[Subtitle:] A Guide for Rural Health and Safety Professionals.
With the nature of agricultural work, farmers are at risk for experiencing chronic pain and being prescribed opioid medication without proper assessment. One hundred farmers and workers sustain injuries daily that prevent them from working and one out of five will receive an opioid prescription for pain management (1). Improvements in communication between healthcare providers and agricultural folks, risk assessment strategies, and identifying effective alternatives for treating pain are key to preventing opioid use disorder among farmers.
- Seventy four percent of farmers and farm workers say they have been directly impacted by the opioid epidemic.
- 3 in 4 say it is easy to access large amounts of opioid without a prescription.
- Only 1 in 3 rural adults say it would be easy to access addiction treatment.
[Source:] National Farmers Union and American Farm Bureau Federation, 2017 (2).
Talking to Farmers About Pain
What do we ask?
Conversations about pain should include a complete understanding of their symptoms. Health and safety professionals should use language that help patients understand pain and help patients describe what that pain looks like.
Determining the Location (“where are symptoms, exactly?”), Nature (“describe your symptoms”), Length (“how long have these symptoms been going on?”), Aggravating and Easing Factors, and Range (“is that tolerable for you?”) of the symptoms are critical for proper assessment.
Asking questions about the specific demands of their job and how this influences their symptoms, their belief about the pain, and their lifestyle behaviors that are linked to pain can improve conversation about options, strategies, solutions, and recommendations for treatment.
Questions to Ask Your Farmers
- How would you describe the pain?
- How is the pain impacting your farm work?
- How is farm working impacting the pain?
- Does your work make the pain better or worse?
- What are you doing to manage the pain?
- What medication are you taking to manage the pain?
- Who is treating you for the pain?
What do we say?
When talking to patients about their pain, using language that is transparent and allows the patient to appropriately explain their history is important to improve communication and trust with provider.
Discussing potential treatment strategies, including those that are inappropriate to their given condition, and informing patient about all available treatments is important for patients understanding of the complexity of pain.
Setting realistic goals and educating patients about the potential risks and benefits of therapies should be discussed. Providers should address the stigma of opioid use disorder and treatments to ensure that patients have the support they need.
Acute and Chronic Pain Treatment Options for Agricultural Workers
Before initiating a treatment plan, providers should take a team-based approach. Include the patient in decision making and consider the patient’s history of pain and specific needs.
It is important to determine whether the patient’s occupation indicates the need for a single pain management approach and or multiple pain management approaches.
[Diagram shows pain as the top category, with the following four categories attached beneath it: pharmacotherapy opioid, pharmacotherapy non opioid, procedures, and conservative approaches. Underneath the four categories, is the word “combo,” indicating that a combination of the four approaches may be used.]
Non-Pharmacotherapies
Providers should take a conservative approach by referring patients to professionals specializing in pain management without medication, such as restorative movement therapies, interventional procedures, complementary and integrative health, and behavioral/psychological interventions to better manage and reduce pain. Non-pharmacotherapies may include:
- Restorative Movement Therapies: physical and occupational therapy, massage therapy, and aqua therapy.
- Interventional Procedures
- Complementary and Integrative Health: acupuncture, yoga, tai chi, and meditation.
- Behavioral Health, Psychological Interventions: coping skills and cognitive behavioral therapy (C B T).
[Photo of woman in a yoga pose, holding a shovel for balance.]
Pharmacotherapy Non Opioids
Evidence suggests that non-opioid medications have been effective in relieving symptoms of chronic pain and are safer than opioid therapy.
Non-opioid medications may be used for treatment of common chronic pain conditions, such as low back pain, osteoarthritis, migraine, neuropathic pain, and fibromyalgia. C D C’s Non Opioid Treatment for Chronic Pain (3) provides a list of non-opioid medications and treatment recommendations specific to the patient’s pain condition. When considering non-opioid pharmacotherapy, clinicians should discuss the risks and benefits associated with long-term use.
Pharmacotherapy Opioids
If non opioid pharmacotherapies and non pharmacotherapies have been initiated without optimal results for patent’s pain and function, providers may consider opioid therapy. Before starting long-term opioid therapy, providers should establish treatment goals with patients and assess whether the expected benefits for pain and function outweigh risks. C D C’s Checklist for Prescribing Opioids (4) provides a comprehensive list of steps clinicians should take when considering, reassessing, and renewing long-term opioid therapy.
Combination Therapies
Pharmacotherapy non opioids and opioids by themselves may not always fully control pain. The combination of therapies (e.g. exercise, C B T, medication) provides a whole patient approach in relieving pain and lowering doses and dependency on non opioid and or opioid medications. If substance use disorder is suspected in a patient, the provider should consider medication assisted treatment (M A T) and or psychological counseling.
Tapering
If opioid therapy has been initiated, providers may recommend tapering opioids and discuss a treatment plan with patients that reflects the anticipated risks and benefits. Tapering of opioids, if deemed medically appropriate, should be patient centered and individualized and be done so that withdrawal symptoms are minimized. C D C’s Pocket Guide: Tapering Opioids for Chronic Pain (5) is a tool to assist providers considering opioid tapering. If needed, providers may consider consultation with a pain management and or addiction specialist to assist with tapering.
A C O E M’s Practice Guidelines: Opioid and Safety Sensitivity Work
Agriculture is a safety sensitive job. Safety sensitive jobs include operating motor vehicles, other modes of transportation, heavy equipment operation and tasks involving high levels of cognitive
function and judgment.
Health and safety professionals should determine the risk of returning back to work for patients using opioids, prescribed or not, and ask comprehensive questions about what the patients’ occupation entails.
American College of Occupational and Environmental Medicine (A C O M) Practice Guidelines: Opioid and Safety-Sensitivity Work (6) defines the best treatment guidelines concerning opioids using safety sensitive work recommendations.
A C O E M guideline does not recommend acute or chronic opioid use for patients performing safety sensitivity jobs.
National Safety Council’s Prescription Drug Employer’s Tool Kit
This toolkit helps employers understand the impact of prescription opioid use and misuse in the workplace and opens communication between employers and employees. The toolkit contains:
- Tools to examine and update your drug free workplace and employee benefit programs.
- Fact sheets and handouts with helpful information to educate your employees.
- Five minute safety talks.
- Poster series focused on home safety and disposal.
Take Action!
Rural healthcare providers are champions in their communities, but changing the course of opioid misuse cannot be done alone. Addressing opioid misuse in rural agricultural communities must involve engaging a variety of stakeholders:
- Farmers.
- Healthcare Providers.
- Healthcare Systems.
- Public Safety.
- Rural Community.
Three FREE Opioid Misuse Prevention Webinars
- Talking to Farmers About Their Pain: The occupational hazards that farmers face put them at an increased risk for acute and chronic pain as a result of ergonomic repetition, accident, or surgical procedure. This module will focus on how to transform the conversation between provider and patient to improve health outcomes and patient satisfaction.
- Assessment of Opioid Misuse Risk Among Farmers: Prescribing opioids to farmer populations that may not seek regular treatment or have access to alternative therapies increases the risk for potential opioid misuse. This module will seek to provide insight on misuse risk factors among farmers to better inform healthcare providers on warning signs among this specific cohort.
- Safety-Sensitivity of Opioid Use in Agriculture: Farm duties frequently demand the use of heavy machinery, and concurrent use of opioids with safety-sensitive work can be very dangerous. This module will educate healthcare providers on how best to manage occupational duties alongside providing adequate patient care which will help prevent further agricultural opioid misuse.
These training modules are intended for various health care professionals, such as:
- Family and Internal Medicine.
- Public Health Practitioners.
- Nurse Practitioners.
- Pharmacists.
- Dentists.
- E M S and E M T.
- Chiropractors.
- Occupational and Physical Therapists.
Additionally, we offer these FREE On Demand trainings:
- Using Naloxone to Reverse Opioid Overdose.
- The Rise of Opioid Use in Rural Communities: Prevalence and Strategies.
- AgriSafe Think Tank: Defining the Rural Health Care Professional’s Role in Prevention of Opioid Misuse.
References
- Center for Disease Control and Prevention. (2018). Opioid Overdose. Retrieved from https://www.cdc.gov/drugoverdose/index.html
- American Farm Bureau Federation. (2017). The opioid impact in farm country, USA. Retrieved from http://farmtownstrong.org/wp-content/uploads/sites/13/2017/12/Infographic-Opioid-Impact -in-Farm-Country.jpg
- Center for Disease Control and Prevention. (2018). CDC guideline for prescribing non opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf
- Center for Disease Control and Prevention. (2018) Checklist for prescribing opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf
- Center for Disease Control and Prevention. (2018) Pocket guide: Tapering Opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf
- Hegmann et al. (2014). ACOEM practice guidelines: Opioids and safety-sensitivity work. Journal of Occupational and Environmental Medicine, 56(7), 46-53. doi: 10.1097/JOM.0000000000000237
Access additional resources and our FREE On Demand webinar trainings at learning.agrisafe.org
[Logo: AgriSafe Learning Lab. Logo: AgriSafe Network, Protecting the People Who Feed the World.]