Archive for September, 2015

Once a year more than 2,000 people gather in Las Vegas to attend a five-day conference on all things pain related. The attendees aren’t just researchers, but all types of healthcare providers and patients as well. I started attending PainWeek nearly three years ago and each year I return with even greater knowledge about pain and more specifically the latest in treatment for my condition — Complex Regional Pain Syndrome; a condition I developed as a direct result of my work related injury.

This year’s conference had several session regarding workers’ compensation and I had the opportunity to attend Dr. Matthew P. Foster’s session on “Pain Management in Workers’ Compensation: Overview of Spend, Utilization, and Treatment Guidelines”. The room filled up quickly, leaving only a few empty seats.

Dr. Foster’s presentation moved quickly explaining how workers’ compensation treatment and drug prescription moved from whatever, without questions, that the doctor ordered for the injured worker to more and more states adopting guidelines that were either created by the state or that followed the Office of Disability Guidelines (ODG) or that followed the recommendations of the American College of Occupational & Environmental Medicine (ACOEM) or that followed some combination.

His presentation showed that by using treatment guidelines, most states had shown some “control” over the rising costs of workers’ compensation, with the exception of State of New York (which has created its own treatment guidelines). One area where treatment guidelines seem to have the greatest impact was in the approval of opioid treatment for injured workers suffering extreme and/or chronic pain. Many insurance companies and their adjusters have used these guidelines, not such as a guide but much more like something which to adhere to very strictly without wiggle room. Nowhere is this more apparent than with prescription opioids.

It was during the question and answer section of Foster’s presentation that members of the audience brought up very similar tales of adjusters using guidelines to basically “cut off” the injured worker from any opioid medication beyond what the “guidelines” suggest. A common thread was the following: the earliest the insurance company will allow a patient refill of their opioid prescription is 28 days (2 days before the patient’s current script ends), when the patient turns in a new script at the 28 days mark some insurance companies then ask for 7 to 10 days to authorize the new opioid script thus leaving the patient without opioid medication to cover for that time period placing the patient at risk for withdrawal, not to mention the emotional and psychological impact the fight every month to fill their physician order medication has on the injured worker. Meanwhile in California a great many of the utilization review physicians are from ER specialty a discipline that doesn’t prepare the physician to take care of patient for the long term, an observation that I shared with the audience and with which the audience agreed.

So in short when it comes to opioid prescriptions the injured worker is basically made powerless by the very program that’s been put in place to “help the injured worker return to pre-injury condition as quickly as possible”.

Thanks to several high profile news articles and news reports a heightened awareness of opioid pill mills and the doctors that run them came into the awareness of not only the American people, but various government agencies, as well. This was not such a bad thing, but what was never addressed by the news articles (many covered in the Los Angeles Times) were the thousands of patients living with chronic pain that were finding benefit from opioids and the conscientious doctors that made a point to monitor their patients for compliance.

The constant focus on those who die from opioid abuse and the doctors that prescribe opioids willy-nilly overlooks the reality that many more people have benefited from opioid use and do so without abusing the medication. The 2012 LA Times series on opioid abuse and deaths has been referenced in nearly all opioid cautionary articles since the series first ran with the factoid that between 2006 and 2011 there were 3,733 opioid-related deaths in four Southern California counties (Los Angeles, Orange, San Diego and Ventura). Though 3,733 is a staggering number of opioid-related deaths, the LA Times reporter failed to provide perspective; such as, during this same period of time there was a total population of 16.9 million people (as of June 2011) in the abovementioned counties and these opioid-related deaths though tragic represents .0002% of the population – my question then how does this make a raging epidemic?

Also missing in many of the reports of opioid abuse is how many individuals were not only addicted to opioids but to other drugs (both legal and illicit), and alcohol. Little effort was done on the part of the experts and reporters alike to deduce which came first the opioid abuse or the alcohol/illicit drug use. Actually in the LA Times series, it was noted that in many of the deaths that were reported as being opioid-related could only be assumed, since at the time of death the death wasn’t identified as an opioid-related death.

While the LA Times did a relatively good job at highlighting deaths related to opioid-abuse they did a disservice by not providing context and by failing to present stories from those living with chronic pain for which opioid use is the only treatment. Instead as a response to the LA Times and other similar articles various agencies and regulatory bodies began to discuss ways to “curb” the opioid epidemic. Meanwhile, few if anyone was talking about what could be done to provide support to those living with chronic pain for which opioid treatment was the only option or one very important part of their therapy to alleviate the constant, chronic pain– because that would be too easy! While the LA Times targeted California for its pill mill and opioid-related deaths (remember 3,733 people died), they failed to mention that California had the lowest person to opioid rate of all 50 states. They failed to address how insurance, in particular Workers’ Compensation, seemed reticent to provide alternative treatment for people living with chronic pain. For example, Workers’ Compensation puts a cap on the number of physical therapy (PT) sessions an injured worker can have, in total, over the course of an injury. This doesn’t mean that a Workers’ Compensation adjuster can’t approve more (PT), but far too many adhere to the strict guideline; even if PT is the recommended course of treatment for recovery from a particular procedure, so all too often doctors have to rely on opioid treatment in lieu of PT.

While it may seem as though states regulatory agencies have done little to curb opioid abuse a map/document produced by Progressive Medical outlined with some thoroughness state opioid rules by restriction, and though this document was published in 2013 it provides a good snapshot of these restrictions by state and can be found here – OpioidRulesByRestriction + MAP_10-15-13_FINAL.

So with so many people and agencies focused on the “problem of opioid-abuse” no one seems willing to advocate and address the needs of people living with chronic pain for which opioid treatment is the only option. There’ve been a few groups that have spoken out, but their voices are often muted by the screams of those who seem intent of removing opioids completely from all formularies. Prescription Drug Monitoring Programs (PDMP) such as California’s Controlled Substance Utilization Review and Evaluation System (CURES) programs have shown little effectiveness. Meanwhile, CURES has a very low utilization by California physicians and pharmacists. Meanwhile few states, including California’s CURES updates in real-time. Oklahoma is one of the few states whose program updates with very little lag-time which allows both prescribing physicians and pharmacists to access the Oklahoma PDMP in real time which helps weed out pill shoppers and helps in the identification of possible pill mills.

Draconian measures will not solve the challenge of opioid-related deaths or abuse or those running pill mills. What’s needed is a balance and sane approach. Doctors need to be well educated on when opioid use is optimum, how to detect possible doctor shopping, non-compliance and so forth. In turn patients and their families need to be educated on appropriate opioid use and provided tools to be both compliant with treatment protocol and to be aware of possible signs of opioid dependency. For example patients who are in extreme pain may not be cognizant that they just took their Vicodin because when a patient is in a state of extreme pain they experience time differently. I should know I had to endure an Ilizarov external fixator for a time and if not for a note that I kept at my bedside where I would document each time I took the Vicodin that had been prescribed to me there would’ve been times when I could’ve sworn that two hours had already passed since my last dose. I can’t recall one occasion where physician, nurse practitioner or nurse ever recommended a method to track when medication, especially opioids, that had been taken.

On the upside conferences such as PainWeek offer caregivers, practitioners and patients alike an opportunity to learn about the various manifestations of pain and the different modalities to treat pain. I’ve truly enjoyed attending PainWeek these past two years and I am looking forward to more networking this year.

On Monday, August 24, 2015, the California Nurses Association (CNA) held yet one more of their dog and pony shows. This time the subject of their display was the firing of two Huntington Memorial Hospital RN’s.   The nurses, Allysha Almada (CA RN License #802190) and Vicki Lin (RN License #832090), claim that they were fired by Huntington administration for being vocal about their support for a nursing union, a union that if the nurses voted in favor of (which they didn’t) would have been represented by the CNA. Want to check an RN’s license all you have to do is go to the California Board of Registered Nursing (BRN) website here – and click the big grey button marked “click to verify a license” and you can check not only if a RN is licensed but pretty much any health/medical profession that is licensed in our state.

Depending on which newspaper you read somewhere between two dozen to 50 nurses/people came out in support of the reinstatement of Almada and Lin. However, if my many years of experience (all up and down the nursing career ladder) has taught me anything, its that sometimes there’s more to the story than what meets the eye – and that would appear to be the case with Almada and Lin.

I’ve learned that at least one complaint has been filed against Almada and Lin. The complaint has been sent to the BRN, the licensing body in our state that has oversight of nearly 400,000 licensed RNs and is responsible for investigating allegations of misdeeds, accusations, etc., lodged against a California RN. So, what pray tell could the complaint be – well it’s not about Almada and Lin’s support of a nursing union for darn sure!

The complaint alleges the following:

  • Nurse Almada provided her username and password to Nurse Lin
  • Nurse Almada provided this in the form of a note, which was later found in a patient’s medical record, and perhaps the most serious of charges
  • Nurse Almada did this so that Nurse Lin could use Nurse Almada’s username and password to confirm as a second “signatory” that Nurse Almada had double-checked a medication that required two nurses to check-off, without Nurse Almada actually being present and having actually verified that she had indeed confirmed that the appropriate amount of medication had been titrated/drawn by Nurse Lin.

If indeed, Nurse Almada did as alleged and Nurse Lin “signed” as Nurse Almada as alleged in the complaint then it would appear to this nurse that they clearly violated our nurse practice act, not to mention potentially placing a patient in harms way – because the medication that was being administered could be deadly – which is why our nursing protocols call for the first nurse to draw the medication and check that the amount is appropriate and for a second nurse to come and verify that indeed the medication is the appropriate medication and that the appropriate amount is about to be administered. Remember the “rights” — the right patient, at the right time, and so forth.

What’s the big deal about requiring two or more nurses to verify that the appropriate medication is about to be administered to a patient, simple some of the medications that a nurse administers can KILL their patient and nurses are only human and can make a calculation error, inadvertently draw too much medication, misread an order and so forth, so nursing protocols require that certain medications such as insulin, heparin and others require a two nurse protocol. Because too much insulin can kill and too much heparin and your patient can bleed out of every orifice of their body. So the two-nurse protocol protects both patient and nurse and to circumvent this safety protocol is unconscionable.

The question that now begs to be asked is how come the CNA is demanding the reinstatement of two nurses that allegedly engaged in acts of what would appear to be not only the falsification of a medical record and the possibility that these two nurses engaged in an act of patient endangerment? I guess, when the rubber hits the road patient safety isn’t what concerns them as much as holding press conferences that continue to spread their propaganda and accuse Huntington Memorial Hospital of being a “bad” hospital that’s mean to its RNs on staff.