Sunday, August 13, 2017

OPIOID PRESCRIBING FOR PAIN IS INHIBITED FOR INJURED WORKERS


   The mechanism of opioid action
is through a receptor mechanism that we all have, namely, mu, delta, and kappa receptors. Human opioid receptors are endogenous (meaning that their mechanism comes from within the system and does not require an external source) and can be activated by endogenous peptides such as the enkephalins, dynorphins and endorphins. These substances are released by neurones and are made available for pain modification. Endogenous opioid peptides comprise a class called endorphins.  

  This class of neurochemical stimulation is available to injured persons and can be mobilized into action without prescribing the likes of vicodin, oxycodone, oxycontin, or similar controlled substances (or illegal non-controlled substances). This level of neurochemical stimulation can be triggered to release endogenous substances in the human body that relieve pain.  For instance, physical therapy, aquatic therapy, or massage can have this favorable effect. When this method doesn't work, analgesic medication including opioids may then  be prescribed.

  The trouble is that in the case of injured workers covered by workers comp, these alternative methods to opioid prescribing are often rejected by Utilization Review (UR). Then that rejection by UR gets rubber-stamped by anonymous Independent Medical Review (IMR) doctors whose prejudices cannot be addressed since their names are kept secret. When the PTP or Primary Treating Physician's attempt to prescribe an alternative to analgesic relief is denied authorization, the next step is pharmacological, usually NSAIDs (non-steroidal anti-inflammatories), then opioids if the NSAIDs fail. That's when the bureaucratic howling begins. What should happen instead is that the UR and IMR doctors who denied treatment by physical therapy or massage should be relieved from duty. 

"Turn the Tide," a publication of The Office of the Surgeon General, discloses resources for the proper prescribing of opioids for pain, chronic pain in particular. For instance, once opioids are prescribed, they should only be continued if "meaningful improvements in pain and function without significant risks or harm" can be documented. Interestingly, the brochure distributed by The Office of the Surgeon General, states in red capital letters, "Start Low and Go Slow."

In fact, in The Weinmann Report, 6/26/17, "Opioid Denials and Obstruction of Alternative Treatments," we discussed how The Washington Post in 2001 made a front-page headline about a doctor in California who was being sued for not prescribing enough pain medication. Two years earlier the Oregon Medical Board actually disciplined a physician for not prescribing enough medication to relieve pain. We also cited a peer-reviewed reference from HEADACHE that stated that opioids were useful in pain management but that that its use had to be slow, slow, slow -- this advice was 17 years ahead of "Turn the Tide" and 10 years before Paduda's original article. 

In a panic-ridden piece entitled "Narcotic use is rampant in workers compensation," we are told that "the problem is showing up in a doubling of emergency room admissions due to prescription drug abuse, driven primarily by oxycodone, methadone, and hydrocodone." This particular article makes no reference to the Utilization Review denials for physical therapy, massage, and alternative treatments that force patients into the pharmaceutical stream.

On the contrary, Dr. John Torres recommended massage therapy on MSNBC with moderator Craig Melvin on August 1st, 2017. It isn't clear whether or not Dr. Torres knew he was recommending a treatment often rejected by workers comp Utilization Review. Since we  had the privilege of evaluating just this kind of patient recently, we'll see what happens if and when the PTP asks for overturn of the denial of massage therapy.

Readers should not be surprised. Since the emphasis now placed on evidence-based-medicine, the reliance on the winds of fashion and bureaucracy has increased. Discipline for not providing enough pain medication has been supplanted by a new chorus chanting for discipline for doctors who provide too much.  

References

The Weinmann Report, 6/26/17, "Opioid denials and obstruction of alternative treatments"

"Controversies in headache medicine," summer, 2000, HEADACHE, V. 11, # 2, Lawrence Robbins, MD (opioids can be used:  "when they are not overused, the opioids are a safe medication")

"Doctor's  duty to ease pain at issue in Calif. lawsuit," Susan Okie, Washington Post, 05/07/2001

"Oregon Board disciplines doctor for not treating patient's pain,"  New York Times, 09/04/99

"Narcotic use is rampant in workers compensation," Joseph Paduda, October, 2010

"Prescribing Opioids for Chronic Pain," TURN THE TIDE, Office of the Surgeon General, CDC

Commentary by Dr. John Torres, 1 August 2017, MSNBC TV (recommends massage for pain relief) 







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