Nancy Carnide

Systematic Review of Intervention Practices for Depression in the Workplace

Design Systematic Review. Objective To determine which intervention approaches to manage depression in the workplace have been successful and yielded value for employers in developed economies. Data Sources We searched MEDLINE, EMBASE, CINAHL, Central, PsycINFO, and Business Source Premier up to June 2010 using search terms in four broad areas: work setting, depression, intervention, and work outcomes. Study Selection Two independent reviewers selected potential articles that met the following criteria: working age individuals with mild or moderate depression; interventions or programs that were workplace-based or could be implemented and/or facilitated by the employer; inclusion of a comparator group in the analysis; outcomes of prevention, management, and recurrences of work disability or sickness absence, and work functioning. Methods Two reviewers independently reviewed each article for quality and extracted data using standardised forms. Following guidelines from the GRADE Working Group, the quality of evidence addressing each outcome was graded as high, moderate, low, or very low on the basis of six criteria: study design, risk of bias, consistency, generalisability, data precision, and economic benefit. Using this information and following Cochrane Collaboration guidelines, the findings for each intervention were summarised and key messages were developed. Results We identified ten randomised trials and two non-randomised studies from various countries and jurisdictions that evaluated a wide range of intervention practices. The evidence was graded as “very low” for all outcomes identified. Therefore, no intervention could be recommended. Conclusions To date, there is insufficient quality of evidence to determine which interventions are effective and yield value to manage depression in the workplace.

Course, Diagnosis, and Treatment of Depressive Symptomatology in Workers Following a Workplace Injury: A Prospective Cohort Study

Objectives: To estimate prevalence, incidence, and course of depressive symptoms and prevalence of mental health treatment following a workplace injury, and to estimate the association between depressive symptoms and return-to-work (RTW) trajectories. Method: In a prospective cohort study, workers filing a lost-time compensation claim for a work-related musculoskeletal disorder of the back or upper extremity were interviewed 1 month (n = 599) and 6 months (n = 430) postinjury. A high level of depressive symptoms was defined as 16 or more on the self-reported Center for Epidemiologic Studies—Depression (CES-D) Scale. The following estimates are reported: prevalence of high depressive symptom levels at 1 and 6 months postinjury; incidence, resolution, and persistence of high depressive symptom levels between 1 and 6 months; and prevalence of self-reported mental health treatment and depression diagnosis at 6 months postinjury. Results: Prevalence of high depressive symptom levels at 1 month and 6 months postinjury were 42.9% (95% CI 38.9% to 46.9%) and 26.5% (95% CI 22.3% to 30.7%), respectively. Among participants reporting high depressive symptom levels at 1 month postinjury, 47.2% (95% CI 39.9% to 54.5%) experienced a persistence of symptoms 6 months postinjury. By 6 months, 38.6% of workers who never returned to work or had work disability recurrences had high depressive symptom levels, compared with 17.7% of those with a sustained RTW trajectory. At 6–month follow-up, 12.9% (95% CI 5.8% to 20.1%) of participants with persistently high depressive symptom levels self-reported a depression diagnosis since injury and 23.8% (95% CI 14.7% to 32.9%) were receiving depression treatment. Conclusions: Depressive symptoms are pervasive in workers with musculoskeletal injuries, but transient for some, and seldom diagnosed as depression or treated.

Examining the impact of worker and workplace factors on prolonged work absences among Canadian nurses.

Objective:To evaluate the impact of worker and workplace factors and of their relationships on work absence duration. Methods:Structural equation modeling of 11,762 female, Canadian nurses from the 2005 National Survey of the Work and Health of Nurses. Results:Worker and workplace factors were associated with prolonged work absence. Key proximal predictors were pain-related work interference, depression, pain severity, and respect and support at work. More distal predictors were multimorbidity, abuse at work, and organizational culture. Conclusions:Worker health and workplace factors are important in explaining work absence duration. Self-management for pain and mood, adapted to the work context, may be useful for nurses with chronic pain or depression. Policy makers and administrators should focus on creating respect and support at work, and improving organizational culture.

Early Prescription Opioid Use for Musculoskeletal Disorders and Work Outcomes: A Systematic Review of the Literature.

Objectives: Musculoskeletal disorders (MSDs) are a common source of work disability. Opioid prescribing for MSDs has been on the rise, despite a lack of data on effectiveness. The objective of this study was to conduct a systematic review to determine whether early receipt of opioids is associated with future work outcomes among workers with MSDs compared with other analgesics, no analgesics, or placebo. Methods: MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to 2014 and reference lists were scanned. Studies were included if opioids were prescribed within 12 weeks of MSD onset. Eligible outcomes included absenteeism, work status, receiving disability payments, and functional status. Two reviewers independently reviewed articles for relevance, risk of bias, and data extraction using standardized forms. Data synthesis using best evidence synthesis methods was planned. Results: Five historical cohort studies met the inclusion criteria, all including workers filing wage compensation claims. Four studies demonstrated a significant association between early opioids and prolonged work disability. One study found a shorter time between prescriptions to be associated with shorter work disability. However, all studies were found to be at a high risk of bias and a best evidence synthesis could not be conducted. The main limitations identified were with exposure measurement and control of confounding. Discussion: Current literature suggests that opioids provided within the first 12 weeks of onset of an MSD are associated with prolonged work disability. However, the conclusions of these studies need testing in a high-quality study that addresses the methodological shortcomings identified in the current review.

Impact of long-term opioid use for chronic non-cancer pain on misuse, abuse or addiction, overdose, falls and fractures

This is the protocol for a review and there is no abstract. The objectives are as follows: To conduct a systematic review (with or without meta-analyses) of the scientific literature on the impact of long-term opioid therapy for CNCP, with a focus on (1) misuse, abuse or addiction, (2) overdose, and (3) falls and fractures.

Opioids for workers with an acute episode of low-back pain.

Over the last several years, concern has been mounting over the use of opioids among workers’ compensation claimants in North America. In 2005, Franklin et al. reported a significant increase over eight years in the use of strong opioids, as well as in accidental opioid-related deaths among claimants in Washington State [2]. This study has since prompted a number of other studies related to prescription opioids among claimants, namely focused on early use. In 2007, Webster et al. published the results of a cohort of 8443 workers’ compensation claimants with an acute onset of low-back pain (LBP) and showed that 21% received at least one prescription of opioids in the first 15 days [5]. After controlling for injury severity and other confounders, those who received higher morphineequivalent amounts (MEA) had poorer outcomes (higher medical costs, prolonged work disability, increased risk of surgery, longterm opioid use) than those who received lower MEAs or who did not receive early opioids. In 2008, Franklin et al. published the results of a prospective cohort of 1843 claimants, examining whether prescription of opioids within six weeks of the first medical visit for a back injury was associated with work disability at one year [3]. They found that 34% of workers received an opioid prescription within six weeks. After adjusting for a number of confounders, the receipt of an early opioid for more than seven days, as well as receiving at least two opioid prescriptions were both significantly associated with work disability at one year. A cohort study of 137,175 claimants in the workers’ compensation board of Alberta, Canada, also demonstrated an association between early opioid prescriptions and prolonged work disability, but the authors hypothesized that their findings were due to claimants with more severe injuries being more likely to receive opioids [4]. The study by Cifuentes et al. published in this issue of Pain [1] is an important addition to this literature. The analysis presented in this study is based on administrative data from a cohort of 2868 workers with new LBP claims. The goals were twofold. The first was to provide a description of opioid prescribing patterns over two years post-claim. The authors found that opioid prescribing generally began early in the course of the claim, with 51.4% of non-surgical cases and 29.1% of surgical cases receiving their initial prescriptions in the first week post-onset. Opioid prescribing was also prolonged, particularly for surgical cases whose median duration of use was 364 days compared to 27 days for non-surgical cases. Weak, combined, and short-acting opioids were most commonly prescribed throughout the follow-up, but decreased in frequency over time, while the frequency of strong, pure, and longacting opioid prescriptions remained relatively constant over time. The second objective was to examine the association between a number of prescription-related features, as well as non-clinical factors, with dose over time. The main factors found to be associated with subsequent dose escalation were increasing number of days

953 The relationship between early prescription dispensing patterns and work disability in a cohort of low back pain workers’ compensation claimants

Introduction Opioids are prescribed early among workers’ compensation claimants with low back pain (LBP), despite little evidence supporting this practice. The comparative effect of early opioids relative to other medications on work disability is unknown. The objective was to examine the association between prescription opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and skeletal muscle relaxants (SMRs) dispensed in the first eight weeks following a compensated, work-related low back injury and work disability. Methods Historical cohort study of workers’ compensation claimants in British Columbia, Canada filing a short-term claim for a LBP injury. Exposure variables were constructed using dispensing data from the first eight weeks after injury: drug class(es) dispensed, drug class(es) at first dispense, days supply, strength of opioids dispensed, and average daily morphine-equivalent dose (MED). Two outcomes (time on benefits, any benefit receipt) after eight weeks and up to one year were considered. Results Compared to claimants receiving NSAIDs and/or SMRs only, the incidence rate ratio (IRR) of days on benefits for claimants dispensed opioids only or opioids with NSAIDs and/or SMRs was 1.09 (95% CI: 1.04 to 1.14) and 1.26 (95% CI: 1.22 to 1.30), respectively. The IRR for claimants dispensed strong opioids only or strong and weak opioids combined was 1.21 (95% CI: 1.12 to 1.30) and 1.29 (95% CI: 1.20 to 1.39), respectively, compared to weak opioids only. Each 7 day increase in supply of opioids, NSAIDs, and SMRs resulted in a 10%, 4%, and 3% increase, respectively, in rate of days on benefits. Each 30 mg/day increase in daily MED resulted in a 4% increase in rate of days on benefits. Larger effect sizes were seen for benefit receipt outcome. Discussion Findings suggest early opioid provision has an adverse effect on work disability. However, residual confounding likely accounts for some of the findings. Research is needed that accounts for prescriber, system, and workplace factors and elucidates the mechanism underlying the relationship.

A systematic review of strategies to improve appropriate use of opioids and to reduce opioid use disorder and deaths from prescription opioids

ABSTRACT Background: Abuse of prescription opioids is a serious problem in North America. Aims: The aim of this study was to conduct a systematic review of peer-reviewed and grey literature to examine existing strategies aimed at improving the appropriate use of prescription opioids and/or reducing the misuse, abuse, and diversion of these drugs. Methods: The following electronic databases were searched to September 2015 without language restrictions: MEDLINE, EMBASE, PsycINFO, and CINAHL; the grey literature was searched to May 2014. Reference lists of retrieved papers were also searched. Studies were eligible if a strategy was implemented and its impact on at least one of the primary outcomes of interest (appropriate prescription opioid use; misuse, abuse, opioid use disorder, diversion; overdose) was measured. Standardized, prepiloted forms were used for relevance screening, quality appraisal, and data extraction. Results: A total of 65 studies that assessed 66 distinct strategies were identified. Due to the heterogeneity of the strategies, a qualitative synthesis was conducted. Many studies combined more than one type of strategy and measured various types of outcomes. The strategies with most promising results involved education, clinical practices, collaborations, prescription monitoring programs, public campaigns, opioid substitution programs, and naloxone distribution. We also found strategies that had some unintended consequences after implementation. Conclusions: Our review identified successful strategies that have been implemented and evaluated in various jurisdictions. There is a need to replicate and disseminate these strategies where the problem of prescription opioid misuse and abuse has taken a toll on society.