CASE MANAGEMENT UPDATES: October - December, 2003 |
December 29, 2003
(CASE MANAGEMENT UPDATE #267)
This Week's Topic: “Too Much Cheer”
Question: “We have a problem with injured workers and
their alcohol intake. We have had more than one claim that their
injury created their alcohol dependence, and without a doubt,
many of their medications should not be mixed with alcohol. My
first question is whether an injury can cause alcoholism.” from
PsychIME.com
Dr. Adams replies: “The short answer is “no.” Alcoholism
is often referred to as a “disease of choice.” The individual is
confronted with options and elects alcoholism as his/her choice.
Admittedly, there is a genetic vulnerability to alcoholism, but
stressors and pain cannot cause alcoholism. And among injured
workers, alcohol abuse after injury is rarely their first
involvement with this chemical. Most often there is a history of
DUI’s, relationships and jobs disrupted by alcohol and one or
more attempts at abstinence.
An individual who is prone to abuse alcohol, and has done so in
the past, increases his risk by defining sobriety as merely not
drinking for several years. The basic underlying problem has not
changed. Conversely, those having approached sobriety with the
assistance of A.A. are more likely to establish and maintain
sobriety.
Alcoholics will use external events as a rationale for alcohol
abuse. In reality, they chose that option rather than others
that are available to them.
Monday, December 22, 2003
(CASE MANAGEMENT UPDATE #266)
This Week's Topic: “Holiday Downers”
Question: “Is this just my observation, but have we had a
surge in psych. Component claims as the holidays approach?” from
PsychIME.com
Dr. Adams replies: “No, this occurs annually, and may be
inherent in the disability process.
Individuals in pain are anhedonic (unable to derive pleasure
from the holidays), and equally important, they have appreciable
financial woes.
They feel that they are to provide gifts and to spend like other
holiday shoppers, but they most often do not have the funds to
do so. They make last minute requests for advances on their
perceptions that a settlement is forthcoming, then are
angered/depressed that the funds are not made immediately
available.
They are certain that their families do not understand and since
they are often awake during the night due to a combination of
depression and pain, they have more than ample time to
obsessively dwell upon how emotionally unrewarding the holidays
are for them. This is especially true for those injured within
the last 12 months since they have a point of comparison with
the holidays of the preceding years.
On a somewhat brighter note, as spring approaches, these
memories fade as well, and those who are going to mobilize,
begin to do so.
Monday, December 15, 2003
(CASE MANAGEMENT UPDATE
#265)
This Week's Topic: Knowing
In Advance…Being Prepared
Question: “Let
me be simple and direct. Is there or is there not a way to know
(even before someone is injured) whether they will develop
posttraumatic stress disorder.” from PsychIME.com
Dr. Adams replies:
Let me give you a very brief overview of the three-factor model
of personality and its relationship to psychopathology
(including PTSD)
1. Positive emotionality/extraversion (PEM) - the capacity to
experience positive emotions and tendencies toward active
involvement in the social and work environments.
2. Negative emotionality/neuroticism (NEM) – is the opposite of
PEM and refers to negative mood and emotion and a tendency
toward adversarial interactions with others.
3. Constraint (CON) – to be planful, show restraint and avoid
harm (high CON) versus spontaneous, reckless and risk taking
(low CON) and reflects differences among individuals in their
brains’ regulatory system.”
Succinctly, High NEM is the primary personality risk factor for
the development of posttraumatic stress disorder.
Low CON and low PEM influence the form and expression of the
PTSD.
Thus, an individual with a pre-injury personality that is high
in NEM with low PEM is predisposed to an internalizing form of
PTSD characterized by extreme social avoidance, anxiety and
depression.
But an individual with pre-injury personality that is high in
NEM with low CON is predisposed to an externalizing form of PTSD
characterized by marked impulsivity, aggression and a propensity
towards antisocial behavior and substance abuse.
In summary, high NEM leads to PTSD and low PEM and low CON will
shape how the PTSD is expressed.
It is imperative that a patient be examined as soon after injury
as possible to assess the pre-injury levels of NEM, PEM and CON.
In that way, both the probability of PTSD and the way it is
going to be expressed can be determined.
Miller, M. W. (2003) Personality and the etiology and expression
of PTSD: a three-factor model perspective. Clinical Psychology,
10, 4, 373-393.”
Monday, December 8, 2003
(CASE MANAGEMENT UPDATE
#264)
This Week's Topic:
Why Won’t You Talk to Me?
Question: “This
worker has a perfectly normal MRI but has been telling others
that he has “a ruptured disc,” and he makes interim appointments
with his orthopedist and now wants a consultation with a
neurosurgeon. Why is he doing this doctor shopping?” from
PsychIME.com
Dr. Adams replies:
“I do not believe that he is doctor shopping. The first thing to
check is whether his doctor is talking to him or if the patient
is seen by a physician’s assistant and/or a nurse practitioner.
That is, does the patient feel that he/she has the attention and
investment of his doctor.
Many injured workers
report that little time is spent with them, that their chart is
not reviewed before (or even when) they are seen. They are
referred for physical therapy or prescribed medication without
what the patient feels is a reasonable physical exam. If they
become frustrated, they are called non compliant. If they do not
improve, they called unmotivated. If they say that they are
depressed, this complaint is often not even reported.
Why does this arise?
When a patient has complaints that exceed initial objective
findings, they immediately become a target of suspicion. Yet
these suspicions are rarely discussed with the patient (“we need
to find out why you have these complaints when the test results
do not support them.”) Instead, the discrepancy is reported to
everyone but the patient. When the patient is finally told, it
is often in the form of “there’s nothing more I can do for
you…(or worse)… “I do not know what you expect me to do for
you.”
Thus, one of the first
considerations when a patient’s complaints (most often pain)
exceed objective findings, be certain that problems in the
doctor-patient relationship have been addressed.”
Monday, December 1, 2003
(CASE MANAGEMENT UPDATE
#263)
This Week's Topic: Get
Her in Gear
Question: “We have
transitional duty work for one of our employees who supposedly
has carpal tunnel syndrome. She is 48 years old, divorced, has
grown kids and has worked at this plant for 14 years as an
assembler. We have a job watching the front entrance (security).
She does everything in her power to thwart our attempts to
assist her. What can we do?” from PsychIME.com
Dr. Adams replies:
“First off, you need to define “help her.” Do you have reliable
information that she, at any level, wants to return to work?
How boring does *she* feel it would be to her to sit all day and
watch an entrance? How isolating does *she* feel it would be is
this setting? Since you referred to this as “transitional,” will
she even be able to return to repetitive movement tasks, or is
this likely to be a permanent assignment? Does she, correctly
or erroneously, believe that she will be terminated when unable
to work full duty?
Fourteen years as an
assembler can either be a career with friends or can be
incredibly tedious and mind numbing work. Would she rather
spend time with her adult children and/or grandchildren? Is
this the first period of her life in which she is not forced to
work in order to support herself? In that regard, do you know
if, and why, she has applied for social security benefits? Will
the sum of her social security benefits and workers’
compensation equal or exceed her pre-injury income?
Often when you see a
single, widowed, or divorced female production worker not
aggressively seeking to return to work, you are witnessing the
end product of many factors likely impacting the patient.
You are very clear about
your own goals for this case, but it is past time to find out
the underlying and unspoken goals of the patient.”
Monday, November 24, 2003
(CASE MANAGEMENT UPDATE
#262)
This Week's Topic: Getting
a Head Start (from PsychIME.com)
Question: “We have
a case that we feel is representative. The patient sustained a
significant back injury. This was three years ago. He eventually
had surgery, and then they sent him to a pain clinic...that
whole oxycontin nonsense. There is nothing more that can be
done. He is capable of alternate work, and he just sits at home
getting fat and letting his wife work. What do you do with such
cases?”
Dr. Adams replies:
“Start earlier. That’s the simple and most direct response. I
am speculating but would wager that this patient was treated for
many months with medication and physical therapy and no MRI.
Then the MRI is finally authorized, and he is given a series of
injections and more physical therapy with a change in
medication.
He is frustrated and asks
for a change of provider. He is seen and given more medication,
more therapy and more injections and told that he is a poor
surgical candidate.
After two more IME’s, he
is told that he needs a diskectomy, laminectomy and/or fusion.
There are more delays because this conflicts with previous
opinions. He is led to believe that surgery will resolve
everything. It is finally authorized, and he (along with
everyone else) is disappointed to note that he still has
substantial pain.
Rather than assess this
as a permanent and partial disability, he is referred to a “pain
center” where he is initially seen frequently, on a host of
medications including narcotics (despite his personal and family
history of addiction), has more injections and is now seen
solely for medication refills.
You want him to mobilize
and return to work.
But…he is now
deconditioned if not morbidly obese. He sleeps away his days
and/or watches television. He and his family have moved into a
smaller home, apartment, trailer or with parents. He has
adjusted to his minimal income, nonproductivity, dependency upon
others and a year ago applied for social security benefits which
he now conceptualizes as the core of his financial well-being.
Most often cases are
driven by patient complaints rather than a true assessment of
probable outcome and recommended course of action. After several
years, the case takes on a life of its own, having less and less
to do with injury.”
Monday, November 17, 2003
(CASE MANAGEMENT UPDATE
#261)
This Week's Topic: “Elavil
for Back Pain Patients” from PsychIME.com
Question: “We see
this trend of using the antidepressant, Elavil, in the treatment
of back pain patients. Surely not all of these people are
depressed. What gives?”
Dr. Adams replies:
“The use of Elavil (amitriptyline) for the treatment of back
pain appeared in the literature many years ago. It was believed
at that time that the drug served several functions:
a.
It assisted those patients who were
depressed
b.
Even if not depressed, it promoted
sleep
c.
It was believed to be effective in
reducing the experience of pain.
However, amitriptyline
has some bothersome side effects:
·
It does not promote effective
sleep, merely a groggy like drowsiness that for some patients
lasts much of the following day
·
Patients have a variable response
to it, and some cannot tolerate even very low (Eg. 25mg) dosages
and are often started at 100+ mg)
·
Elavil is associated with increased
appetite, and quite often the last thing these patients need is
weight gain
·
It has several other side effects
including annoyingly dry mouth, sometimes blurred vision and
occasional problems with urination
There are antidepressants
which are more effective in managing mood. There are others
which are certainly more effective in promoting appropriate
stages of sleep (called “sleep architecture), and many of the
newer drugs have minimal side effects
Whoever is prescribing
the amitriptyline needs to determine whether the Elavil itself
is not promoting some of the very things that would interfere
with recovery.”
Monday, November 10, 2003
(CASE MANAGEMENT UPDATE #260)
This Week's Topic: “Which Conditions Disable” from PsychIME.com
Question: ““We always ask for a PPD rating on a patient with psychological complaints, but we get a variety of responses. In general, what is the percentage of disability…the rating…for a depressed person?”
Dr. Adams replies: “In general, the answer would have to be 0%. Depression is a disorder and not a disability. There are unquestionably some individuals who are severely (and sometimes psychotically) depressed and are simply immobilized by their disorder. But a hundreds of thousands of Americans are depressed and work consistently.
We have a misconception that psychological disorder, whether mood, anxiety or addictive disorder, are unable to work, are to some extent permanently disabled. This is inaccurate. There is, admittedly, a high potential for a person with a major depressive episode, panic disorder, or alcoholism, to have recurrent problems with their disorder. But, again, this does not mean that they are unable to work even if they are not working to peak efficiency.
Then we have the issue of “rest” versus “productivity.” A person is more likely to recover if they remain productive. Withdrawing them from their work and society is often more detrimental than providing them with daily, although sometimes moderated, daily responsibility.
Thus, the terms disorder and disability are not synonymous. The former refers to a diagnosable disease or condition, and the latter refers to a degree of compromise, often temporary, that results from the disorder.”
Monday, November 3, 2003
(CASE MANAGEMENT UPDATE #259)
This Week's Topic: “Utterly Inconsistent” from PsychIME.com
Question: “If there is a patient history in the chart, why bother to get another?”
Dr. Adams replies: “My experience is that no one truly gets a patient history. They ask `where does it hurt’ and occasionally `how did it happen’ and sometimes `what did Dr. Smith do’ or `did the medication help.’ Rarely, does anyone even ask if the person is now or has ever had problems with substance abuse, mood disorder, impulsive behavior or past injuries, lawsuits or arrests.
I also find that there is most often no consistency in the way the injury was reported. There is often appreciable anger regarding the timeliness and quality of care after injury. Few ask about this, but it is critical because it sets the stage for how the patient will respond to current (and future) care.
Clinically, I look not only for missing data but for inconsistencies. An exam can be an extended period of observation. You can determine whether the restrictions and assigned physical limits are consistent with what is seen in the office. You can also determine if the history contradicts what was said elsewhere (almost always the case…whether deliberate or accidental).
The most critical inconsistency is where others are making elaborate efforts for transitional duty with the employer, and, yet, the patient has no intention of returning to that job…and often no intention of returning at all.
Inconsistency is not always a sign of dishonesty. It can be a sign of confusion and/or depression. In either case, inconsistency can obstruct access to appropriate care.
Monday, October 27, 2003
Question: “Under what conditions do you discontinue care?”
Dr. Adams replies: “There are three times when I personally discontinue care:
a. When the patient has benefited and is at maximum improvement and further gains are either unlikely or unnecessary for the patient to function in his/her society and workplace.
b. When the patient is not responding to care and little if any progress is being made or likely to be made.
c. When the patient is manipulating and I feel that he/she is using the patient role to further some other agenda whether interpersonal or financial.
In most cases, I release the patient as maximally improved. Additional contact from the patient rarely occurs.
In the vast majority of cases, closure is achieved by seeing that patient in a final one month return visit to insure that there has not been a change in status.
In some case, however, the patient is orchestrating symptoms for some tangible gain. The patient does not need or want care but feels that continuing in care serves some purpose. In the latter case, I release the patient to prn return but tell him/her that I will not reschedule unless the case manager contacts me with valid reasons for the patient to again be seen.
Monday, October 20, 2003
(CASE MANAGEMENT UPDATE #257)
This Week's Topic: “How Frightened Should I Be?” from PsychIME.com
Question: “As you have heard, we had a patient come to the office and threaten the doctor and staff. He left but returned, and we had to call the police. Are these people just blowing steam or should we be concerned?”
Dr. Adams replies: “You need to be very concerned. While I have seen cases in which patients fake dangerousness in order to intimidate and/or to inflate the value of their claim, many of these individuals truly represent a danger to you and others. This is especially true if they are drug seeking, have a past history of domestic (or other assault) violence, a police record, and/or have been consistently labile and verbally abusive.
Do not assume the position that “this is merely a manipulation.” Often, but not always, there are warning signs of impending dangerousness. For example, the patient has made demands while being examined, been verbally insulting/demanding at the front desk, crude/rude on the telephone and/or announces that they “will not tolerate” reasonable limitations on their behavior in the office.
Another warning sign can be the way in which they handle frustration in person or on the telephone (such as delays in scheduling an appointment, delays in being seen, or delays in prescriptions being filled.
This is another reason why medicating some patients with narcotics, especially those with past drug/alcohol histories, is very much a problem. Substance abuse *disinhibits* an individual: removes their ordinary restraint against being physically aggressive. Additionally, if they have become dependent upon prescribed narcotics, they are will to use threat and coercion to secure refill or to use violence in the prescription is not refilled.
There is a recent article regarding violence toward doctors in Great Britain, indicating that 95% report verbal abuse from patients in the past year. Just as in spousal abuse, physical violence is often (but not always) preceded by unregulated verbal attacks.
Monday, October 13, 2003
This Week's Topic: “Do we pay for addiction?” from PsychIME.com
Question: “We have a back injured patient whom we sent to a pain clinic. Aside from all the injections, they put him on hydrocodone and oxycodone, and he began forging prescriptions and getting the drugs from multiple sources. We are now told he is addicted and that we have to pay for his inpatient addiction program. We also learned now that he has a past history of alcohol abuse. It is illogical that we are stuck with this.”
Dr. Adams replies: “It is painful to have to assume those expenses, and they are considerable, but it is not illogical. Before anyone is referred to some facility in which narcotics are the standard of care, you need to know not only if the patient has a past history of addiction but is it prevalent in other family members. There are some individuals who have addicted first degree relatives but themselves have never abused alcohol or drugs. That is, “never” until these drugs are prescribed for injury.
We also see patients who consider prescribed narcotics as quite different from alcohol and street drugs, and they fail to see a connection between past alcohol/drug problems and those prescribed for injury.
The core problem is that no one even asks the patient(s) about addiction in self or family. They prescribe narcotics presumably to “improve the quality of life” of those with pain complaints. They then permit the patient’s subjective complaints to determine the level of narcotics prescribed. This is often done without a specific plan for tapering and discontinuing the drug.
Since this all occurs under authorized care, then the addiction is iatrogenic (arising as a result of care itself). The solution is prevention: be certain that all patients maintained are narcotics are queried as to the role of alcohol and drugs in themselves and family prior to treatment with such agents.
Monday, October 6, 2003
(CASE MANAGEMENT UPDATE #255)
This Week's Topic: “Primary Diagnosis” from PsychIME.com
Question: “We have this claimant who has supposedly been using alcohol to cope with pain, and now his wife says he is depressed. What if the alcohol is depressing him? That can happen, right? I think it is unfair that we have to pay for his depression.”
Dr. Adams Replies: Alcohol is referred to as “an addiction of choice,” in that it is a behavior chosen by an injured worker or disabled individual. It does not naturally and unavoidable arise from injury, pain, etc.
Addictions, including alcohol, are considered to be *primary diagnoses* in that whatever else is going on, the main problem is considered the alcohol abuse, and it must be addressed first.
Alcohol is, indeed, a CNS depressant, and unquestionably many depressed individuals consume excess alcohol, but it is incorrect to believe that injury gives rise to alcohol abuse or that such abuse is the cause of clinical depression.
Therefore, if you should suspect alcohol abuse (or be warned that it is occurring), it is important to direct the family to care within their financial means and involvement of their family member in A.A. and family in Alanon.
Alcoholism can be reported following injury, but it is not the province of injury related care.
Contact the
Practice
Atlanta Medical
Psychology The clinical
practice of Dr. David B. Adams is located in The Medical Quarters in
the northside of Atlanta at the junction of Scottish Rite, Northside
and Saint Joseph's Hospitals. Dr. Adams consults to occupational
medicine, surgeons, nurse case managers, insurers and employers
regarding the psychological impact of work-related injury and the
role of psychological factors in short- and long-term
disability.