2. PAIN, PILLS, PROCEDURES and THE WOUNDED WORKER SYNDROME William Nemeth MD CPE Texas Association of School Boards Risk Management Fund SUMMER 2007

3. DISABILITY EPIDEMIC!!!!

4. Before After INSANITY!

5. " Doctors are men who prescribe medicine of which they know little to cure diseases of which they know less in human beings of which they know nothing.“ Voltaire

6. UTILIZATION UTILIZATION v. OUTCOMES + OUTCOME 4-6 WEEKS - DEPENDENCE

7. Wounded Worker Syndrome Chronic Pain Chronic Pain – “Suffering” - soft tissue injury Stay off Work Repetitive Treatment Failures Repetitive Treatment Failures multiple providers multiple providers Victimization Victimization (External Locus of Control) Job Dissatisfaction

8. HOW DID THEY GET THIS WAY? HOW DID THEY GET THIS WAY? “MEDICINABLING” System ENTITLEMENT Attitude “MEDICALIZING” Docs

9. MEDICINABLES! System MEDICINABLES! INDEMNIFIES Chronic Disease Chronic Pain Lost Time PROVIDES Socioeconomic Safety Net

10. DISINCENTIVIZE! System(Payers) DISINCENTIVIZE! Pay for the wrong things Non-work-related diseases Surgery, injections, and other non-EBM interventions Do NOT pay for the right things E&M Codes (Face Time-Education) RTW and Case Management Services Risk Assessment-Early Intervention

11. MEDICALIZE! Doctors MEDICALIZE! Mis-diagnose Over-treat Give work excuses

12. MISDIAGNOSIS!!!!!! MISTREATMENT!!!!! Denial- PsychosocialDenial- Psychosocial IgnoranceIgnorance Medical Economics-Medical Economics- Profit Motive Profit Motive Can’t Say “NO!”Can’t Say “NO!”

13. BECOME VICTIMS!!! Injured Workers BECOME VICTIMS!!! Entitled- Fear AvoidanceEntitled- Fear Avoidance Psychological issuesPsychological issues Expect “quick fix”Expect “quick fix” External “Locus of Control!”External “Locus of Control!” Unfulfilling jobUnfulfilling job

14. Wounded Worker Syndrome “True” Wounded Worker Disorder“True” Wounded Worker Disorder Fear-Avoidance / Entitlement / Fear-Avoidance / Entitlement / Age / Degenerative Disease(s)/ Age / Degenerative Disease(s)/ Workplace Factors Workplace Factors Chronic Pain DisordersChronic Pain Disorders

15. PSYCHOLOGICAL BEHAVIORS “SOMATIZATION” “SOMATIZATION” ABNORMAL ILLNESS ABNORMAL ILLNESS BEHAVIOR BEHAVIOR “SYMPTOM MAGNIFICATION”“SYMPTOM MAGNIFICATION” “CATASTROPHIZING”“CATASTROPHIZING”

16. CHRONIC PAIN DISORDERS Physical Condition “COPERS” “SOMATIZATION” Malingering-Factitious Disorder True “Wounded Worker Syndrome” Mood/Anxiety Disorder Pseudo-addiction Substance Abuse (Addiction) Personality Disorders

17. WHAT CAUSES THE PAIN ???

18. CHRONIC PAIN IS COMPLEX! CHRONIC PAIN IS COMPLEX! Biopsychosocial Model PHYSICAL PAIN GENERATOR (ACUTE) PSYCHOSOCIAL (CHRONIC)

19. INJURIES HEAL DISEASES PERSIST!

20. CHRONIC PAIN IS A BRAIN DISEASE NEUROPLASTICITY

21. LOOK FOR THE CO-MORBIDITY! LOOK FOR THE CO-MORBIDITY! IT AIN’T THE NOCICEPTOR NO MORE! WORKERS’ COMPENSATION OR ? DIABETES MELLITUS MOOD-ANXIETY DISORDER ADDICTION OPIOID HYPERALGESIA

22. RISK FACTORS DOI DUTY DOB DOCTOR/ATTY DIAGNOSIS DEGENERATIVE DISEASE DIABETES DRUGS DEPENDENCY DEPRESSION D10

23. CHRONIC PAIN IS REAL! PSYCHOLOGICAL CONDITION Characterized by COLOSSAL MIS-MANAGEMENT! WRONG DIAGNOSES and WRONG TREATMENTS!

24. The Wounded Worker Syndrome THE PROVIDER’S ROLE Mis-Diagnose - Malingering (Fraud), Depression, Anxiety, Substance Abuse, True “Wounded Worker Syndrome” Over-Diagnose - MEDICALIZATION Over-Treat - Rehabilitation, Injections, Drugs, even Surgery Dis-Enable SAW/RTW - inappropriate restrictions and work excuses

25. What Doesn’t Work? MRI Discography IDET Repeated Blocks Pain Pumps Back Fusion Disc Replacement Many Drugs

26. WHAT DOES WORK? EARLY INTERVENTION DISABILITY MANAGEMENT and TREATMENT PLANNING OUTSIDE GUIDELINES or 60 DAYS PREAUTHORIZATION- “PEER TO PEER” NEGOTIATION EVIDENCE BASED- ODG FUNCTIONAL RESTORATION

27. DISABILITY MANAGEMENT DISABILITY MANAGEMENT ID “AT RISK” and CO-MANAGE MEDICAL/VOCATIONAL REHABILITATION

28. EARLY FUNCTIONAL RESTORATION Risk Assessment Early Intervention Cognitive Behavioral Therapy Exercise Adjunctive Care SAW-RTW

29. Why Disability Management? Because we can’t afford NOT to!!!” “Because we can’t afford NOT to!!!”

30. THAT’S IT FOLKS!!!! William Nemeth MD Somi Healthlink LLC A Pain & Disability Management Co nemethw@sbcglobal.net (512) 695-5599

31. DISABILITY MANAGEMENT STRATEGIES Education-SAW/RTW-Incentivize Treatment Planning - Benchmark “At Risk” IWS (Stop Medicalization) RTW Resource Centers Functional Restoration (CBT-Exercise) Policy-Activism

32. Lumbar Fusion Rates by Primary Diagnosis Degenerative Changes Spinal Stenosis Spondylolysis, Spondylolisthesis Herniated Disc

33. INJURED WORKER EMPLOYER Benefits access Job costs

35. The Texas 20/80 Rule 14% of Cases Create 75% of the Medical, and 85% of the Indemnity COSTS

36. Disability Management “Injury” OV1 TD MO1MO 2-33 MOS Guides - Benchmarks Lost Time > 3 Wks (or) High Risk NO YES At risk? TREATMENT PLANNING YES PREAUTHORIZATION CASE MANAGEMENT EARLY INTERVENTION

37. Relationship with the SAW Case Manager Injured Worker Treating Doctor Carrier Employer Case Manager

38. Disability Management Employers control work status SAW Case Manager facilitates SAW- RTW activities Providers practice hassle-free evidence-based medicine (EBM) Carriers encourage EBM Injured workers SAW-RTW

39. PREVENT DELAYED RECOVERY Recognize: “Injury” PAIN- SOFT TISSUE INJURY AGE- JOB- WORK STATUS DIABETES MELLITUS, OBESITY, SMOKING MOOD-ANXIETY DISORDER SUBSTANCE ABUSE (ADDICTION) MEDICATIONS- BENZOS, OPIOIDS, SOMA, PSYCHOTROPICS, MULTIPLE DRUGS