For example, it is well established that workers with asbestos exposure have a greater risk of respiratory disorders, including asbestosis, pleurisy and lung cancer.⁴ Working in the presence of respiratory irritants can cause reactive airway disease and worsen pre-existing respiratory conditions.

Conversely, comorbid respiratory disorders increase the risk of developing an exposure-related condition and can result in long-term disability and increased costs.

Smoking can impact wound healing

Smoking is the most recognized cause of respiratory diseases and lung cancer. While it is associated with increased rates of respiratory infections such as pneumonia, smoking also has been linked to higher rates of infection in wounds, post-injury ― impairing wound healing.

A 2005 study shows smokers with open leg fractures did not achieve complete bone healing and had an increased risk – nearly three times that of non-smokers – of developing bone infections (osteomyelitis).⁵

Potential long-term effect smoking-related cancers may have on return to work

Smoking is a well-known contributing factor for a multitude of cancers beyond lung cancer, such as bladder cancer and pancreatic cancer.⁶

With advances in oncology medicine, some cancers may evolve into chronic conditions that are treated and followed for years. An estimated 41 to 84% of cancer survivors return to work.⁷ Most can return to full duty. However, there is a subset that may require work modifications and/or a change in job function. These functional restrictions could hinder a return to work.

Strategies to prevent and manage respiratory issues

Clearly, respiratory health is vitally important. While employers may be able to limit environmental exposure to irritants, it is up to individuals to manage personal contributors. One way employers can assist is by offering smoking cessation programs to support employees’ efforts to quit smoking.

Clinical intervention improves claimant health and financial outcomes

Clinical management of respiratory conditions is critical to improving the overall care of impacted individuals. After smoking cessation, clinician management can provide oversight of any complex medication regimens. Claimant and clinician review of medication history can identify potential compliance concerns, address medication adverse effects and assure the claimant is utilizing all treatments as appropriate. Routine clinical review of all medications can help reduce costs and potentially improve quality of care.

Common comorbid conditions that may be a contributing factor and/or a complication of an injury are diabetes and obesity. With over 30 million patients with diabetes (PWD) in the United States, diabetes presents a potential concern when it comes to injuries.¹

Diabetes complicates injuries

An example of the impact of diabetes is an accident involving ankle or foot fractures. The potential for complications and negative outcomes is amplified in PWDs compared to non-diabetics.²

Diabetes is associated with wounds that may have prolonged healing times. Delays in recovery are related to decreased blood flow and increased blood glucose, which may promote bacterial growth.

Plus, elevated glucose levels negatively impact surgical wound healing and infection rates. Overall infection rate nearly doubles for individuals with glucose >200 mg/dl. (Normal fasting glucose for non-diabetic <100 mg/dl).