EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

Acute and chronic pain is extremely common in injured workers, and makes pain medications a huge cost factor in the California Workers’ Compensation system. As cost, morbidity and mortality rates from prescription drugs, particularly controlled substances, spiral out of control, it is important to understand the medical and legal burden placed on physicians.

More than half of EK Utilization Review is centered on medication requests. Pain medications are reviewed based on California’s Medical Treatment Utilization Schedule (MTUS), which are based on the Official Disability Guidelines (ODG) Chronic Pain Chapter guidelines. However, I believe that the California Intractable Pain Treatment Act is a secondary consideration because of the specific requirements it places on the treating physician.

The California Intractable Pain Treatment Act was revised in 2007 in an attempt to balance the overtreatment and undertreatment of pain and to also permit the prescribing of controlled substances to known addicts. In general, the Act favors physicians prescribing controlled substances to patients complaining of pain and does not strongly require documentation of functional improvement and objective measurements of pain and improvement.

General principles of the California Intractable Pain Treatment Act:

Prescription Regulations: Physicians shall not be subject to disciplinary action for prescribing, dispensing, or administering dangerous drugs or prescription controlled substances for the relief of pain.

Treatment: Coordinating care when prescribing chronic pain medications is of paramount importance.
Comment: We have found this to be a very common problem for our Next Step patients!

Pain Contract: A written consent or pain agreement for chronic use is not required but may make it easier for the physician and surgeon to document patient education and the treatment plan.

Prescribing Medications: Physicians are permitted to prescribe, dispense, or administer prescription drugs, including prescription controlled substances, to an addict under his or her treatment for a purpose other than maintenance on, or detoxification from, prescription drugs or controlled substances.
Comment: This aspect of the Act has made it very difficult to control the use of prescription drugs in addicts.

Initial Evaluation: A medical history and physical examination must be accomplished and include:

a.    Assessment of pain, physical and psychological functions
b.    Substance abuse history
c.    Prior pain treatment history
d.    Underlying or coexisting diseases or conditions
e.    Documentation of the presence of a recognized medical indication for the use of a controlled substance

Treatment Goals and Objectives: In the treatment plan, physicians should

a.    State objectives by which the treatment plan can be evaluated
b.    Make note of pain relief and/or improved physical and psychosocial function
c.    Indicate if any further diagnostic evaluations or other treatments are planned.
d.    Use control of pain, increase in function, and improved quality of life as evaluation criteria for treatment plans.

Periodic Review:
1)    Physicians should periodically review the course of pain treatment of the patient and any new information about the etiology of the pain or the patient's state of health
2)    Continuation or modification of controlled substances for pain management therapy depends on the physician's evaluation of progress toward treatment objectives
3)    If the patient's progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan
4)    Documentation of the periodic reviews should be done at least annually or more frequently as warranted
5)    Physicians should keep accurate and complete patient records, including
           a.   Medical history and physical examination
           b.   Other evaluations and consultations
           c.   Treatment plan objectives, informed consent, treatments, and medications
           d.   Rationales for changes in the treatment plan or medications
           e.   Agreements with the patient
           f.    Periodic reviews of the treatment plan

Functional Improvement:
   a. Notes about pain levels, levels of function, and quality of life
   b. Subjective complaints of patient and caregiver
   c. Objective findings by the physician

Discontinuing Medications: When the patient is requesting opioid medications for their pain and inconsistencies are identified, physicians who make clinical decisions to withhold opioid medications should document the basis for their decision.

Possible Medication Abuse: Physicians should give special attention to those pain patients who are at risk for misusing their medications, including those whose living arrangements pose a risk for medication misuse or diversion.

These principles impact utilization review decisions, and Workers’ Compensation as a whole, particularly when physician reviewers need to respond to requests for controlled substances that include excessive prescribed dosages and duration of usage. Physician reviewers are required to make a decision based on both the MTUS Chronic Pain Guidelines and the California Intractable Pain Treatment Act, unfortunately neither document gives them the scientific or legal basis to deny the egregious use of prescription medications.

You can review the California Intractable Pain Treatment Act at:
http://www.medbd.ca.gov/pain_guidelines.html