Monday, March 25, 2002

This Week's Topic: Light Duty Return to Work 

Question: Our client companies routinely provide very reasonable light duty alternative work for injured workers, but we have a terrible time getting the patient to comply even with these. Do you have any idea as to the cause of this other than just low motivation? 

Dr. Adams Replies: There are numerous reasons which you need to examine and have examined:

a.    Does the patient believe that they are being incompletely or misdiagnosed and that they are being sent back to work by someone incompetent to know what is truly wrong with them?

b.    Does the patient believe that returning to any form of work run the risk of re-injury?

c.    Does the patient believe that returning to any form of work will reduce the amount of their cash settlement?

d.    Is the patient angered at the employer (and/or coworkers) and feel that not returning to work will punish the employer?

e.    Does this light duty work place the patient in a position where they fear they will be resented and ridiculed by harder working coworkers?

f.    Will the employer truly comply with the work restrictions or slowly force the patient to engage in tasks that exceed objective limitations?

g.    Is the prescribed medication resulting in adverse side effects which make any day time activities physically uncomfortable (sedation, GI upset, etc) 

Light duty alternate work may correspond with the treating physicians recommendations, but only the patient knows the real reason/fears/expectancies that underlie the refusal to return. You need to find out what factors are leading to the patient’s decision not to comply.

This Week's Topic:  Psychological Exams Increase Our Costs

Question: As an adjustor, I have always believed that ordering a psychological exam merely open’s Pandora’s Box and increases our exposure and costs. I know some feel just the opposite. I would like to hear your comments.

Dr. Adams replies: You have two claimants with identical injuries and equally adequate care – one works hard to get back to work, and the other fails to recover or actually works against recovery - - the differences between these two claimants are psychological. 

You can, therefore:

a.    Order a psychological examination to determine why one of the two elects not to recover

b.    Allow the psychological factors to drive the case but fail to investigate and determine what those factors are 

The psychological foundation for failure to recovery exists even if you try to ignore them. 

Research indicates that a thorough psychological exam tells us why a patient is not mobilizing. By doing so, it alerts those involved in the patient’s care so that they know how best to proceed. A thorough exam tells them how to manage the situation. 

It is very uncommon for these claimants to seek psychological care. It is not part of their family or cultural background. Those injured at work to come from backgrounds where psychological problems, most often addiction and depression, are frequent and ignored. 

Thus, a psychological exam is merely a tool to determine “what is going on with this case.” If the results are appropriately utilized, it substantially lowers the timeframe and cost while maximizing resolution.

This Week's Topic:  Anti-depressants After Injury

Question:

3 Related Questions:

1.    From a claims adjustor: “A surgeon has put one of our claimants on Elavil. Do anti-depressants help the injured worker, and how much of this depression are we stuck with?”

2.    From a physical therapist: “One of my clients is tearful in every physical therapy visit, and when I asked him if he were depressed, he said that he was…I think he needs medication.”

3.    From a nurse case manager: “How do I differentiate between injury as a cause of depression and all the craziness that is going on in this patient’s personal life?”

Dr. Adams Replies:  Dr. Adams Replies: First and foremost: is the patient truly depressed? And has this been validated with diagnostic testing or simply assumed based upon the patient’s (or someone else’s) statements.

Unless clinically validated using recognized diagnostic testing, then all we have is a subjective impression that the patient “might” be depressed. 

He/She could just as easily be angry, frustrated, impatient, annoyed, and/or exasperated with the direction and outcome of care. You do not treat these emotions with anti-depressants.  

Elavil is a very sedating drug with numerous side effects, chief among which is sedation. Patients on Elavil, even at low dosages, sleep much of the time…and it potentiates appetite…they gain weight. If they have a spinal or knee injury, this weight gain is certainly counterproductive.  

Depression accompanying injury is not uncommon. However, the form of depression (major depressive disorder) that responds well to anti-depressants is not the same as the most common form of depression (dysthymia) seen among injured workers. Dysthymia responds less well to medication.  

Also, be aware that many of the medications prescribed for pain can themselves be the cause of the depressed mood. Vicodin, Percodan, etc etc can evoke depressed mood in some patients.  

There are many forms of depression, and you must first be certain that you know the cause and course of this particular patients depression. Again, this is determined by having the patient examined and not by a subjective impression that the patient is depressed.

This Week's Topic:  Oxycontin, Pain Clinics and the Rural South?

Question: ““Okay, I am very concerned about this widespread use of Oxycontin. Certainly, I am not alone. What is the prevailing opinion about this narcotic used for pain?”?”

Dr. Adams Replies:  Let me summarize a recent article by Dr. Stephen G. Gelfand, rheumatologist. It is lengthy but very well worth taking time to read this summary: 

“A serious medical and social problem today is under intense media, law enforcement, and regulatory scrutiny: the misuse and abuse of OxyContin (oxycodone) for chronic nonmalignant pain… In addition to recent Drug Enforcement Agency (DEA) autopsy findings of nearly 300 OxyContin overdose deaths nationally since January 2000, a large volume of patients with chronic nonmalignant pain have become dependent or addicted as a result of legitimate prescriptions written for OxyContin, as well as other opioids… 

In a recent case, the DEA suspended physician narcotic licenses and closed a South Carolina pain clinic for the excessive prescribing of OxyContin, although the physicians involved believed they were following current established standards… 

How did this situation occur? In the first place, certain …narcotic guidelines …have(not been followed). These include the recommendations on the importance of psychological and substance abuse evaluations and the requirement for consultation with or referral to an expert for comorbid (mental) disorders. 

These are common omissions, particularly in rural environments, where the OxyContin problem first originated, and in which psychosocial factors receive less attention, resulting in fewer numbers of referrals to mental health providers. Even before OxyContin came on the market, however, another opioid, hydrocodone, was one of the most widely abused drugs, particularly in rural areas of the South. 

…Contributing to this situation has been an attempt to expand the indications for opioid therapy to the entire spectrum of chronic pain, regardless of cause. 

Thus, the indications for opioid therapy have been extended to this large…group closely associated with a wide range of psychological distress… These vulnerable patients are especially at risk for the dangers of opioid therapy, especially in rural regions where insufficient attention is given to pain-generating and amplifying psychosocial factors… 

…Consequently, as cited above, a number of pain clinics have formed for the primary reason of prescribing analgesics, especially opioids, while at the same time frequently downplaying or disregarding nonpharmacologic approaches, including psychological testing and management necessary for a large number of the chronic pain population. 

In the last several years, OxyContin abuse has spread and reached epidemic proportions.  

The types of chronic pain for which opioids were originally intended are caused by pathological processes in tissues or organs from diseases such as cancer or intractable nerve or joint damage. In these conditions, the drugs combine with opioid receptors on nerve cell bodies in the brain and spinal cord that connect to and attenuate the electrical activity of these afferent nerve pathways stimulated by peripheral tissue lesions. 

In other common types of chronic pain, similar structural abnormalities in peripheral tissues are not present; instead, pain is produced and intensified by central brain mechanisms, including emotions… 

Because opioids may have mood-elevating or altering effects, particularly in individuals with chronic pain and psychic distress (conscious or subconscious), these drugs may facilitate psychological dependence by their action on central affective nerve networks, as opposed to the peripheral afferent nerve pathways of tissue damage or destruction in patients with malignant pain. This central action may also occur in vulnerable patients with nonstructural low back pain and tension headache. 

The lessons of OxyContin could serve to strengthen the importance of good clinical judgment and the need to evaluate each patient in context. Pain should not be treated in isolation without understanding of its roots, just as fever mandates a search for causes. Diagnosis and care should be individualized and involve…clinical psychology…stress management, health education, and physical and/or occupational therapy. 

OxyContin will show that a "one drug fits all" orientation to chronic pain is a risky practice with many pitfalls. In the public interest, more attention must be paid to proper patient selection rather than to marketing ploys intended to increase drug sales.”

This Week's Topic:  Injury and Psychological Care?

Question: “Sometimes we do not authorize psychological care because we have been burned in the past. Some psychologist gets a hold of an injured worker and won’t let go. How much care is appropriate…and is it even helpful to these people?”

Dr. Adams Replies:  Additionally, psychological care has always carried a stigma for lower socioeconomic classes, implying that only those who are weak would require such care. Common question of an injured worker: “Was you father ever depressed?”  Answer: “No, he was a strong man.” 

Psychological care in relation to injury should occur every two to three weeks to avoid development of emotional dependency. Psychological care in groups is often a decidedly poor idea since patients in pain merely share their misery without sharing their solutions (which occur after settlement). 

Patients carry much emotional baggage into an accident. They may then seek to use injury related psychological care for non-injury agenda such as their  marriage, children, and extended family problems as well as their criminal past, addictions, and then a host of phobias, sexual, and financial problems.  

Also, once in psychological care, some patients attempt to feign or amplify emotional symptoms feeling that this will contribute to their PPD rating. 

In toto, it is best to have a patient examined/evaluated. Care will be recommended for decidedly few, fewer still will comply and those that do should be seen for 8-12 visits and then reassessed for progress. If progress cannot be objectively demonstrated, it is not reasonable for the care to continue.

This Week's Topic:  Are Husbands and Wives Helpful?

Question: “I get stuck on the telephone explaining things over and over to a claimant. Often, they just don’t “get-it,” and I have often thought that if their husband or wife got involved, I could go through them to communicate to the patient. Do you think that is a sound approach?”

Dr. Adams Replies:  Maybe so…then again, maybe not. It depends upon their relationship and the goals of the spouse.  

We often see husband direct the course of care and obstruct any meaningful progress for the injured wife.  Equally as often, we see the wife over nurturing this big and robust husband whose injury is modest but who loves all the attention. 

I strictly enforce the policy that the spouse is not permitted in the room while I am examining the injured worker. It is very, very common for the patient then to reveal the role that the husband (or wife) is playing in the injury. 

For a psychological exam, it can be revealing as to whether:

• the patient comes alone or

• the spouse sits for six+ hours in the waiting room and/or

• the spouse keeps asking staff questions

• the spouse makes unrealistic demands

• on breaks the spouse interrogates the patient

• the spouse wants to offer data about doctors, insurers, case managers, etc

• the spouse dispenses medication

• the spouse potentiates ill will toward the doctors involved

And, likely, you can think of other spousal behaviors that suggest more problems than solutions are coming from the marriage. 

However, there are times when husband/wife involvement can be very helpful. Patients often cannot “hear” what they are told, and a husband or wife can serve as a note-taker and case-summary communicator. Not infrequently, there are educational and/or intellectual differences between husband and wife, and the brighter or more educated of the two may retain more of the data. 

From a psychological standpoint, knowing the role of the spouse is a key element in determining whether this patient will recover from injury or even comply with care.

This Week's Topic:  Absolute Chaos?

Question: “I performed a lumbar fusion on a patient who had been briefly employed for a company. The company has been very supportive as has his attorney. The patient was very appreciative if not overly appreciative of my work. Then, following surgery, he became suddenly and abruptly hostile, demanding, and began drug seeking, accusing me of malpractice and asked for a change of provider to what I consider to be a questionable surgeon. I have seen this only twice before, and each time it was with an injured worker. Does this sound familiar and have an explanation?”

Dr. Adams Replies:  There is a disorder upon which we have previously touched. It presents itself as follows:

a.    More common among injured workers than the general public

b.    Characterized by an unstable sense of identity illustrated by frequent and sometimes radical changes in occupation

c.    Accompanied by intense-unstable relationships and often frequent divorces

d.    A history of reckless acts varying from shoplifting to DUI, spousal abuse, and impulsive spending while already in debt

e.    Common pattern of substance abuse and misuse of prescribed narcotics

f.    Rapid change from idealized affection for another person and sudden rejection and hostility toward them

g.    Paranoid suspicion of being mistreated, misunderstood and unsupportive

h.    Frantic attempts within a relationship to avoid abandonment, only to then leave and disparage the relationship

i.    Destroying a situation just prior to achievement of a goal (Eg. Quitting treatment just prior to release, leaving school prior to graduation…)

j.    Chronic feelings of emptiness

k.    Inappropriate intense anger to the point of rage

l.    Recurrent major depressive episodes and suicidal attempts

m.    Early death from reckless and self-destructive behaviors 

75% of these patients are female. There appears to be a genetic pattern for the behavior, and those with this disorder in mother and/or father are five times as likely to themselves develop this disorder during the first 18 years of life.  

Approximately half of those diagnosed with a Personality Disorder have this specific personality disorder. 

It is common among injured workers since they place themselves at risk and early school termination forces them into high risk professions. They may often fire their attorneys equally as impulsively. 

We are, of course, talking about Borderline Personality Disorder. Such patients are driven by their own chaotic moods, contradictory beliefs and impulsive behaviors. 

If you treat an injured worker who appears to overly endorse you, appears to unrealistically praise you, but who has a brief recent employment history and a “colorful” past including arrests and substance abuse (or a family with these characteristics), you likely are treating/managing a patient with this disorder. 

It is neither caused by, nor made worse by, an injury. It is opportunistic in that the injury becomes a place where the chaotic moods and actions can be expressed and justified by the patient.  

If you suspect it, have it confirmed, and then take the recommendations regarding the setting of boundaries.

This Week's Topic:  Hidden Fears and Growing Expectations?

Question: ““So what is it that happens as these “old dog cases” begin to span many months, if not years…what are these patients looking for…I feel surgically I have done a good job, and every Monday, I find them lining my waiting room. And don’t tell me that I don’t educate them…I do…and I am sure they hear me…so what’s the problem?”

Dr. Adams Replies:  As time passes, patients do not become more acceptant of their limitations. Quite often, their resistance to accepting permanent and partial disability increases. 

They see their financial, marital and social situation deteriorate. With the passage of time, they perceive that they need more and different care, not less, and they need more financial compensation, not closure. Also, not surprisingly, their financial and marital plight worsens. 

The problem originates early in case management. When a patient is post-surgical and clinically optimal, yet care is continued because the patient continues to have pain complaints, the patient becomes conditioned to a series of new trials, new attempts, and often a procession of physicians.  

Their life becomes a schedule of various visits, therapies and often a drug regimen that their spouse tracks. Their spouse also becomes the intermediary and spokesperson for all case management. 

The patient becomes convinced that the right doctor, the right medication, or some as-yet-unknown procedure will eventually emerge and change what you know to be an inevitable outcome that was obvious months, if not years, ago. 

When I ask the patient (now two years post surgery) if there has been any, even slight improvement, in the past year, I have as yet to hear a patient say that they are better. They consistently say that they are worse. 

However, checking back with patients who have settled, whether they returned to work or not, they do believe that they were better than when they were still in care. 

Sorry, but a major share of this problem is your own. You truly do know when you have done all that you can. Rather than stating this with finality and releasing the patient, you feel you must punt the patient on to “pain management.” 

The patient hears the term “pain management” and translates it into “pain treatment” (two very different terms) and believes that rather than narcotics, injections, pumps and stimulators, that you are sending them for something special that they have not previously tried. They then wait for the pain-doctor to disappoint them.  

There is a time after surgery when you know that the patient has reached maximum, yet not ideal, improvement. The patient is not served by then languishing, gaining wait, losing all motivation, becoming increasingly dependent upon family and narcotics. The patient needs closure, and you cannot be “the good guy” by stepping away from that role.

This Week's Topic:  Side Benefits?

Question: ““In a seminar recently, you indicated a psychological examination does more than provide a diagnosis. I am not certain I understood…is that not the goal, and what else could such an exam accomplish?” 

Dr. Adams Replies: While the central goal is a diagnosis of a psychological disorder and its relatedness to injury (as well as a determination of whether the disorder is disabling), there are five other functions of a psychological exam: 

1.    Since the exam, and travel to the exam, spans an entire day, it lets the patient see how many hours they can perform sedentary tasks. This is very often a great deal more productive hours than the patient believed he/she was capable.

2.    The exam enables the patient to discuss, often for the first time, the true reason (often fear of failure) that they do not return to the workforce and their limited concept of employment options.

3.    The exam allows the patient to confront what if any progress has been made physically and whether they are willing (or beginning) to accept the chronicity of at least some of their complaints.

4.    The exam helps redirect patients who are spending their days tracking complex medication regimens, interspersed only with watching mindless television

5.    And the exam very often assists the patient in realizing that tensions in the home are wholly emerging from the patient’s failure to assume control of their own future. 

This Week's Topic:   What is wrong with objective findings?

Question: “I am a neurosurgeon. I base my work upon objective diagnostic findings. I objectively communicate those findings to the patient. I then operate based upon those objective findings. I gauge success based upon post-surgical objective findings.  

I have to admit that the surgical outcome is still not always predictable. Even when I exclude those who are malingering, I have a significant number of patients who do not recover. Would a pre-surgical psychological exam have changed that to any extend…and how?” 

Dr. Adams Replies: Objective findings are necessary, but they are not sufficient to account for a patient’s response.  

I suspect that even though you may feel you know your patient well, the patient keeps from you significant information regarding their family, finances, future, fears and expectancies. 

The patient often hears only that surgery is needed and that “there is a high degree of success.” Most patients interpret the latter to mean that after surgery there will be no limitations…and there will be no pain. 

The conduit to the patient’s family is the patient, most often not you. The patient miscommunicates the findings and the surgical plan to his/her family. The family then repeatedly discusses these misinformtation it in the home, and information regarding the surgery and its probable outcome become increasingly distorted. 

When the patient enters surgery, he/she then carries not what you have carefully explained but the shared distortion held within the family. This can be combined with comments made by nurses, staff, and even those in the waiting room.  

Not surprisingly, the patient’s subjective outcome to surgery is not as expected. 

This Week's Topic:   Who's Responsible

Question: “I believe that psychologists contribute to the problem of everyone involved in an accident being seen as a “victim” and that this causes their failure to mobilize. Care to comment?” 

Dr. Adams Replies: I agree, but please read the following: 

Whether it is failing in school, abusing alcohol, gambling away your savings, engaging in numerous extramarital affairs, harming your children or committing suicide, the perpetrator permits the situation to be reworked so that he/she becomes the victim. 

We increasingly conceptualize everything in terms of mental illness or mental disorder - a disease process. 

With the disease model, we remove responsibility for our behavior. In effect, we say it was our brain chemistry, genetics, medication…or parents, teachers, employers or society that are responsible for the things we do. 

I agree that psychology contributes to that image of patient-as-victim. This arose 150 years ago because we did not want those with valid disorders to be persecuted. We wanted abnormal behavior to result in humane treatment. 

However, that was then, and this is now. Using the disease model to account for all of human behavior has resulted in people assuming decreased responsibility for their own lives and actions. 

Injured workers must early accept those activities in which they are engaging, those which complicate their recovery…medication abuse, weight gain, sedentary lifestyle, social isolation, failure to aggressively seek options, dependency upon family and friends, blamefulness  and verbal abuse of others, etc….are their own responsibility. 

If the patient exclusively entrusts the future to others, and spends available time blaming others of the past events, the probability of a viable future is almost nonexistent. 

When a patient is accepted into psychological treatment, the first question from the psychologist must be: “Regardless of all that has happened, what are *you* now willing to do to put your life back together?” 

The answer to that question will determine case outcome.

This Week's Topic:  Minor Surgery and Major Consequences 

Question: “What frustrates me as a surgeon are not the cases where a fusion has been required but where a simple diskectomy or laminectomy has been performed and in the absence of objective limitations, the patient simply never returns to work. I believe this to be psychosocial, and I assume that you do as well, correct?” 

Dr. Adams Replies: I believe the problem is three-fold:

a.    BIOlogical in that there is a difference in pain management capacity among patients, and it is also biological in that some were already obese and deconditioned before injury and many others become that way after injury.

b.    It is PSYCHOlogical in that the patient learns to fear and avoid the experience of even mild discomfort, readily adapts to taking narcotics (and/or self-medicates with alcohol) and spends days endlessly obsessing about their plight, including finances and the family.

c.    It is SOCIAL in the sense that the family (and often the community) creates an environment in which passive-dependent patients readily adapt. They learn to watch TV, remain at home, and the entire family becomes involved in their pain and monitoring it and the medication on behalf of the injured family member. 

This long understood BIOPSYCHOSOCIAL problem then becomes an entrenched environment that the patient and the family help create and maintain.  

This is complicated further when surgeons (or via referral to a “pain center”) lead the patients to believe that they can be passive in their own rehabilitation, that some medication, some injection or some implant will alleviate all of the patient’s pain. The patient, in turn, is expected to do very little. 

Most of us have seen a 45 year old male who, after a diskectomy and/or laminectomy who now spends years, at home, living on medication, self-pity and self-indulgence. He, in turn, uses his having qualified for social security benefits as proof that he is objectively unable to engage in any daily productive activities.  

The factors that create this environment must be identified and aggressively addressed.“