PAIN, PILLS, PROCEDURESPAIN, PILLS, PROCEDURESandand

THE WOUNDED WORKER THE WOUNDED WORKER SYNDROMESYNDROME

William Nemeth MD CPETexas Association of School Texas Association of School

Boards Risk Management FundBoards Risk Management FundSUMMER 2007

DISABILITY DISABILITY EPIDEMIC!!!!EPIDEMIC!!!!

Before After

INSANITY!INSANITY!

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

VoltaireVoltaire

UTILIZATION

UTILIZATIONUTILIZATION v. OUTCOMESv. OUTCOMES                             

                             

+

OUTCOME

4-6 WEEKS

--DEPENDENCEDEPENDENCE

Wounded Worker Wounded Worker SyndromeSyndrome

Chronic PainChronic Pain – “Suffering” - soft tissue injury Stay off WorkStay off Work Repetitive Treatment Failures Repetitive Treatment Failures multiple providersmultiple providers Victimization Victimization (External Locus of Control) Job DissatisfactionJob Dissatisfaction

HOW DID THEY HOW DID THEY GET THIS WAY?GET THIS WAY?

“MEDICINABLING” SystemENTITLEMENT Attitude“MEDICALIZING” Docs

SystemMEDICINABLES!MEDICINABLES!

INDEMNIFIES• Chronic Disease• Chronic Pain• Lost Time

PROVIDES• Socioeconomic Safety Net

System(Payers)

DISINCENTIVIZE!DISINCENTIVIZE!Pay for the wrong thingsPay for the wrong thingsNon-work-related diseases

Surgery, injections, and other non-EBM interventions

Do NOT pay for the right thingsDo NOT pay for the right thingsE&M Codes (Face Time-Education)

RTW and Case Management ServicesRisk Assessment-Early Intervention

Doctors

MEDICALIZE!MEDICALIZE!

• Mis-diagnose• Over-treat• Give work excuses

MISDIAGNOSIS!!!!!!MISDIAGNOSIS!!!!!!MISTREATMENT!!!!!MISTREATMENT!!!!!

• Denial- PsychosocialDenial- Psychosocial• IgnoranceIgnorance• Medical Economics- Medical Economics-

Profit MotiveProfit Motive• Can’t Say “NO!”Can’t Say “NO!”

Injured Workers

BECOME VICTIMS!!!BECOME VICTIMS!!!

• Entitled- Fear AvoidanceEntitled- Fear Avoidance• Psychological issuesPsychological issues• Expect “quick fix”Expect “quick fix”• External “Locus of External “Locus of

Control!”Control!”• Unfulfilling jobUnfulfilling job

Wounded Worker SyndromeWounded Worker Syndrome

• ““True” Wounded Worker True” Wounded Worker DisorderDisorder

Fear-Avoidance / Entitlement /Fear-Avoidance / Entitlement /

Age / Degenerative Disease(s)/ Age / Degenerative Disease(s)/

Workplace FactorsWorkplace Factors• Chronic Pain DisordersChronic Pain Disorders

PSYCHOLOGICALPSYCHOLOGICALBEHAVIORSBEHAVIORS

• “ “SOMATIZATION”SOMATIZATION”

• ABNORMAL ILLNESS ABNORMAL ILLNESS

BEHAVIORBEHAVIOR

• ““SYMPTOM MAGNIFICATION”SYMPTOM MAGNIFICATION”

• ““CATASTROPHIZING”CATASTROPHIZING”

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

WHAT WHAT CAUSESCAUSESTHE THE PAIN ??PAIN ????

CHRONIC PAIN IS COMPLEX!CHRONIC PAIN IS COMPLEX!

Biopsychosocial Model

PHYSICAL PAINGENERATOR(ACUTE)

PSYCHOSOCIAL(CHRONIC)

INJURIES HEALINJURIES HEAL

DISEASES PERSIST!DISEASES PERSIST!

CHRONIC PAIN IS A BRAIN CHRONIC PAIN IS A BRAIN DISEASEDISEASE

NEUROPLASTICITY

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

RISK FACTORSRISK FACTORS•DOI•DUTY•DOB•DOCTOR/ATTY•DIAGNOSIS•DEGENERATIVE DISEASE•DIABETES•DRUGS•DEPENDENCY•DEPRESSION

D10

CHRONIC PAIN IS REALCHRONIC PAIN IS REAL!!

PSYCHOLOGICAL CONDITIONPSYCHOLOGICAL CONDITIONCharacterized by Characterized by

COLOSSAL MIS-MANAGEMENT!COLOSSAL MIS-MANAGEMENT!

WRONG DIAGNOSESWRONG DIAGNOSESand WRONG TREATMENTS!and WRONG TREATMENTS!

The Wounded Worker SyndromeThe 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

What Doesn’t Work?What Doesn’t Work?

MRIMRIDiscographyDiscography

IDET IDET Repeated BlocksRepeated Blocks

Pain PumpsPain PumpsBack FusionBack Fusion

Disc ReplacementDisc ReplacementMany DrugsMany Drugs

WHAT DOES WORK?WHAT DOES WORK?EARLY INTERVENTIONEARLY INTERVENTION

DISABILITY MANAGEMENT DISABILITY MANAGEMENT and TREATMENT PLANNINGand TREATMENT PLANNING• OUTSIDE GUIDELINES or 60 DAYS

• PREAUTHORIZATION- “PEER TO PEER” NEGOTIATION

• EVIDENCE BASED- ODG

• FUNCTIONAL RESTORATION

DISABILITY MANAGEMENTDISABILITY MANAGEMENTID “AT RISK” and CO-MANAGE

MEDICAL/VOCATIONAL REHABILITATION

BENCHMARKSGUIDELINES

TREATMENTPLANNING

FUNCTIONALRESTORATION

DISABILITYMANAGEMENT

EARLY FUNCTIONAL EARLY FUNCTIONAL RESTORATIONRESTORATION

• Risk Assessment• Early Intervention• Cognitive Behavioral Therapy• Exercise• Adjunctive Care• SAW-RTW

Why Disability Why Disability Management?Management?

“Because we can’t afford Because we can’t afford

NOT to!!!”NOT to!!!”

THAT’S IT FOLKS!!!!THAT’S IT FOLKS!!!!

William Nemeth MD

Somi Healthlink LLC

A Pain & Disability Management Conemethw@sbcglobal.net

(512) 695-5599