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) 

How so-called "guidelines" become hard-and-fast "regulations"

Our previous post showed how Utilization Review decisions sometimes turn out to be regarded and applied as actual practice mandates and how 80% of such decisions are actually denials of care that get upheld by Independent Medical Review. 

The quizzical situation is that many of the UR doctors are not licensed in California. Neither are many of the IMR doctors. More to the point is that the UR doctors and their IMR colleagues often reject diagnostic studies and treatment that has been recommended by MPN (medical provider network) doctors that have been selected by the same companies that approved the UR panels that then denied treatment. Practicing doctors and their patients who know that an injury is real have long since figured out that cost-control, not patient care, is the name of the game. Even the AMA has gotten into the game, purveying and selling to any and all willing buyers a book called Guidelines to Impairment. This book has proved to be a goldmine for insurance companies and their employers who don't want to pay for whatever they can get away with denying as a "covered" item.

Meanwhile, seeing the business success of the AMA Guidelines, other organizations have jumped onto the regulatory bandwagon, e.g, the ABMS boards who now sell "recertification" and "maintenance of certification" programs to their own members. In fact, the eagerness with which physicians' own organizations have sought to subjugate its own members has actually provoked enough ire among physicians that 14 states have already passed legislation modifying the greed-encrusted thrust of the ABMS boards to sequester themselves as well paid bosses (about $800,000 for the ABMS chief, see previous post).

Likewise professional organizations such as the American Academy of Neurology (AAN) which recently published a "position paper" on chronic pain and opioid medication -- without submitting a draft to the California Neurology Society (CNS). THAT caught the attention of  then CNS president Robyn Young, MD, who also reviewed a similar advisory from the Medical Board of California (MBC) which seemed more in line with CNS practices than the AAN paper which was widely regarded as one-sided and biased.

That situation in turn led to CNS' asking its own Director of Government Relations to testify at the MBC hearing in October of 2014. The MBC considered several subjects one of which was a unified and reasonable approach to the treatment and management of chronic pain. Accordingly, the CNS Director of Government Relations, Steve Cattolica, stated "these guidelines are not the only treatment of this issue prescribing controlled substances for non-cancer pain." It was acknowledged that such guidelines, however,"should represent the standard of care for physicians in California ... that fact begs the question how these guidelines will be used or IF they will be used as the Board has intended."

Cattolica then pointed out that "our constituents with heavy emphasis in treating injured workers face a difficult situation" because "any inconsistency will cause all physicians to perhaps compromise the standard of care." Using the Division of Workers Comp (DWC) as an example Cattolica stated how "the DWC's treatment guidelines have a long and proven track record of being misapplied ... to control costs and identify physicians they no longer want in their medical provider networks."

The MBC chair, Ms. Yaroslavsky, was quoted as having said that guidelines are just that, guidelines, not regulations. Cattolica then stated why vigilance is essential: "the physician community's experience with the application of treatment guidelines in the workers' compensation system is as rigid criteria." In other words, it needs to be emphasized that AAN Policy Paper on the use of opioids in non-cancer pain is a guideline, not a regulation, and that the same goes for the guidelines proposed by the MBC. It can be anticipated that the MBC and the AAN recommendations will compete for attention from treating physicians. Either way the mere presence of written guidelines opens the way for automatic rejections of treatment by utilization reviewers in all walks of medical practice including government plans such as Medicare and Medicaid, or managed care plans such as HMOs and PPOs, or workers compensation where remote control medicine is already rife among UR doctors and their legally anonymous IMR counterparts.

Cattolica advised a change in wording-- drop the phrase "very consistent" from the recommended statement of Guidelines and replace it with the word, "equivalent." 

DRUG TESTING FOR LAWYERS AND PHARMACEUTICAL EXECUTIVES

District Attorney Tony Rackauckas representing Orange County and County Counsel Orry Korb from Santa Clara County have filed a consumer protection lawsuit against five opioid manufacturers. The accusation is that the five companies conducted a more than decade-long marketing campaign to mislead doctors about the risk of long-term opioid management. The named defendants are Purdue Pharma, Teva Pharmaceutical Industries Cephalon, Janssen Pharmaceutical, Endo Health Solutions, and Actavis. The lawsuit also names the American Pain Foundation, the American Academy of Pain Medicine, and the American Geriatric Society.

The lawsuit asserts that "opiod makers were not the first to mask their deceptive marketing efforts in purported science. The tobacco industry also used key opinion leaders in its effort to persuade the public and regulators that tobacco use was not addictive or dangerous."

We owe this information to Tom Lynch whose editorial, "Another Day, Another Battle in the War on Over-Prescribing," was published as a column by WorkCompCentral on 5/28/14.

Our interest is how this matter now dovetails with the Malpractice Initiative that the trial lawyers are expected to qualify for the November ballot in California in an effort to repeal the MICRA reform instituted by Gov. Brown during his first administration. The Initiative is aimed at drug-testing for physicians and doesn't mention that annual insurance premiums for a family of four may be increased by as much as $1,000.

Although the trial lawyers espouse drug testing for physicians, pilots, and others, they do not include themselves.

We now recommend that they find a way to include drug testing not only for themselves but also for pharmaceutical companies, their executives, and all of their employees including sales department personnel.

Just call it The Full Employment Drug Testing Act (FEDTA).

Late Flash: the trial lawyers' initiative to increase malpractice awards for themselves has been designated Proposition 46 while the campaign against it, which we support, will be called the No on 46 Campaign.

Additional References

"When Should Lawyers be Drug Tested?" by Dr. Robert Weinmann, www.workcompcentral.com, 4/28/14

"Random Drug Testing for Lawyers," The Weinmann Report (www.politicsofhealthcare.com, 4/24/14)

"California's Ballot initiative will mandate random drug testing ONLY for doctors (why not attorneys?)," by Rehan Sheikh, facebook.com/PhysiciansForFairness, {https://www.facebook.com/PhysiciansForFairness}, twitter.com?Voice_MD {https://twitter.com/Voice_MD} 5/20/14