There are actually two problems here.  First you are defining someone who does not drink as “sober.”   They may be clean for now, but the fact that this man has never attended AA, still heavily drinks at certain parties and has used alcohol several times since injury to “cope with pain” is a significant concern.  He is still an alcoholic. All he has displayed is some degree of control. That is not the same as being clean and sober.

But there is a much more important issue:  Many alcoholics who have maintained reasonable control over their alcohol intake have a new problem when injured.  They are prescribed abusable narcotics which they take in excess.  Their rationale is that: a. “this is not alcohol,” and b. “my physician prescribes them for me.”  They then justify it further with statements such as “I am in pain and should have these drugs until I no longer have any pain.” 

From the onset (and this is due to poor patient education) they believe that narcotic abuse and alcohol abuse are somehow unrelated. They also believe that narcotics like Oxycontin, Opana, Vicodin, etc will be available to them until there are no pain complaints whatsoever. “Since I still have pain, I still need these drugs, and” the concerns that apply to people prescribed such analgesia does not apply to them.

What is most daunting is that whoever is prescribing the drug also may be unaway (they may never ask) if the patient has a personal or family history of alcohol abuse, what problems have arisen in their past with substance abuse and have they ever had a problem curtailing alcohol intake. By the way, “beer is not alcohol” to make patients.  I had one who stated that “I never drink unless you’re one of those doctors who believes that a case of beer every day is `drinking.’”

Monday, November 26, 2007

Dr. Adams’ Case Management Update (Since 1999)
This is the 463rd Weekly Issue

This Week's Topic:  "Lost Focus"

Q^uestion:
"You mention, and likely we all concur, that the longer a case goes unresolved, the less likely it is to do so.  That being said, do you think that there is a specific source of this problem?"

D^{r. Adams replies:}

There are actually three sources; some of which we cannot directly influence:

1. The patient's source of the patient's complaints are slow to be diagnosed since there is that tendency to dismiss everything as a minor problem until so much time has passed, complaints have built and providers changed that there is no choice but to look at, and for, more serious problems.  In this process "the simple back strain" winds up, in actuality, being multiple bulged discs.

2. The input from family, friends, coworkers and others who encourage the patient to dwell upon the concept of preventability of the injury, unsupportive response of the employer and suggesting that the complaints have a financial/numerical value.

3. The response of the insurer who declines to approve diagnostic tests, recommended therapy and prescribed medications.

The latter is a significant concern because the patient will become increasingly futile feeling and blameful.  If he/she is provided a target for that blame, the patient's attention is focused away from the injury and self-accountability for rehabilitation to retaliating against the employer/insurer.  While the patient's perceptions of what the employer/insurer has done, and is doing, may be entirely accurate, the focus upon these misdeeds becomes a distraction and displacement from a healthier focus.

If you want a patient to assume individual responsibility for the process of recovery, you must be certain that you do not provide them with a convenient distraction that justifies their inactivity.

Monday, November 19, 2007

Dr. Adams’ Case Management Update (Since 1999)
This is the 462nd Weekly Issue

This Week's Topic:  "Procedure Crazy"

Q^uestion:
"Any pet peeves as we head into the holidays?"

D^{r. Adams replies:}

I have several concerns that are recurrent themes each year:

• The patients who receive a procedure even though they are poor candidates

• Patients who are encouraged not to mobilize as part of case building maneuvers

• Patients who use injury in a futile attempt to solve longstanding personal problems

Addressing just the first theme, it has always concerned me that there is a disparity between those who receive procedures and those for whom procedures are clearly contraindicated.

I routinely see patients for spinal column stimulator implant candidacy.  From a psychological standpoint, greater than 95% are very good candidates, and of the remaining five percent, all that is lacking is a better understanding by the patient as to their responsibilities after the trial and their options if the implant is not as effective as they had hoped.

However, a few patients are decidedly poor...actually horrible...candidates. They are abusing street drugs, they are selling their prescription drugs, and a host of other issues. 

In a recent case, the patient was frankly schizophrenic.  He was delusional, had recurrent hallucinations and was emotionally labile.   Although he was obviously working when injured, he was one of the walking-wounded of mental health.  He was clearly dysfunctional and now, without the structure of work, was more suitable for an inpatient stay in a mental health facility than a stimulator implant candidate.

However, his physician was sorely disappointed in this outcome. She wanted to know if the patient could be successfully treated to the point where he would be able to tolerate the stimulator trial.   Even with further clarification, she could not separate from her own (largely financial) goals for the implant and the fact that the patient was likely to have frankly psychotic thoughts about anything put in his body...especially ones with wires.

Interestingly, the patient did not want the procedure. He was actually increasingly acceptant that he would have back pain.

Sometimes, it is not the patient who needs the education. And sometimes no amount of education will dissuade someone from wanting to perform a procedure.

Monday, November 12, 2007

Dr. Adams’ Case Management Update
This is the 461st Weekly Issue

This Week's Topic:  "Unfit for Duty"

Q^uestion:
"We sent you a patient actually hoping that he was psychologically unfit for duty.  He is quite a problem in the workplace. He is argumentative, controlling, confrontational and frankly lies every chance he gets.  You said that he has characterological (whatever that is) problems but that he is not unfit for duty.  How in the world can he be fit for duty and be so unfit to be in this company?"

D^{r. Adams replies:}

I am afraid that you are confusing some terms.  A person can be quite unsuitable for his/her job but still be fit for duty.

Fitness-for-duty is a reference to health status: does this employee have a physical or psychological problems that make him/her disabled from doing this or alternative work. 

What you are referring to (the characterological problems) are a series of personality traits, and perhaps even a personality disorder, that interferes with the patient's occupational and social functioning.

There are some severe personality problems (for example paranoid personality with its overwhelming distrust of others or borderline personality with its chaotic emotions) that can truly be a disability.  However, personality characteristics and many more mild personality disorders are simply not disabling; merely a source of annoyance.

Using clinical disorders as a reference, an analogy would be that a patient with moderate depression can (and most do) work.  A patient, however, who is frankly schizophrenic is quite likely disabled.

We are referring here to the degree of inability to cope with the demands of the workplace, whether psychological or physical.

A person may be (psychologically and/or medically) "fit for duty" but "socially unfit" to work for your company.   We should refer to this as "unsuitable" for duty.  An unsuitable employee becomes an administrative problem/decision, and those decisions must be made within the company's hiring, promoting and firing policies.

Bottomline:  "Unsuitable" is not a statement of disability; it merely indicates a mismatch between the employee and the job/company.

Monday, November 5, 2007

Dr. Adams’ Case Management Update
This is the 460th Weekly Issue

This Week's Topic:  "Maximally Medically Improved"

Q^uestion:
"Listen, our only concern and responsibility is to see that these folks are at MMI [maximum medical improvement].  Whatever else is going on in their lives is of absolutely no interest, relevance, concern or importance to us. If they are MMI, we ship them back to work, and if they do not comply, we simply suspend their benefits; end of story."

D^{r. Adams replies:}

Does that really mark the end of the story, and does that process reliably work?  In my experience, it works some of the time, but most of the time there are other agenda that are impacting the patient, and if he/she elects not to return to work, this is not the end but the beginning of a whole new series of challenges and problems for you.  With other agenda in operation, the patient will seek additional opinions and emphasize other complaints.

You must assume, using your procedure, that the patient will now relinquish all subjective complaints (e.g. pain).  You must assume also that the employer will comply with whatever restrictions have been assigned.  You must also assume that the patient is fully functional from a psychological perspective. That is, the patient and family are coping with the financial aftermath of the injury, that the patient can emotionally deal with permanent limitations regardless of their scope, and that the family unit remains intact after months or years of living a disability lifestyle.

So, I suspect that MMI does not, in fact, "clear" a case as often as you would like. We tend to view all physical conditions as though they can be defined totally in terms of objective measurements (xray, MRI, CT-scan, etc).  The reality is that there is often extreme variability between and among patients with essentially identical injuries.  You may have an uneducated, obese, hypertensive, diabetic middle aged patient with a lumbar injury, or you may have the same injury in a high school educated, otherwise healthy, patient who has always lived on the brink of financial despair.  Each will respond to being released MMI in quite different ways.

Dare I repeat that: it is often far more important to know what type of patient has the injury as it is what type of injury the patient has.

Monday, October 29, 2007

Dr. Adams’ Case Management Update
This is the 459th Weekly Issue

This Week's Topic:  "A Good Call "

Q^uestion:
"Here's a frustration: I often am able to predict what is going on with a patient, but I lack the credentials that would permit me to put that in writing. So I see patients jerk around people or intentionally falsify what is going on or even lie about what they said to the last person. It is such a helpless feeling to feel you know more about a case than other people and yet feel your hands are ties."

D^{r. Adams replies:}

Monday, October 22, 2007

Dr. Adams’ Case Management Update
This is the 458th Weekly Issue

This Week's Topic:  "The Problem is not Inevitable"

Q^uestion:
"There is a trend to depression in chronic pain patients with a peak in the next two months.  Do you thing that this is seasonal...biological?"

D^{r. Adams replies:}

While seasonal variations in depression are well documented; the frequently described and research "seasonal affective disorder (SAD)," in the case of injured workers, there is a more important factor, and it is called The Holiday Season.

Depression commonly occurs among injured workers during this season, but it is not an inevitability. There are ways to mitigate or eliminate its occurrence.

Depression during the holidays is largely a "problem of comparison."  The patients see the festivities in their community, in the media and in the retail markets. They see sales and discounts on attractive items that, in the past, they could have given and received as gifts.  They compare themselves unfavorably with family, friends and neighbors who are still able to consider such purchases.  They feel a sense of loss and futility.

This is also a time when those responsible for scheduling their appointments, sending their checks and approving their medications and procedures are inordinately busy.  Things are not done in a timely fashion.

Beneath the thin veneer of depression is often anger and resentment.  It is far easier and often healthier to be angered rather than depressed by ones circumstances.  So the physician, nurse case manger and adjustor all become targets of patient anger.  Demands for medication increase yet compliance with procedures may decrease. 

Neurasthenia is a term that describes the sense of decreased energy that can occur. Anhedonia describes the joylessness that does occur.  Together these two response most often send the patient to bed where he/she sleeps poorly or to some area of the home or apartment where they sit nonproductively for hours, days, weeks.

Anticipate that this will occur, that this is a brittle, fragile and vulnerable time.  Be more precise in your case management efforts between November and January of each year since this is clearly a period of decreased endurance for the patient.

Monday, October 15, 2007

Dr. Adams’ Case Management Update
This is the 457th Weekly Issue

This Week's Topic:  "The Best"

Q^uestion:
"We have short term disability, long term disability, social security disability, worker-compensation, family sick leave and other programs that provide incentives for non-productivity. Many of us feel this is bad for the patient and society, but are there any research data on this?"

D^{r. Adams replies:}

There is a recent, interesting and important article (Lancet. 2007;370:1146-1152) on this topic. That article states in part:  "It is very important for clinicians to be aware that they are not risking the fragile health of their patients by getting them back to work. We should take more risks in encouraging even very disabled patients to seek work with assistance."

The authors also note: "Europe has less of a "hire-and-fire" culture than the United States, and its more generous welfare system might create a "benefit trap," where patients could face real or perceived financial disincentives for returning to work."

We daily see patients who would better be served by being back in the marketplace. They would feel greater worth, feel less hopeless, be less of a burden to friends and family and can contribute to society. However, there are forces that encourage dependency, often exaggerated disability and provide assistance in finding financial rewards for non-productivity.

Are there people who are totally disabled by pain?  Yes, but these are rare.  Are there patients totally disabled by depression?  Unquestionably, but these are few. Many patients have productive things that they can, and want to, do despite their pain. Many have alternate skills, and most loathe the role of remaining at home. But when their disability income is equivalent to that obtained by working, and disability income is given almost as a reward for staying in bed, fewer each month attempt to mobilize their remaining resources.

When managing patients, whether they be in pain and/or depressed, it is important to step back and determine objectively if these patients can obtain not only self-worth but actual symptomatic relief from the daily competition and interactions in the workplace.

Monday, October 8, 2007

Dr. Adams’ Case Management Update
This is the 456th Weekly Issue

This Week's Topic:  "Golden Opportunity"

Q^uestion:
"You were talking last week about exacerbation of pre-existing psychological problems.  What about those that are not exacerbated but just pre-existing?  I am talking about those who carry problems into an injury, and the injury has not made the problems worse at all...don't patients take advantage of open access to care just like they take advantage of access to narcotics?"

D^{r. Adams replies:}

If I understand your question, you are referring to what I have labeled the goose that concurrently lays two golden eggs.

The patient, as is true in the cases of 1/3 of all injured workers, has one of more psychological disorders and countless personal problems that he/she has had for many years. 

The individual gets injured, and what emerges are two fresh opportunities:

1. I can now get "free" care for my myriad of longstanding problems including medication to make me to feel better emotionally, and

2. This will increase the "financial value" of my case for which I will receive a greater cash treasure chest when it closes.

You may feel that this is particularly annoying and unfair. However, an even greater problem is that the patient is being encouraged by outside sources to tie together these unrelated issues for financial gain. In such cases, the patient is very reluctant to accept termination of care.

So, what should you do?

a. Require a diagnostic determination that not only tells you what is going on but also why it is occurring and for how long it has existed

b. Ask for an assessment of pre-injury baseline functioning. Insist upon a statement of probable length of time required to return to baseline (in many cases, the patient is already at baseline but this baseline was always a compromised level of functioning).

c. Ask for a treatment plan that includes number, duration and spacing of visits

d. Do not authorize additional care without a review after the delivered care's benefit can be determined.

Far too often, when a patient elects not to improve, enjoys being in treatment, finds that it gives him/her something to do, those treating the patient erroneously believe that somehow additional care will divert the path that the patient is following.  It almost never does.

Always be certain of relatedness to injury and specifically how treatment will improve the quality of the patient's life.

  .

Monday, October 1, 2007

Dr. Adams’ Case Management Update
This is the 455th Weekly Issue

This Week's Topic:  "Exasperation over Exacerbation"

Q^uestion:
"Since many Americans suffer from some form of depression, are we not accepting a huge pool of these individuals into the definition of exacerbation of pre-existing condition?"

D^{r. Adams replies:}

Allow me to very briefly to break down the three types of depression that one is most likely to see following an injury:

1. Adjustment Disorder with Depressed Mood – is a transient problem, lasting several months in which the individual has mild depressive symptoms associated with physical discomfort and loss of productivity.

2. Dysthymic Disorder (a.k.a. “Dysthymia”) – was once called depressive neurosis. These are moderate symptoms that span two or more years, wax and wane, and arise from the conflicts that are created within and outside of an injury. Dysthymic Disorder can be exacerbated by injury but quite often there are other issues that are of equal or greater concern.

3. 3. Major Depressive Disorder (or Major Depressive Episode) – may be a misnomer in that the term “major” tends to influence how many see this quite common mood disorder. There is a form of the disorder called “early onset” in which a patient may have a long history of depressive episodes, created by changes in brain chemistry and may be unrelated to external events.

Obviously, it is crucial that we know which form of depression we are witnessing. It would be inappropriate, expensive and quite counterproductive to treat a depressed patient as though the injury was the sole and enduring cause of the mood disorder.

The true purpose of including “exacerbation of pre-existing” depression among our concerns is that we must return the patient to baseline.
This is critically important because the “baseline” of patient’s with recurrent major depression and dysthymic disorder may not be the same high level of functioning that characterizes our own life.

In other words, treatment of that part of the depression that is injury related is only meant to return the patient to the point where he/she can then seek care (or return to care) for the other contributing factors that may have existed for many years before injury.