Morphine anyone?

Morphine anyone? That’s the 64 thousand dollar question.

I don’t usually do this, but I’m going to post a very personal observation. During the last few years, CID Review has posted a number of articles about the use and abuse of narcotic medications. In fact, CID Review recently posted about some prescription guidelines that have been implemented in Ohio.

But, this post is personal…

Morphine anyone?

The other day, my wife was in a fender-bender on the freeway. She’s fine and the car is fine. She was actually in stop-and-go traffic, LA style. The car in front of her stopped and my wife stopped. Unfortunately, the lad behind my wife did not stop. He bumped her from behind and her car was forced forward, hitting the car in front. So, she had a duel collision; a twofer, if you will.

After the accident, she seemed to be shaken but all right. She checked her car, found it to be okay and pulled it to the side of the freeway.

She then got out of the car and was visibly shaken. The gentleman who hit her called 911 and paramedics responded.

Since my wife was a bit dizzy and said she had some shortness of breath and chest tightness, the paramedics elected to take her to the nearest emergency room (ER). Good call on their part. Better to be safe than sorry.

By the time I got to the ER my wife had settled down. However, since she stated she had some chest tightness, she was scheduled for a stress EKG on the following morning. Again, good call. As an aside, it was normal.

At any rate, while I was there, the ER nurse came in the room to check on my wife. The nurse asked her how she was feeling. My wife stated that she was feeling much better but her neck was a bit sore. Understandable.

The nurse asked my wife to put a number on the neck pain. She said to rate if from 0 to 10, with 10 being the worst. That’s a pretty common thing to do.

My wife indicated that her neck pain was about a 4. Not being able to “feel her pain” and not knowing how much pain she was really in, having the patient rate the pain makes a lot of sense. Puts a perspective on things. With that in mind, a 4 on anybody’s scale is considered tolerable.

The ER nurse later asked my wife if she would like some morphine for her neck pain. Nothing against the ER nurse, but I have a few problems with that question.

First, a 4 on a 10 scale does not warrant narcotic medication. Period!!! A 4 is a tolerable pain. And, tolerable pain does not warrant morphine. Period!!!

Second, when you have a patient who potentially (I said potentially) has a heart problem (remember the chest tightness?), giving a sedative like morphine doesn’t seem to make sense. At least not to me.

Third, it doesn’t seem to me that a clinician should ask a patient if they want morphine. If they really need it, fine. But asking the patient if they want it seems a bit curious, if not wrong.

So here’s the take-home message… with all of the concerns about the use and abuse of narcotic medications (opioids), it seems the medical establishment is far too casual with their readiness to use them. Some better training in the problems with morphine and morphine derivatives seems to be in order.

I have nothing against the ER staff. They did their job superbly. But, I do have a problem with the apparent casual regard for something as powerful, and potentially problematic, as morphine.

Just my thoughts…


Prescription guidelines

The state of Ohio has put together some prescription guidelines. The guidelines are an attempt to reign in the abuse of prescriptions, particularly opioids.

In January 2011, Ohio Governor John R. Kasich announced the Governor’s Cabinet Opiate Action Team (GCOAT). One of the products of the team was the formation of a Professional Education Workshop (PEW). The PEW was made of clinical professional associations, pain management clinicians, state licensing boards, state agencies, and other stake holders.

In the spring of 2012, the PEW announced opioid prescribing guidelines for hospital emergency departments. Opioid prescription guidelines for all those who prescribe were released in October 2013.

Prescription Guidelines

Prescribed pain medication doses are often calculated as a Morphine Equivalent Dose (MED). The odds of an overdose at 50-99 MED are three times higher than an MED lower than 50. In Ohio, the number who died from a drug overdose went from 327 in 1999 to 1,765 in 2011. Since opioids are the largest contributor to this problem, particular attention was paid to them.

The new guidelines recommend that 80 MED for more than three months for those patients with chronic, non-terminal pain should serve as a trigger. At that level, the prescriber is asked to reevaluate the effectiveness and safety of the pain management plan.

It’s worth pointing out that the guidelines are intended to supplement, not to replace, the prescriber’s clinical judgment.

The guidelines also suggest that prescribers optimize therapy and ensure patient safety by reestablishing informed consent, provide the patient with written information about the potential adverse effects of long-term opioid therapy, review the patient’s functional status, review the patient’s progress, use the Ohio Automated Rx Reporting System (OARRS), consider using a pain treatment agreement with patients, and consider a second opinion.

The PEW also developed a website to help prescribers learn more about the guidelines.

An interesting side note can be found in an article on the Los Angeles Times website. The article claims that the maker of OxyContin, Purdue Pharma, has a list of hundreds of doctors who are suspected of recklessly prescribing. The company suggests that the epidemic of prescription drug deaths has been fueled by pharmacy robberies, doctor-shopping patients and teens raiding home medicine cabinets.

If that’s the case, the guidelines aren’t likely to help much.


Obesity linked to back pain

Not surprisingly, obesity is linked to back pain. With the recent declaration of the American Medical Association (AMA) that obesity is a disease, CID Review wondered what impact this might have on the workers’ compensation system.

According to one article, the annual cost of back pain to the workers’ compensation system is $20-50 billion. Another article states that lumbar injuries result in 149 million lost work days per year. Roughly two thirds of these days are the result of occupational injuries. The annual productivity losses that result from these lost work days are estimated to be in the neighborhood of $28 billion.

Obesity linked to back pain…

Writing in WebMD, Brenda Goodman, MA, states, “A slew of chronic conditions that cause pain are also more common in people who are overweight and obese. Those conditions include arthritis, depression, fibromyalgia, type 2 diabetes, and back pain.”  In other words, obesity is linked to back pain.

Researchers from Stony Brook University in New York surveyed over 1 million people in the United States. The researchers found a clear association between obesity and pain.

In their survey, 38% of the respondents were classified as overweight, and 25% were obese. When compared to individuals with low or normal weight, the overweight group had 20% higher rates of pain. The heavier the individuals, the higher the pain ratings.

There should be no doubt that there is a link between obesity and back pain. Some state that there may be a number of explanations for this relationship. These include a physiologic process that results in inflammation and pain, depression, and reduced activity levels.

It has been stated that individuals covered by workers’ compensation have more office visits, hospital admissions, treating physicians, diagnostic referrals, therapeutic procedures, and longer duration of care than those with other forms of coverage.

However obesity is linked to back pain, adding the “disease” of obesity to this equation is not likely to be a helpful step.


The smartphone and neck pain

The use of the smartphone contributes to the development of neck pain. So says a study recently published in the Journal of Occupational Safety and Ergonomics.

The study stated that 53% of mobile phone (smartphone) users suffer from numbness or neck aches. The culprit is the forward head posture that is assumed during the use of the smartphone. The neck pain has been termed ‘text neck’.

A similar study in a population of university staff, faculty and students found that 84% of people have experienced some pain in at least one body part. The study made an association between the total time spent using a mobile device (e.g. smartphone) and the development of neck pain.

Some claim that the use of the smartphone is also involved in a somewhat new condition, “iGrind”. In this condition, children grind their teeth while they are using a tablet or a smartphone for an extended period of time.

Smartphone use…

It has been reported that the average person looks at a smartphone 110 times each day. This is referred to as a “checking habit”. It has also been stated that the smartphone is ‘habit-forming’, perhaps even addictive.

According to a 2012 survey by the Pew Research Center, 46% of all American adults now own a smartphone. That’s up 25% from 2011. And smartphone use can get very heavy. In a study of 1,600 managers and professionals, Leslie Perlow, PhD, the Konosuke Matsushita professor of leadership at the Harvard Business School, found that:

  • 70% said they check their smartphone within an hour of getting up,
  • 56% check their phone within an hour of going to sleep,
  • 48% check over the weekend, including on Friday and Saturday nights,
  • 51% check continuously during vacation, and
  • 44% said they would experience “a great deal of anxiety” if they lost their phone and couldn’t replace it for a week.

The smartphone not only impacts our physical well-being, it also takes a toll on our psyche. Whether smartphones really “hook” users into dependency remains unclear. But “we already know that the Internet and certain forms of computer use are addictive,” says David Greenfield, PhD, a West Hartford, Conn., psychologist and author of Virtual Addiction: Help for Netheads, Cyber Freaks, and Those Who Love Them.

The smartphone allows us to seek rewards (e.g. videos, Twitter feeds, news updates, and email) anytime and anywhere. But, their use is disruptive. Such a disruption could be small — like ignoring your friend over lunch to post a Facebook status about how much you’re enjoying lunch with your friend. Or it could be big — like tuning out colleagues in a meeting to check email.

Try these steps to control your usage of the smartphone:

  1. Be conscious of the situations and emotions that make you want to check your phone,
  2. Be strong when your phone beeps or rings. You don’t always have to answer it,
  3. Be disciplined about not using your device in certain situations or at certain hours.

Properly used, the smartphone provides an array of advantages that weren’t available a few years ago. Improperly used, the smartphone can lead to physical and mental problems.


California wins again

The State of California wins again! California leads the nation in questionable workers’ compensation claims.

According to a recent news release by the National Insurance Crime Bureau (NICB), California is the leader in the number of questionable workers’ compensation claims.

In 2011, 3,474 questionable claims were referred to NICB. In 2012, the number increased to 4,460. That’s’ a 28 percent rise! The most common reasons for referring claims to the NCIB were claimant fraud, prior non-work-related injury, and malingering.

California is number one…

Of the 3,474 claims that were referred to the NICB, California ranked first generating a total of 2,270 questionable workers’ compensation claims.

Questionable claims are those that are submitted (referred) to NICB for closer review and investigation. The referral is based on one or more indicators of possible fraud.

CID Review recently posted about questionable workers’ compensation claims. CID Review included a number of “red flags” for questionable claims. They include;

  1. The injury occurs early on Monday morning or late on Friday afternoon,
  2. The reported accident occurs immediately before or after some type of job change,
  3. An employee’s medical providers or legal consultants have a history of handling suspicious claims, or the same doctors and lawyers are used by groups of claimants,
  4. There are no witnesses to the accident,
  5. The description does not logically support the cause of the injury,
  6. The workers’ description of the accident conflicts with the medical history or injury report,
  7. The individual has a history of other suspicious of litigated claims,
  8. The worker refuses a diagnostic procedure,
  9. There are delays in reporting the claim with no reasonable explanation,
  10. The allegedly disabled claimant is hard to reach at home, and
  11. There is a history of frequently changing physicians, addresses or jobs.

Given that California is one of the more populous states, it makes sense that it would have more workers. More workers equate to more work-related injuries. More injuries, more claims. More claims, more questionable claims.