This article is the second in a two-part series on chronic pain and the prescription opioid crisis. Part one argues that chronic pain is not a given, it's a public health catastrophe. Read it here.
As more and more workers were injured by repetitive motion, and filed complaints, unions like the (US) AFL-CIO negotiated for ergonomic improvements to their workplaces. Some employers recognized that inefficient workplaces caused the workers' injuries.
Employers as different as Red Wing Shoes, Lilydaly poultry packers and General Motors brought in ergonomics experts, asked their workers to identify awkward spots and suggest solutions, and redesigned their workplaces to fit their workers, not the other way around. They quickly proved that working together with workers and installing ergonomic equipment more than repaid their investment, especially compared to the cost of one lifetime disability claim.
Most employers, however, balked. They balked at the investment, they balked at inviting in ergonomic consultants, and most of all they balked at sitting around a table taking advice from shop floor workers. Unless a limb swelled up like a balloon, they accused injured workers of malingering. They were already practicing Milton Friedman's economics, which puts workers on the "liability" side of the spreadsheet, rather than seeing workers' skills as assets.
As OSHA prepared ergonomics regulations that would have provided guidelines for confused US employers, a new cottage industry sprang up in opposition. Eugene Scalia, son of Supreme Court Justice Antonin Scalia,became known as "Mr Anti-Ergonomics." He addressed employers' conventions with scary stories about ergonomics costs and workers in charge of their companies. He crusaded against ergonomics rules not only at OSHA, but in Washington and other states that already included ergonomics in workers' health and safety regulations. Since then, the Wall Street Journal reports, he has moved on to defending big banks against government regulation aimed at protecting consumers.
OSHA never was able to announce an ergonomics standard for industry, let alone offices. For office ergonomics, U.S. experts rely on the Canadian Standards Association (CSA) guidelines.
Worse, the George W. Bush administration solved the problem by banning any mention of RSIs. He ordered OSHA and BLS to stop tracking repetitive strain injuries (which they called MSDs, MusculoSkeletal Disorders), as they had been doing since 1970, when Richard Nixon signed OSHA into being. The rancour endures. In 2011, U.S. Chamber of Commerce opposition prevented reinstatement of an MSD column on the event-based OSHA incident report.
The Bureau of Labor Statistics, though, somehow continued to gather and report statistics, which are pretty consistent with 1990s figures.
"Musculoskeletal disorders (MSDs) accounted for 32 percent of all injury and illness cases in 2014 for all ownerships....
"Injuries and illnesses to women for all ownerships accounted for 39 percent of the total days-away-from-work cases in 2014. Compared with men, women had higher incidence rates and number of cases associated with intentional violence by persons, falls on the same level, and repetitive motion."
Gender is another factor -- in both the 1990s MSD epidemic and the 2016 opioid epidemic, especially the drug poisoning deaths. Middle-aged women are over-represented in both groups, especially fatalities, which affect more white women. As I wrote last April, the US has to be the only place in the industrialized world to see an increase in mortality rates for mid-life white women.
In the 1990s, many medical articles dismissed any claim that linked workplace duties to invisible symptoms like pain -- calling patients "hysterical" because complaints came mainly from women employees. Never mind that the women were doing intensely repetitive jobs while working at desks designed to fit men. Doctors diagnosed their pain as psychogenic, more related to unhappiness at home than to too-tall workstations.
Some of the current medical community discussion about opioid patients closely echoes that rhetoric. For example, the Cleveland Medical Clinic article about patients who use opioids states,
"Risk factors are biologic, sociologic, psychological, and environmental. It [opioid use] is more common in those with depression, anxiety, and substance-use disorders. Pain-associated disability is also more common in those from lower socioeconomic strata and in those who dislike their work or feel underpaid and unsupported at work."
Let me play devil's advocate here and suggest that most people with disabilities are already struggling to pay their bills, and to find honest jobs with decent wages. Moreover, people get injured at low-paid jobs because the jobs tend to involve heavy-duty, labour-intensive work, whether the workers be hauling logs or laundry. Low-wage jobs also tend to be unprotected jobs, precarious work, outside labour legislation because they're "independent contractors" or part-time workers at two or three jobs.
Most of all, low-wage jobs tend to be repetitive: hoeing vegetables, carrying trays, completing forms, cleaning bathrooms...workers do the same exact thing, over and over. Anybody stuck doing the same action over and over is liable to develop aches and pains. Just clicking a mouse with your forefinger all day can be enough to cause forearm tendinitis. Yet the endless push for productivity encourages employers to break jobs down into the simplest tasks, and have each worker do only one task, so the employer doesn't have to pay for a skilled worker who can perform the entire task.
Prescribing opioids for soft tissue injuries, even for back pain, may seem like overkill. But that's what happened. Sam Quinone's book about the opiate crisis, Dreamland, begins with the story of Carol Wagner, whose "handsome, college-educated" son Chad developed carpal tunnel syndrome (an extreme aching wrist). His doctor prescribed OxyContin. Chad became addicted. The drug became his life. "He lost home and family," writes Quinone, "and five years later he lay dead of an overdose in a Cincinnati half-way house."
In 2011, the American Chronic Pain Association produced a 30-second TV public service announcement warning that pain prescriptions were killing people -- their legitimate users and others. The ACPA newsletter explained that, while opiates "can make the difference between disability and the ability to function at a more normal level," most patients received little or no information about how dangerous they were. Hence, the TV spot, with advice about how to keep the medicine safe.
Last on the list of concerns (such as safe storage, not sharing, and keeping close track of doses), the ACPA reported that half of those using opioids legitimately were worried about addiction -- 19 per cent very worried, and 34 per cent somewhat worried. The ACPA's executive director offered reassurances that the risks of addiction when opiates are used legitimately under a professional's care are "modest."
A 2016 paper in the Journal of Chronic Pain seems to indicate that specifically RSI patients received opioid prescriptions early and often. The authors searched five medical databases for a year's worth of studies about opioids and MSDs (Musculoskeletal Disorders, another name for RSIs) and found five historical cohort studies -- five groups of comparable people -- who filed Workers' Compensation claims and who received opioid prescriptions within the first 12 weeks. Instead of ordering physiotherapy, the doctors gave RSI patients something that stopped the pain, and sent them back to work. This is like short-circuiting your car's low-oil light instead of topping up your oil. It's a recipe for burn-out. In four out of five cohorts, early opioid prescriptions were associated with much longer disability.
The good news is that the entire medical establishment seems to be working on finding other ways to deal with chronic pain. In addition to a wider range of nerve prescriptions (eg, Lyrica), doctors are working with other disciplines such as physiotherapists, chiropractors, massage therapists, and acupuncturists. They're prescribing pain-relieving ointments like diclofenac and sending patients to radiologists for steroid injections to their painful spot. Some doctors still look to surgery for remedies in severe cases.
The bad news is that the U.S. and (apart from Ontario and BC) most provinces in Canada still don't have workplace regulations to protect workers from RSIs. Although the fentanyl crisis has spread far beyond the patients who received the early opioid prescriptions, we'd be fools to let it overshadow the workplace factor.
MSDs (RSIs) accounted for one-third of U.S. workplace injuries in 2015, according to the U.S. Bureau of Labour Statistics, and probably about half of lost-time days. Jobs at highest risk were laborers and freight, stock, and material movers; nursing assistants; and heavy and tractor-trailer truck drivers (14,900). Nursing assistants often have lift patients. Workers who sustained strains, sprains or tears (the MSD descriptor) required longer to heal than other kinds of injuries.
Behind the opioid menace is another, less visible threat. RSIs exact a heavy financial and human toll in the workplace. Yet the chronic pain of RSIs is more easily prevented than cured. While employers may save a few short-term dollars by ignoring RSI-caused worker turnover, while Workers' Comp may have saved a few dollars by encouraging doctors to dope injured workers so they could function a little longer, the rising toll of opioid deaths shows who bears the real costs: society.
Varying the work throughout the work day, fitting the job to the worker, taking frequent breaks -- ergonomics techniques involve common-sense measures to protect workers' health. While artists and athletes suffer RSIs, they consciously take risks for the sake of their passion. Assembly line workers and office workers usually just want to earn a living. They have every right to expect that their employer provides a safe workplace and job description that won't injure them while they do their duties -- that won't leave them facing years of constant chronic pain.
Until the U.S. enacts ergonomics regulations to make workplaces safer, the American chronic pain problem is only going to increase. Awful as they are, opioid fatalities also signal a deeper problem.
This is the second article in a two-part series. To read the first part, go to: Failure to treat chronic pain real issue behind prescription opioid epidemic.
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Image: Flickr/Eric Norris