EK HEALTH

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

UR doctors are repeatedly asked to determine medical necessity about treatment requests for combinations of opioids, benzodiazepines, sleepers, etc., many years after an injury. The worse combinations, and highly suspect for unrestrained drug abuse and addiction, is a combination of 2 different opioids (usually brand names), an anti-anxiety drug, a muscle relaxant, and sleepers to initiate sleep and sleepers to maintain sleep. So when you see a request for Opana® ER, Oxycontin®, Xanax®, Soma®, Ambien® and Lunesta® – look out! We see it all the time, and it always presents a challenge.

It is difficult for a reviewer to “approve” such requests without becoming both an enabler and part of the prescription drug problem. Additionally, many reviewers do not want their name associated with probable chronic drug problems/addiction and prescription drug abuse. Yet, appropriate care must be maintained for injured workers. The problem is sorting out how much the medications are used for “pain” and how much they are used for maintenance long after the original pain is gone. Unfortunately, many of these same patients taking all of these medications have also had multiple surgeries, all to no avail, and perhaps even worsening the problem.

There are a few things a reviewing physician must know before making a determination to approve multiple pain medications, but unfortunately they rarely have access to this clinical information from the requesting doctor. Documentation of baseline and ongoing information and continuous updates are recommended by both the California Medical Treatment Utilization Schedule (MTUS) and the California Intractable Pain Act.

The following is suggested information that physician reviewers must have regarding a chronic pain patient needing ongoing powerful, addicting, and possibly lethal medications:

•    Specific diagnoses – both industrial and non-industrial

•    Specific treatment goals

•    Specific function levels – Is the patient improving? Is the patient working?

•    All current medications – both industrial and non-industrial, including dose and frequency

•    All treating/prescribing physicians (who is the PTP?)

•    Frequency of visits – last visit, next visit

•    Date and results of last CURES report

•    Date and result of last urine drug screen (UDS)

•    Pain contract - Does it address the presence of illegal drugs, the presence of legal drugs not being prescribed, the lack of presence of drugs being prescribed, the presence of marijuana?

•    Has there ever been an addiction assessment? i.e. Opioid Risk Tool (ORT), Screener Opioid Assessment for Patients with Pain (SOAPP).

The above criteria does not need to be documented at every visit, but it all must be documented somewhere in the medical records. In a perfect world the treating doctor would provide this information. However, this is seldom the case when reviewing difficult medication requests. At EK Health, we ask our reviewers to carefully press the requesting doctor for such information. We think everyone wins when such information is available to all concerned.

SUMMARY: NO documentation – NO approvals – NO exceptions.