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Pain is a problem that is frequently treated with painkillers. As we are all aware, this has led to a significant problem with addiction to and overdose from opioid painkillers in this country. The reasons for the crisis in prescription opioid addiction and overdose are myriad and have been discussed extensively here and elsewhere. This post is not about the problem, but instead about an opportunity to address it.
The NY Times recently posted an article about the potential to harness the placebo effect to help treat pain which offers an intriguing possibility in the struggle to treat pain without causing addiction and overdose. As Jo Marchant reports, “even when we take a real painkiller, a big chunk of the effect is delivered not by any direct chemical action, but by our expectation that that drug will work. Studies show that widely used painkillers like morphine, buprenorphine and tramadol are markedly less effective if we don’t know we’re taking them.” In fact, placebo effects are so powerful “that drug manufacturers are finding it hard to beat them.” Hence, Marchant suggests that more research should be done to figure out if “prescription” placebos could be used to treat pain.
Marchant recognizes the difficulty with placebos: namely that the effect is generally observed in clinical trials where individuals don’t know if they are getting the active drug or a placebo. In controlled studies, patients expect they will receive a drug that will improve their condition even though they know they might in fact get a placebo. This, as Marchant notes, appears to be a key component of the placebo effect: “[t]he greater our belief that a treatment will work, the better we’ll respond.” There have, however, been studies in which patients knowingly taking placebos still reported statistically significant improvement in their reported level of pain. This leads Marchant to ask the eminently reasonable question, “[w]ith placebo responses in pain so high – and the risks of drugs so severe – why not prescribe a course of ‘honest’ placebos for those who wish to try it, before proceeding, if necessary, to an active drug?”
Pain is ubiquitous in our society and, when chronic, often proves disabling. We know from experience that prescribing opioid painkillers is not the answer to the problem of pain. Perhaps it is time for those of us in the medico-legal world to use whatever muscle we have and advocate for change. A good place to start would be the use of “honest” placebos to treat pain.
Worker’s compensation claims involving chronic pain are typically difficult and expensive to administer. We know that simply putting a person on prescription painkillers doesn’t work, yet that is often the treatment claimants end up on. In these cases, the end result is usually an employee who doesn’t return to work and ends up filing a long term disability or SSDI claim. Either way, the result is not good for the employee, the employer, or the worker’s compensation insurance carrier.
Fortunately, the medical research community is tackling the issue head-on. As a result, the medical community is making some exciting strides in understanding how chronic pain works and, accordingly, what treatments are likely to be the most effective. Researchers at Northwestern University Feinberg School of Medicine reported on one such stride. In an animal study, researchers discovered that chronic pain looks a lot like addiction in the brain. As one author put it, “chronic pain actually rewires the part of the brain controlling whether you feel happy or sad.” In other words, "The study shows you can think of chronic pain as the brain getting addicted to pain," said another author. "The brain circuit that has to do with addiction has gotten involved in the pain process itself."
With this knowledge, the study combined a Parkinson’s drug and an NSAID that target the brain area chronic pain affects. Remarkably, the combined drugs “completely eliminate chronic pain behavior when administered to rodents with chronic pain.” Yes, you read that right: the drugs completely eliminate chronic pain in rodents. Unfortunately, the study involved rodents. Still, the authors are optimist that the effect will translate to humans and have already begun designing human trials.
This development bears following. As those of us in the worker’s compensation world know, chronic pain is debilitating and expensive. Also, it often devolves into chronic use of opioid pain medication that has deleterious psycho-social effects and almost guarantees injured workers will develop a disability mindset. Any new treatment that can stop the downward spiral often associated with chronic pain claims would be a remarkable development.
Most of us have New Year’s resolutions and most of us follow them for a couple of weeks or even a month. Many of the abandoned resolutions focus on improving our health. Usually the reason we abandon the resolutions is that they require us to change our daily routines and habits too much. This is unfortunate because if we, as a nation, improved our health even modestly the results would be enormous. For example, the CDC reports that “the estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars.” Reducing the obesity rate by 25% would produce a $37 billion savings. This is not small change.
Employers would benefit greatly if Americans became healthier. After all, employers provide the lion’s share of health insurance benefits and bear the brunt of our unhealthy habits in the form of workplace absence, reduced productivity, and disability-related costs. But what can employers do if most of us can’t keep the promises we make to ourselves to become healthier?
According to a new study, employers probably can do more than they think. Medical News Today reported on a recent study presented at the American Heart Association Scientific Sessions 2015 which found that just three minutes of light exercise every 30 minutes has significant blood pressure-lowering effects in overweight and obese persons with Type 2 diabetes. Bronwyn Kingwell, PhD, one of the study’s coauthors noted that "It appears you don't have to do very much. We saw some marked blood pressure reductions over trial days when people did the equivalent of walking to the water cooler or some simple body-weight movements on the spot." This is where employers can make a difference: develop policies that encourage employees to get up and move. As Kingwell notes, even movements done at a person’s workstation have blood-pressure-lowering effects. And the effects of lowering blood pressure are profound both in direct medical costs and indirect employment costs. So dump the resolutions and get your employees to move. Even 3 minutes helps.
Geography determines many things. It should not, however, determine how likely you are to survive cardiac arrest. Unfortunately, geography does just that. According to a New York Times article, persons suffering out-of-hospital cardiac arrest treated by emergency medical service (“EMS”) providers in Seattle have a 19.9% survival rate while persons in Detroit have only a 3% survival rate. It appears that the wide variation in survival rates is due primarily to the quality of the training EMS providers receive and to “spreading awareness that cardiac arrest is a treatable condition, so citizens are quick to perform bystander CPR.”
Survival rates vary widely even for hospitalized patients treated for cardiac arrest. For example, CPR should be attempted for a minimum of 45 minutes but is usually only performed for 15-20 minutes in clinical settings. In addition, clinicians often fail to use more powerful interventions available to them such as extra corporeal membrane oxygenation, in which a patient’s blood is artificially oxygenated. According to one expert interviewed for the article, extra corporeal membrane oxygenation is more common in Japan and South Korea where “they routinely bring people back to life who would remain dead here.” Unfortunately, even in hospitals “it’s a lottery of what you will get” that largely “depend[s] on which doctor happens to receive you, since none of these treatments are regulated.”
It is tragic that 17 out of every hundred people who could survive out-of-hospital cardiac arrest will not simply because they live in Detroit. While cardiac arrest is not a medico-legal issue of the sort we normally address here, it is a human issue. And at this time of year, many of us ask ourselves what we can do to help our fellow human beings. Taking a CPR course that teaches up-to-date techniques is one place to start. Another place is to spread awareness that out-of-hospital cardiac arrest is treatable with immediate bystander CPR. As the article notes, “if Seattle’s innovations could be implemented nationwide for out-of-hospital cardiac arrests…as many as 30,000 lives annually could be saved.” That is a gift worth giving.
Mild traumatic brain injury claims may well be the most vexing for claims professionals. They usually involve comparatively minor incidents for which little objective testing exists and they are frequently entangled with psychological co-morbidities which further complicate matters. In addition, the chief method to diagnose and assess mild traumatic brain injury involves subjective reports and evaluations of cognitive symptoms and functioning, making these claims particularly susceptible to exaggeration, malingering, and fraud.
The mild traumatic brain injury paradox is that those who are often at greatest risk of reinjury are often the most eager to return to the risky activity while those with the lowest risk of reinjury are most concerned about returning even to the activities of everyday life. Hence, the competitive athlete will mask symptoms in an effort to return to the playing field as quickly as possible while the truck driver who pulled an overhead trailer door onto his head may complain of cognitive symptoms for weeks or even months to avoid returning to work. The subjective nature of diagnosis and assessment makes it difficult for medical professionals to know when the athlete is not ready to return to competitive play and simultaneously when the truck driver is ready to return to work.
Unfortunately, recent research muddies the water and makes the development of an objective test for traumatic brain injury all the more important. In a study presented to the American Radiological Society, researchers from the Medical College of Wisconsin found that persons suffering from mild traumatic brain injuries demonstrated neuropathology on MRI scans days after their cognitive functioning returned to baseline. This is a potential problem because it is generally accepted that injured neurons subjected to a second trauma before they are healed are at risk of significant and permanent injury; further, the traditional mechanism for assessing when a mild traumatic brain injury has resolved is a subjective assessment that the injured person’s cognitive functioning has returned to baseline.
And as noted above, those who are most eager to return to the activity that caused the mild traumatic brain injury are often the most susceptible to suffering another head injury. If they return before they are fully healed from the first injury, the second injury could have devastating effects. This further exemplifies why it is so critical to develop a reliable and rapid objective test to assess the presence of mild traumatic brain injury. As an added bonus, a reliable and rapid objective test would have the felicitous effect of being able to catch those trying to use a mild traumatic brain injury to stay out of work or to collect a financial windfall in a personal injury action.
Sometimes the old adage rings true and you do get what you pay for. Other times, it does not. According to the American College of Physicians, the adage does not ring true for prescription medications. Medical News Today reports on a recent meta-analysis from the American College of Physicians Clinical Guidelines Committee which concluded that “the majority of peer-reviewed studies found that generic equivalents to brand-name drugs produced similar clinical outcomes.” In addition, the report’s authors found that patients adhered to their prescriptions better when receiving generics because of their lower costs, noting that “prescriptions for branded medications are almost twice as likely to go uncollected after being filled than generic medications.” Further, the cost of choosing branded medications over generics is significant. Substituting generic prescription drugs for brand name ones “combined with therapeutic interchange” would save $1.4 billion just among Medicare beneficiaries with diabetes.
Health insurers and employers bear a huge amount of the unnecessary direct costs of prescribing brand name drugs instead of generic equivalents. They also bear many of the indirect costs when an insured/employee doesn’t fill a brand name prescription due to lost time and increased medical intervention costs when the condition for with the brand name prescription was written is not controlled. Thus, health insurers and employers should staunchly advocate that physicians receiving reimbursement from group health or worker’s compensation plans prescribe the lowest cost drug or therapeutic equivalence rather than a brand name drug that adds no therapeutic value. They should also aggressively educate employees so they understand that with many prescription drugs you do not, in fact, get what you pay for.
Researchers have developed a blood test that holds promise to detect traumatic brain injury with greater sensitivity than even CT scans, according to this report from Medical News Today. Equally significant, the blood test appears also to be able to measure the severity of the traumatic brain injury accurately. The test measures glial fibrillary acidic protein (GFAP), which is released when the brain suffers an injury. Although the test was performed on children, researchers note that it is likely to be equally valid for adults.
A blood test with sensitivity on par or better than a CT scan would be an improvement in diagnosis for at least a couple reasons. First, CT scans use x-ray radiation, and any ability to reduce the amount of radiation to which we are exposed is a good thing, especially in children. Second, portable detection devices similar to blood sugar monitors persons with diabetes use could be developed for the brain injury-measuring blood test. A portable detection device would be a boon to monitoring traumatic brain injury in sports like football or hockey. It would also be enormously useful to measure brain injury in the workplace. Third, a blood test would provide an objective means to diagnose traumatic brain injury with considerably greater sensitivity and ease than current concussion/traumatic brain injury protocols which rely chiefly on subjective interpretation of spoken or computer-based cognitive tests.
We recently wrote about how stunningly ineffective opioid pain medications are at treating chronic pain in women. A new study provides a perfect example of why prescribing opioids to treat chronic pain in women is a bad idea. Researchers at McMaster University in Ontario, Canada found that 52% of women treated at a methadone maintenance clinic for opioid dependency developed their addiction while taking prescription painkillers, according to a report from Medical News Today. The study’s authors concluded that women are more susceptible to become addicted when prescribed opioid pain medication, but they are not sure why. Regardless of the reason, women’s apparent increased susceptibility should further caution prescription opioid use to manage long-term or chronic pain in women.
Arthritis is the bane of many lives and many claims. How many claims hinge on whether symptomatic arthritis is wholly preexisting or was aggravated by a work injury or a non-work-related accident? But what if there was a way to combat arthritis from developing in the first place? Perhaps there is. As Medical News Today reports, a team of engineers from the University of Delaware recently presented research suggesting that staying physically active appears to prevent arthritis from developing. Specifically, researchers found that hydrodynamic pressurization caused by normal joint movement causes synovial fluid back into cartilage.
To understand why this is significant, it helps to understand how joints are made and how arthritis develops. Synovial fluid is the viscous substance that lubricates the hyaline cartilage lining the surface of most joints. This enables the joint to move smoothly and without pain. Synovial fluid also constitutes 80% of hyaline cartilage. Arthritis develops when the hyaline cartilage deflates. The cartilage deflates when it loses synovial fluid. This is a normal process because hyaline cartilage is porous, which allows synovial fluid to leak into the joint space. Unfortunately, the cartilage does not reabsorb as much synovial fluid as it leaks out. Hence, the cartilage thins and eventually wears out, causing the pain that occurs in arthritis when exposed bone rubs against the opposite surface of the joint. As lead presenter David Burris stated,
We observed a dynamic competition between input and output [of synovial fluid]. We know that cartilage thickness is maintained over decades in the joint, and this is the first direct insight into why. It is activity itself that combats the natural deflation process associated with interstitial lubrication. (emphasis added)
The bottom line is that joint activity, i.e. moving, keeps the cartilage thicker longer, forestalling or preventing the onset of arthritis.
This is good news for employee wellness programs, especially those that help employees achieve an active lifestyle. The potential reduction in the occurrence of arthritis from such programs could benefit employers in many ways. First, arthritis saps productivity because it is painful, reduces mobility, and can cause absences. Second, arthritis will increase employers’ group health-related costs. Put another way, every joint replacement that can be avoided will have a positive impact on health insurance premiums. Third, arthritis is often alleged to be work-related, increasing worker’s compensation costs. Helping employees stay or become active makes sense for myriad reasons. Reducing employees’ arthritis is a powerful one both for employees’ well-being and employers’ bottom line.
At Medical Systems, we don’t often see separated shoulder cases, known to medical professionals as acromioclavicular (“AC”) joint dislocations, because the injuries are acute and painful. Hence, there usually isn’t much dispute about whether the injuries are work/accident-related or not. Still, these injuries happen at workplaces and in personal injury accidents. They are painful and, if severe, usually treated surgically (read, “expensively”).
New research suggests that this is probably the wrong approach. A recent study in the Journal of Orthopaedic Trauma found that surgical repair of moderate and severe AC joint dislocations did not result in improved outcomes versus non-surgical repair, bucking what has been considered common knowledge among doctors. Not only did surgery not improve patient outcomes, but patients that did not have surgery actually recovered faster. In fact, 75% of the non-surgical patients returned to work within 3 months of the injury while only 43% of the surgical patients did. According to the study’s author, "For severe AC joint dislocations, surgery is the common practice but there's not much evidence to suggest this is actually the best treatment." An additional benefit is that those treated non-surgically (use of a sling and rehabilitation) suffered much lower rates of complication. The only noticeable benefit to surgery was that the AC joint appeared more normal after surgery.
One hopes that the medical community will pay attention to the findings and stop recommending surgery for every moderate to severe AC joint dislocation. It would seem that this would be the best result for both claimants with AC joint dislocations and claims professionals managing their claims.