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New changes in the law creates limitations on treatment for injured workers.

“Is There Hope Without Dope?” That is what one wise guy yelled out from back of the room as the lecture began. Personally, I was wondering when the other foot was going to come down on limiting pain control medications in the Worker’s Compensation system after Jerry Brown signed SB-863 into law last year. The answer came in a recent seminar that the California Applicants’ Attorneys Association presented earlier this year.

Oxycodone, Vicodin, Fentanyl, Methadone and Percocet all very serious opiates routinely prescribed by physicians treating painful industrial injuries here in the state of California. How these and other medications will be prescribed is changing.

The California Department of Worker’s Compensation sponsors the Medical Evidence Evaluation Advisory Committee (MEEAC). MEEAC is charged with the task of making treatment recommendations to the Executive Director to revise, update, or supplement treatment guidelines. Their recommendations ultimately serve as the basis of the Medical Treatment Utilization Schedule (MTUS).

What was pretty obvious at the seminar was the fact that more conservative medical treatment protocols for the prescription of opioids are going to become a fact of life under the MTUS guidelines.

Just a Little Background Note: Last year, Big Insurance, Big Labor, the California Legislature, and the Governor’s office decided to make some big changes to the Worker’s Compensation System---again! It was a typical example of the Golden Rule; “She who has the gold, makes the rules”. No one’s opinion mattered but their own.

In exchange for modest in- creases in permanent disability payments for people injured on the job on and after 1/1/13, insurance companies now have another powerful tool in their kit to reduce medical treatment costs: Independent Medical Review (IMR).

The IMR system was de- signed to centralize the decision making process for handling Utilization Review Denials for physician requested medical treatment, prescriptions and diagnostic studies. The pundits say that insurance companies are going to save billions of dollars because appeals from denials will be sharply limited for injured workers. Gone are the days of running off to the Worker’s Compensation Appeals Board to fight the good fight over denied procedures and medications.

On the front lines of all of this, I see clients that have significant injuries that really require long term compassionate pain control. It is heart breaking to look at the x-rays of folks who have undergone multiple-level spine surgeries complete with titanium cages and Herrington rods. Failed back surgery. Bone on bone. They live in a lot of pain, and there is something that can be done about it. These people cannot be short changed or ignored concerning what modern medicine has to pro- vide. Others, well, the use of such medications becomes a life-style choice and perhaps the temptation of strong opioids is not in their best interest. It is not an easy problem to solve.

If you are using some heavy duty triplicates, the larger question that you need to ask is whether or not your life is better through modern medicine? To be sure, opiates are great at controlling pain and are certainly part of an appropriate treatment plan. But, are they worth the risk of long term usage? One of the presenters at the seminar, Dr.  Steven Feinberg, MD, wrote a very thoughtful article on the subject, Google SB 863 and the Opioid/Chronic Pain Dilemma. It really is a must read for all people on significant pain medications.

Prior to the 90’s, opiates were not as widely prescribed for pain control as they are now. Dr. Russell Portenoy (a New York pain control specialist) campaigned for wider prescription of pain medications like Vicodin, Oxycodone and Percocet.

A movement in the medical community had begun. Between 1997 and 2006, the use of opiates increased as follows: Fentanyl 479%, Oxycodone 732% and Methadone a whopping 1,177%. It has been a veritable gold rush for big pharmaceutical companies.

The United States consumes more prescription drugs than any other country. While Americans are only 4.6% of world population, we use 80% of the world’s prescription opioid supply. Death rates from painkiller overdoses tri- pled over the last decade. In 2008 there were 14,800 opioid-related deaths in the US. Opioids have pushed drug poisoning ahead of MVA’s as the leading cause of accidental death in many states.

Also, Consider the Side Effects of Opiate Medication: Nausea, vomiting, constipation, swelling, urinary retention and respiratory depression (think checking out in your sleep as one young client of mine did). Opiates also cause tiredness and daytime sleepiness (which require prescriptions for stimulants like Provigil--yikes). Other problems include internal organ damage (liver, kidney), poor coordination and balance.

Furthermore, the use of opioids can also cause cognitive problems (memory/concentration), depression, hormonal imbalance (endocrine problems), weight gain, risk of addiction and sexual dysfunction. There is even evidence out there that long term opioid use actually increases pain sensitivity (opioid-induced hyperalgesia).

So if you are on a boat load of pain killers, what happens if an insurance carrier decides to really clamp down on your pain control meds? One alternative would be a functional restoration program. Many people have had some significant improvements in their life by just getting off their medications and learning how to cope with the pain. These in-patient programs are horrifically expensive for the carriers, usually last around 6 weeks and involve a “multi-disciplinary” approach, i.e. medical doctors, psychiatrists, PhDs and physical therapists.

Conclusion: I have been humbly representing the interests of injured workers for almost two decades now. While I am not a doctor, I have seen a very predictable cycle that many of my clients fall into. While opioids are very helpful in controlling acute pain, the same can’t be said when people go into the long term/ chronic aspect of pain control. Some people just go crazy. Even before SB-863, it would take over 30 days to get before the WCAB on an expedited hearing regarding denied pain meds. People go through withdrawals. It is serious stuff. With IMR upholding approximately 50% of the Utilization Review Denials, things are looking downright scary.

Simply put, while I can only offer anecdotal observations, the clients I have had the honor to represent over the years that do the best in the long run, are the ones that get off these very strong medications. Many clients just go through a chronic post injury time period where their life is upended, and not many are helped by the mind altering effects of pain medication. For these clients, getting off such medications is like having a veil lifted off of their life. Suddenly, people can see and understand what you’ve been trying to do for them all those years, and that’s a good thing.


Thomas Ledgerwood
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Proprietor Ledgerwood Law Group