Monday, December 31, 2001 

This Week's Topic: Dire Consequences of Oxycontin 

Question: “I regularly prescribe Oxycontin for pain management. It is effective and makes life manageable. I get the impression that you have some reservations about this practice.” 

Dr. Adams Replies: Serious reservations. Ideally, you know what kind of pill you are giving the patient, but do you know what kind of patient is taking the pill? 

It is erroneous and dangerous to assume that because a patient eagerly takes Oxycontin that he/she is a good candidate for the drug.  

For example, like many narcotic pain killers, Oxycontin can/does produce mood, sleep, anxiety and cognitive changes. Patients in pain sleep poorly, not only quantity of sleep but quality of sleep. What is the impact of Oxycontin on sleep architecture?  Certainly the drug can produce drowsiness, but does it permit effective sleep…and what does the patient do when deprived of sleep? Often, they take more Oxycontin. 

Additionally, what is your goal in the use of the drug?  Is it to permit the patient reasonable pain management while he/she learns ways of coping with the pain without narcotics?  Or is the medication prescribed, the patient merely warned not to take more than prescribed and then chastised when he/she calls between refills due to “running out of my medication.”  

Additionally, what plans are being made to wean the patient from the medication? They will eventual “settle” their workers’ compensation claim. Are you expecting their family physician to prescribe, titrate and manage this drug? 

What is the patient doing with his/her days; eagerly awaiting the next prescribed dose?  This is not uncommon. Watching television, eating and gaining weight, depressed and lonely, fearful and helpless, they wait for the medication.  

Are they sharing the medication with others? Do they have access from multiple sources?  Do they visit the ER for supplemental pain management? Will Oxycontin instill in them a sense of direction, future, or goal setting? 

In toto, who and what is this patient for whom you prescribe this narcotic? Is this a patient who is participating in his/her own rehabilitation, or is this a patient with family, marital, sexual, occupation, financial and social problems pre-existing as well as arising from injury? 

Is Oxycontin a dangerous drug? Likely so. Is it being unwisely or inappropriately prescribed? Unquestionably so.

Monday, December 24, 2001

This Week's Topic: The Drama of Being on Stage  

Question: “I truly do not understand why many of my patients behave as though their injuries are some form of melodrama…as though they are performing… This seems to be a contradiction, either they hurt or are suffering or they are not and are enjoying their role. Which is it” 

Dr. Adams Replies: Histrionic individuals can be injured. Injured individuals may become histrionic. The dramatics, theatrics, rapidly shifting and shallow moods, the need to be the center of attention, the continual use of complaints to draw attention to themselves, and exaggerated emotionality can become a hallmark of post-injury behavior. 

These individuals derive secondary gain in the form of attention, affection, special considerations in their family/social group and are financially remunerated for their complaints. 

From a clinical perspective, they can also be quite suggestible, and respond in the affirmative when asked about even obscure/unlikely symptoms. 

They are frequently provocative if not outright seductive in behavior which would seemingly be in contrast to someone suffering.  

Rather than attempting to be courageous, stoic and strong, they dramatically emphasize their symptoms with grimaces, groans and outcries of pain and discomfort. 

Rather than being annoyed with such patients, whose behavior admittedly can be grating, it is important to identify them, their sources of secondary gain and whether they can (and how to) redirect the melodrama of their injury into a more appropriate “courage to recover.” 

Thus, if their goal is to be the center of attention, psychological care would ideally have that attention derived from their strength in the recovery process.

Monday, December 17, 2001 

This Week's Topic: …Greedy and Manipulative

Question:  “I am a nurse case manager for a self-insured company. This is the time of the year when I would like to believe that the best comes out in people. ..but the claimants whom I assist are greedy, demanding and manipulative during the holiday season. It is as though they sense that I need this time of the year, and they deliberately make my life miserable. Thoughts?”

Dr. Adams Replies: Sometimes we are not as special as we would like to believe, and all the bad that occurs in our lives is not due to some unique role that we serve. Indeed, sometimes the misery to which we are exposed is due to factors we fail to investigate. 

For example, the following issues would be important:

1.    Is the patient under extreme financial pressure at the time of the year due to self- and family holiday expectancies?

2.    Will the patient be expected to interact with family and friends despite physical and emotional discomfort?

3.    Has the patient’s irritability resulted in a sense of alienation rather than a festive holiday?

4.    Was the patient anticipating a cash advance on his/her settlement to manage increased holiday expenses?

5.    Is the end of the year a “marker” for the patient in which he/she must address that this is the least financial productivity they have created, and/or is this a year in which symptoms have not resolved (or have worsened)?

6.    Do the patients see your life as better than their own? Indeed, it is.

7.    Do the patients experience increased anxiety because they will have less medical contact, infrequent or discontinued therapies, and all those who deliver care will be celebrating…while the patients will not?

8.    And finally, are the holidays a contrast between external celebration which contrasts with the patient’s bleak and pessimistic perception of life? 

Many cardiac events occur during holidays due to the stressors of increased expectation. Depression increases the risk for heart attack. Perhaps this is for some a season to be jolly, and for others, it is the season merely to survive.

December 10, 2001 

This Week's Topic: …or Just Plain Mean

Question:  “OK, I am an adjustor. I do not have a question; I just have a statement. These people are just plain mean…maybe some are depressed, but I think most of them are just mean, nasty and inappreciative. Care to comment?” 

Dr. Adams Replies: I won’t argue your conclusion, but consider the following: 

·         What if their “meanness” is a combination of disappointment and/or rage? 

·         What if they wait for hours in waiting rooms and see a difference in the way they, versus private patients, are treated? 

·         What if the accident itself was the result of under-trained co-worker(s) whom they believe should never have been performing the job? 

·         Or, worse, as in a patient this week reported, they have ample confirmation that their “accident” was really sabotage at the hands of an envious or retaliatory co-worker.  

·         What if the accident resulted from faulty equipment or safety standards that they have reported numerous times and which are implemented as soon as they are injured. 

·         What if their spouse left, their children’s needs cannot be met, they are rapidly approaching bankruptcy, and their check, which is one-half their previous income, is arriving late, mileage checks not arriving at all, and they do not have viable transportation to their appointments.  

I am not saying there are not numerous, or even a preponderance, of truly recalcitrant and anger-filled injured workers, but I am wondering if merely labeling them does much to improve the efficiency and accuracy with which we manage their cases.  

I do not think we can dismiss them as solely or simply obstinate until they are examined, and we know what is driving their hostility…and a viable means to more effectively deal with them.

Monday, December 3, 2001 

This Week's Topic: Liar, Liar 

Question: “I am a nurse case manager. When I send a patient for a psychological exam, your report contains so much data that the patient withheld from me. I am left with the feeling that they all lie and that they all lie just to try to get more money…am I burning out or are there things I need to know so that I do not feel so badly about these people?” 

Dr. Adams Replies: Let’s first address the last part of your question: if you feel your efforts are futile and that you no longer derive any satisfaction from your work and that your work is under appreciated, then perhaps burn-out does apply. However, perhaps the following will better help you understand what is occurring with the patients and that your work is not in vain: 

As a nurse case manager (or adjustor, surgeon or attorney), the patients feel that there are specific data you are seeking and other data of which you would have little interest. Often, the patient does not even recognize the importance of unspoken facts. 

Do patients lie? Of course they do.  Do patients lie for the sake of money? Yes, that is part of any compensated disability process. However, if we define lying as deliberate withholding or distorting of data, there may be some other explanations which bear examining. 

Patients often feel that if they revealed some data, respect for them would be lost, and efforts to assist them would cease. This can include anything from holding a job while receiving benefits to lesser issues such as their sexual preference.  

Patients also fear that any information they provide would be misunderstood, misconstrued and misreported. 

Patients often do not understand the implications of their own behavior and do not admit to the behavior because it frankly frightens, humiliates or confuses them.  

The other part of your question is a common one, and one that I am asked continually: to wit, why does a patient tell me and not tell you. The answer to that is deceptively simple -  the patient believes that this is my role, that I cannot be offended by their thoughts, feelings or behaviors. Often they have long wished to tell someone/anyone about these private aspects of their life. Revealing these data and seeing its relevance to their disability claim is part of patient education and often occurs within the confines of an I.M.E.

November 26, 2001.

This Week's Topic: Holiday Season Vulnerability

Question: “Just prior to Thanksgiving, we had a patient “turn sour.” He is doing very poorly, calling us all the time, and we do not clearly understand his needs. Nothing has really changed in his case…is he manipulating us?” 

Dr. Adams Replies: He likely is not manipulating. Have you asked him whether he can financially cover the base for his family for Christmas or how this Thanksgiving has different from past Thanksgiving holidays? 

Likely, in past years, he got together with family and was a productive participant. This year he may be overwhelmed by his pain, have an uncertain future, knows he will not meet the financial needs for Christmas.  

This may be an “adjustment disorder with anxiety and depressed mood” and tied situationally to the holiday season. (There are also those patients who suffer from seasonal affective disorder (S.A.D.) for whom decreased daylight hours triggers a depressive disorder.  

This is the time when some injured workers need cash advances, need brief psychological support, and develop appreciable fear of the future.  

Obviously, the easiest way to determine this is ask the patient if he is worried about Christmas and how this Thanksgiving different from those in the past.  

The holiday season has been scientifically shown to be a significant stressor even in the lives of perfectly healthy individuals.

Monday, November 19, 2001. 

This Week's Topic: Self-Destructive Patients 

Question: “We have a patient whom her physician believes is inflicting harm on herself. Do you see this often, why does this occur and how is this managed?” 

Dr. Adams Replies: It occurs far too often and is distressing and confusing for most people to conceive of someone causing serious or even minor injury to him or herself.  

The goal of such self-abusive, self-destructive and self-mutilating acts are most often twofold:

1.    To remain in the role of a patient wherein

2.    They are rewarded, gain attention, play the victim and escape responsibility 

In psychological evaluation, they most often over-endorse their limitations and vulnerabilities and frequently offer that others suspect they are being self-destructive and how insulted they are by that attribution.  

There are several things that must be done:

a.    The history and progression of their initial injury must be meticulously outlined to insure whether it is following a standard clinical course

b.    Attempts need to be made to determine what has happened developmentally with this patient and how the family/friends responses have changed since their complaints continued and increased

c.    What would be the negative (or adverse) consequence for them of recovery

d.    How vigorously do they combat attempts to rehabilitate them

e.    Do they resist a change of provider due to fear of exposure

f.    Most importantly, self-destructive acts represent not only serious life risks to the patient but, on occasion, they can include dangers to others as well. 

Careful documentation and synthesis of all data are necessary.

Monday, November 12, 2001.

This Week's Topic:  “Dysmorphophobia”

Question: “We have a patient who lost the tip of her index finger in a work-related accident. She appears genuinely out of control over this relatively minor event. We are uncertain as to whether she is case-building or could actually have a valid problem. Is there a condition or disorder that accounts for this?”

Dr. Adams Replies: People have normal concerns about their appearance, but when excessive time is consumed by their preoccupation with their appearance and social and occupational functioning is impaired, it is referred to as Body Dysmorphic Disorder or “Dysmorphophobia.” For those who are depressed or have an anxiety disorder, 5% to 40% suffer from this disorder as well.  

These individuals experience their preoccupation with their “deformity” as intensely painful. Work and social interaction are avoided. They will spend many hours of the day thinking about their “defect” to the point that it dominates their lives.  

Their days are characterized by obsessive checking of their perceived defect and weak attempts to block such thoughts. 

Since a work related amputation is a sudden event for which an individual is not prepared, “Dysmorphophobia” is often acute and time limited. It simply takes a few months to accept that the event has occurred and that the change in appearance is manageable.  

I have found that it is more often seen in women when fingers are involved since hands and fingernails are so much a part of grooming and appearance. For men, the occurrence of “Dysmorphophobia” appears to be associated with greater bodily loss and perception that their occupational (manual labor) path is forever changed and/or their masculinity is impugned by their new appearance.  

The situation does occur with work-related amputation injuries and can be managed when recognized and differentiated from depression and anxiety associated with financial loss and pain/suffering.

Monday, November 5, 2001.

This Week's Topic: The Abnormal Personality 

Question: “I think I basically understand what a personality disorder is, but I am not certain how knowing that a claimant has such a disorder helps me.” 

Dr. Adams Replies: A personality disorder is a developmental defect. It is an enduring and inflexible pattern of behavior that effects social and occupational functioning. 

A personality disorder impacts the way the claimant perceives himself, events and others (cognition), his range, intensity, appropriateness, and lability of mood (affectivity) and it influences interpersonal functioning and impulse control. 

Since ~50% of claimants may suffer from a personality disorder, knowing which disorder has influence over their behavior enables us to understand, predict and ideally control any inappropriate behaviors that arise. 

Thus, if we know a patient is a (socially) avoidant personality, a paranoid personality, a dependent personality, a negativistic personality or an anti-social personality…or even an amalgam of several personality disorders…we are able to predict how the claimant will respond to the stressors and demands of his/her injury. 

Conversely, if we do not have a formal measure of their personality functioning, we jump through hoops, trying to adjust our own behaviors to suit them…a process that is destined to failure.  

The earlier we assess personality functioning, the sooner we have reasonable understanding and control over the injury management process.

Monday, October 28, 2001 

This Week's Topic: Early Administrative Closure  

Question: “We have developed an unofficial corporate policy of settling claims very rapidly. We do not feel we get very far with these patients, and the longer treatment continues, the less likely recovery seems to occur. It is easier just to assign a dollar amount. Wondered what your thoughts on this were.” 

Dr. Adams Replies: Clearly, this would seem not to be a clinical matter, merely a financial one. But I suspect that early settlements occur because an insurer or employer has found case management to be burdensome, unrewarding, unending and often punitive. 

Many insurers and employers perceive that ultimately the patient and his/her family solely want a monetary conclusion.  

While this may be true in some cases, my clinical experience is that insurers/employers (including adjustors/nurses) are not able to discern the patient’s goals and try to find a dollar amount that allows closure since the underlying goal appears elusive.  

Many patients want the unachievable: they “just want things back the way they were” (pre-injury status)… “want my life and my family back” … “want to go back to the work I did.” 

These often unattainable goals are often unrecognized and, therefore, never addressed. The patient languishes, all become frustrated, and the money which precedes closures is misperceived as the true goal. In reality, the money is often just resignation. 

A much more effective approach would be to determine, from the patient and the patient’s spouse, what goals are not being verbalized and whether the patient can be assisted to discover which can, and ultimately, which cannot be achieved.  

This is the answer to people who ask “what is the role of psychotherapy with these patients?”

This Week's Topic: Psychological Examination – When Is It Needed? 

This Week’s Seminar will be presented at:  Builders and Insurers Group 

Question: “We need a psychological examination of the patient to determine if they are a candidate for psychological care. Then, can we assume that this is the only time we need a psychological evaluation?” 

Dr. Adams Replies: No, that is not accurate. It is true that treatment cannot proceed without diagnosis. It is also true that a diagnosis cannot be made without examination. 

However, the vast majority of patients seen are not referred for treatment. Most are referred because they are failing to recover.  They are being provided with adequate post-injury care, but either there is no change, or their complaints are worsening. 

There are numerous psychological factors that can contribute to this. Some of these are withheld by the patient. Others are outside the patient’s immediate awareness. All of these factors conspire to block the patient’s recovery. 

Sometimes these are referred to as “treatment resistant patients.”  Often they are not resistant to injury care, their true needs and fears are merely not known. 

This Week’s Seminar:  Concentra 

Question: “After surgery, my patients complain of chronic pain. I cannot keep them on narcotics, and there are no measures available to me. So I refer them to one of several pain clinics. Are there any other alternatives?” 

Dr. Adams Replies: This is a major concern. If the referral to a pain clinic is meant to be a discharge of the patient, it is not interpreted that way. The patient expects that when/if the pain center does not resolve the pain, the patient will return to see you. If you have nothing more to offer the patient, you need to state that, release the patient MMI with a PPD rating. Some patients, unfortunately, will have chronic pain for which there is currently no resolution. 

Secondly, patients in pain do not sleep well when prescribed narcotics. They become habituated to the narcotics, their sleep architecture is impaired, they awaken during the night, they are in more pain when sleep deprived, and they are reactively depressed.  There are antidepressants that, even in low dosages, assist with establishing normal sleep patterns, enabling the patient restful/restorative sleep, assist with the depressed mood, and enable more effective coping with pain. 

This Week's Topic: The Last Minute Bail Out

Question: “We proceed to settlement with an injured worker, and then, at the very last moment, the patient suddenly asks for another opinion, a change of providers or some other obstacle toward closure. Why do they consistently do this, and can it be predicted?” 

Dr. Adams Replies: I am tempted to reply with “what else are they supposed to do?”  What I mean is that very often these individuals have nothing to do once their “case” settles. They know that the money will not last, and they have established no future plans. After 1-3 years of living as a workers’ comp patient, they have little other meaning or direction to their lives.  

As anyone approaches a goal, the closer you get, the more anxiety you experience. This is why people fail to show for their own weddings, or why they back out of closing on the purchase of a home.  

Closure implies a commitment and acceptance of its long term implications. Closure is frightening for some individuals. 

Yes, it can, indeed, be predicted. An examination of the patient’s concept of future goal and direction is what is needed. While for you, closure seems logical and appropriate, the patient may perceive it as an empty conclusion, one without a future. Patients are able to verbalize this. Unless someone assists them in determining not only what to do with their money but what would constitute a viable future path, they are likely to balk as settlement approaches.  

At the end, patients realize that they are quite alone, all accounts are financially settled but not emotionally resolved. Many patients need brief assistance with an emotional resolution as things come to a financial ending.

This Week's Topic: Stress, Back Pain & Back Injury 

Question: “I read on your website, and have heard you state in several lectures that stress can predispose an individual for not only back pain but back injury. Did I hear you correctly?” 

Dr. Adams Replies: For us to fail to look at stress factors in the occurrence of back pain and back injury is a grave oversight.  

These findings are reported by Dr. Christine Power of the Institute of Child Health, London, and an international team in the October issue of the American Journal of Public Health.  

“People in their early 20s who have high levels of psychological stress are at increased risk of developing low back pain in their early 30s. Smoking also has a modest independent effect on the likelihood of low back pain. 

The investigators used data from the 1958 prospective British birth cohort study to examine predictors of low back pain in 571 individuals who developed low back pain between age 32 and 33 and 5210 individuals who did not. Study participants provided "extensive information" at age 23 and again at age 33 on back pain as well as psychological and somatic symptoms by completing the Malaise Inventory checklist.  

In adjusted analyses, individuals who reported high levels of psychological distress at age 23 were more than twice as likely to report low back pain at age 33 (odds ratio 2.52). Incident low back pain was also elevated among smokers (odds ratio 1.63). "These risk factors were established for the 11% of men and 8.8% of women with incident low back pain at 32 to 33 years," the authors report.