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Injury and Trauma

Fewer People Taking Prescription Narcotics —but Abuse Remains a Problem, Study Suggests

Last week pharmacy benefits manager Express Scripts released a study of 6.8 million Americans who had at least one prescription for an opioid filled between 2009 and 2013. The findings? One piece of good news and a lot of red flags related to a medication that was involved in 16,000 overdoses in 2012 alone.

  • Nearly 60 % of patients taking the painkillers to treat long-term conditions were also being prescribed muscle relaxants or anti-anxiety drugs that could cause dangerous reactions.
  • Nearly one-third of patients were prescribed an opioid and a muscle relaxant in the same month, and around the same percentage were prescribed a muscle relaxant and an opioid at the same time.
  • About 8% of patients were taking all three types of drugs — a combination known as a “Houston cocktail,” which gives a heroinlike high — during the same period.
  • 27% were taking more than one opioid at a time, another hazardous combination.
  • Of the patients taking the mixtures, two-thirds were being prescribed the drugs by two or more doctors
  • Nearly 40% filled their prescriptions at more than one pharmacy.
  • Overall use of opioids had fallen, especially for people using them to treat short-term ailments.

“Not only are more people using these medications chronically, they are using them at higher doses than we would necessarily expect,” said Dr. Glen Stettin, a senior vice president at Express Scripts. “And they are using them in combinations for which there isn’t a lot of clinical justification.” Read more…

 

Emergence of the Trauma Industry

This article from The New York Times focuses on a particular criminal ex-cop. But reference is made to many other defendants involved in this particular crime, of “feigning mental illness” and invoking the 9-11 attacks as a source of psychological scarring. These crimes did not take place in a vacuum. They occurred in a social context where the defendants, many sworn officers, believed they could get away with it, and likely saw themselves as damaged and entitled.

The experience of trauma and even the development of a diagnosis such as Post Traumatic Stress Disorder does not correlate with a person being damaged or disabled. Trauma is part of the human condition, and in most cases the victims adjust, move on, and support themselves and their families – at times with the help of some therapy. Men and women have gone to war, and returned to productive civilian lives. A bureaucracy of entitlement for compensation and pensions based upon ones experiences, rather than one’s actual impairment, did not exist.

Only in recent years have we observed an emergence of a trauma industry, where both individuals and clinicians all too frequently appear to correlate an unfortunate experience or experiences with damage. The ability to obtain compensation likely has driven this process and outcome.

Those who die in performing their jobs or who sustain serious injury warrant eternal respect and honor. What of those who ride on the coat-tails of dramatic news, and do their sometimes unpleasant and highly stressful jobs? Has the human condition and the nature of trauma and war changed fundamentally in the past couple decades to explain or justify the increased level of diagnoses and compensation for trauma-related experiences?

The article reflects some who were caught. In the culture of cynical entitlement that appears to be reflected in the article, what remains unrecognized? Does one really believe that this case and the Long Island Railroad abuses cover and resolve the core issues?

How a tattoo can help reconstruct a life

Would you travel around the world for a tattoo? More than 5,000 women have, to visit Little Vinnie’s in Finksburg, Maryland, where proprietor Vinnie Myers specializes in 3-dimensional nipple tattoos, an important final step in breast reconstruction after cancer surgery.

After a woman undergoes a mastectomy and breast reconstruction, the darker, sensitive skin of the nipple and areola is usually removed entirely. Surgical reconstruction is possible, but obtaining a tattoo allows women to forego further surgery and the resultant scar. Mr. Myers has been providing such tattoos since 2001, introducing a new specialization that has helped thousands of women worldwide. Read more…and watch the video.

Why Can’t Doctors Identify Killers?

by Brian L. Grant MD

As a forensic psychiatrist, I find myself as pained as the rest of society when a mass murder takes place. But like Dr. Friedman notes in this article,  I am also aware that efforts to accurately identify and intervene with, in advance of a tragedy, those individuals who are going to commit such acts is impossible. For every person who commits such acts, there are many more with similar personality and mental health issues who would find such acts unthinkable, just as there are those who kill and maim with no obvious mental health impairments. One can’t confine those with a psychiatric diagnosis without casting a net that would include millions of productive individuals who pose no harm. A kinder and gentler society that focuses on empathy and kindness might make a difference in some cases, but by no means all. The most attentive parenting and caring communities may still fall short when it comes to troubled individuals with distorted senses of reality.

In the absence of the ability to meaningfully predict and intervene before troubled individuals act out, whether they have a psychiatric diagnosis or not, we may wish to look to and study those places where violent deaths are far fewer and consider the differences in place. Are these differences those of demographics, politics, economics, values, or perhaps access to firearms? We make many tradeoffs as a society to achieve certain results and goals. Considering and studying these choices in an open and objective manner may be of great value to all.

Narcotic Subsys Draws Attention

Last week we blogged about controversy over Zohydro, an opioid approved last fall by the FDA. Another narcotic, Subsys, is generating attention, as is maker Insys Therapeutics. Subsys, a form of fentanyl which is sprayed under the tongue, is a narcotic used when painkillers such as morphine aren’t effective. Subsys was approved by the FDA in 2012 to treat a small number of cancer patients. In the past year, sales of Insys Therapeutics have soared and its share price has jumped nearly 270 percent. Over the last week, however, shares of Insys have lost roughly a third of their value after the arrest on federal fraud charges of a Michigan neurologist who was a top prescriber of Subsys.

Concern over Subsys are centered around aggressive marketing practices and off-label uses (uses the drug was not originally intended for), as the drug was approved to relieve cancer patients but fewer than 1% of prescribers are oncologists. Read more…

Serious Concerns with New Prescription Pain Killer

The prescription pain-killer Zohydro (pure hydrocodone in an extended-release formulation) was approved last fall by the FDA against the advice of its own advisory panel. Given the number of people in the U.S. who live with chronic pain (estimated to be around 100 million, though the figure is disputed), and that about half the drug overdose deaths in the U.S. are from prescription painkillers, Zohydro’s launch has drawn its share of attention.

In March, Gov. Deval Patrick of Massachusetts sought to ban Zohydro outright, calling it “a potentially lethal narcotic painkiller,” and 29 state Attorneys General have asked the FDA to reconsider approval. A number of patients had to leave the clinical study because they had serious adverse side effects or didn’t comply with the terms of the trial. Fewer than 300 subjects made it through a full year in the long-term safety trial, and there were five deaths.

Members of the F.D.A. committee who voted against approval acknowledged they were influenced by the drug overdoses claiming more and more lives each year. But they were also disturbed by red flags raised during the clinical trials of Zohydro.

“You still have a 1 percent, almost, death rate from this drug,” said Dr. Jeanmarie Perrone, a committee member from the University of Pennsylvania. What will happen in the doctor’s office, she wondered, where those receiving the drug will not be as carefully screened?

Tracking Patient Data to Reduce Emergency Room Visit Frequency – and Cost

As the Affordable Care Act expands Medicaid to a greater number of patients, the need for states to keep emergency room costs in check will become more pressing.

In a trial program in Washington State, ERs are now required to upload information on patients they’ve treated into a new database.  This allows other ER doctors and providers to research incoming patients, making a big impact on cost savings, with doctors now able to track patients whose situations would be better served by far less expensive office visits.

Patients with multiple visits (those who went to the ER more than four times a year) — suggesting they are using the ER in lieu of visiting primary case visits — made up a fifth of all ER visits paid for by Medicaid.

Data released on March 20 shows that ER visits by Medicaid patients fell 10 percent in the 2013 fiscal year, and the rate of ER visits that resulted in a non-acute diagnosis decreased by more than 14 percent. Database use is credited for a substantial amount of the state’s $33.7 million reduction in 2013 Medicaid costs. Read more…

 

A Clinical Story Worth Sharing

Most IMEs answer straight-forward questions on known issues. But there are those rare but important moments where we are reminded that things are not always as they seem, and that an examination can have extraordinary and unexpected value and impact on peoples’ lives. Allow me to share such a story.

Recently MCN conducted an IME on a 46-year-old woman who had back pain complaints in a workers’ compensation claim. The physicians who evaluated her found her to not be fixed and stable, and elected to order an MRI of the spine. It should be noted that the doctors felt that the findings they observed did not wholly fit with the injury claim but that they were significant. Typically an MRI would not be ordered for a low back pain complaint.

Five days after the evaluation she underwent the study. That same day MCN received a call from the radiologist who reviewed the film, calling our attention to unexpected findings of a mixed signal intensity mass involving the lower pole of the right kidney, approximately 4.5 by 4.4 centimeter. He noted that this may represent a renal cyst, but that a renal cell neoplasm could not be ruled out.

We informed the examining doctors who saw the claimant about these findings as well as the claims manager. As Medical Director, my priority at MCN changed in part from processing a report for her claim to doing right clinically by the claimant and ensuring that she was aware of these findings. I called her and told her that we had found something unexpected and explained to her the importance of prompt follow-up, and forwarded her the radiology report along with this email:

It was nice speaking to you this evening. As I mentioned, I am the Medical Director of MCN where you were seen for an IME on November 9, 2013 for your workplace injury. The report is in draft form at this point in time and when completed, will be sent to the department. I do note that the doctors who evaluated you did not regard you as fixed and stable and that you warrant either further treatment or evaluation.

As part of your evaluation, you underwent an MRI on November 14, 2013. The report is attached to this email.

As you can see, the radiologist reading this study noted an unusual mass that caused them to call our office, and it thus came to my attention. We will be letting the examining doctors know about this as well.

While I do not wish to alarm you, it is most important that you seek evaluation for this finding. It is possible that some of the symptoms you experience may be related to this rather than the injury. Regardless, it should be assessed to determine if it is of significance and warrants treatment.

I would recommend that you present these findings to your personal physician and work with them to investigate and follow up as appropriate.

I would appreciate any follow-up that you wish to offer and hope that the findings turn out to be insignificant and that you recover nicely from your injury.

Please let me know if you have any questions or if we can be of further assistance.

Thank you for your attention.

Brian L. Grant, MD

One week later I was surprised and touched by the following text:

Hi, this is (name withheld). I found out yesterday at the mass on my kidney is cancer. Will know more on Monday. Seeing oncologists and urologist. Thank you and please please please thank the two wonderful doctors that ordered the MRI and for taking my complaints seriously. Bless you all.

Several weeks later she underwent a partial nephrectomy at a large University medical center in the region. The subsequent weeks were rocky emotionally for her but in the end she was relieved to learn that she had a clear cell renal carcinoma and that the surgery was able to completely remove the tumor with all margins clear for carcinoma.

And by the way, her claim was also processed with an impairment rating relative to the back findings, and a settlement from the carrier.

My point in sharing this is that the work we do has impact, sometimes in ways we would never anticipate. In this case we identified a tumor causing back symptoms and took the necessary steps to help this patient get the right care in a timeframe that perhaps contributed to a great outcome. I am proud of all involved in this case and we all wish the claimant the best outcome.

Brian L. Grant, MD

A Preview of “Life, Animated” by Ron Suskind

This Sunday’s New York Times Magazine published an except of Life, Animated: A Story of Sidekicks, Heroes, and Autism, by Ron Suskind, a Pulitzer-Prize winning journalist with the Wall Street Journal. And father of Owen, who at age 3 was diagnosed with regressive autism.

The excerpt is beautifully written and moving, and provides a candid, eloquent glimpse into the twenty-year struggle of one family to communicate — through Disney characters, movies, and their themes — with their son. Well worth the read, as are the on-line comments.

Chronic Pain: Back in Control

Brian L. Grant, MD
My friend and colleague David Hanscom MD recently appeared on Dr. Oz discussing his experience and research on chronic pain, and the tragedy of operating on basically normal backs, on people in pain. He has published a book that anyone considering back surgery might consider reading first.

Sadly, common sense and good care as represented by Dr. Hanscom does not pay. No expensive back implants are sold, no surgical fees generated and no hospital stays take place. And for those who were not truly injured but underwent the knife for symptoms and not true pathology, they decidedly have an injury afterwards. This is tragic.