Download Prescription Narcotics: An Obstacle to Maximum Medical

March/April
2011
In this Issue
Prescription Narcotics:
An Obstacle to Maximum
Medical Improvement
Editors’ Commentary: Pain evaluation, management, and impairment assessment
are all controversial topics. The overuse of narcotic (opioid) therapy is epidemic and
while it is agreed that routine use of narcotics is not recommended, there are different perspectives on whether they have a role for very select patients. This article
provides excellent insights to the controversies and the problems associated with the
use of narcotics, and articulates why it is medically probable that a patient taking
narcotic prescriptions is not at maximal medical improvement.
Adjacent Segment Disease:
What Is It, and How Is It Rated
Case Example - Rating Lower
Extremity Injuries Involving
Multiple Diagnoses in One
Region: AMA Guides, Sixth
Prescription Narcotics: An Obstacle to
Maximum Medical Improvement
Robert J. Barth, PhD
Upcoming issues
International Use of the
AMA Guides
Impairment Assessment and
Activities of Daily Living
Report Standards and the
Sixth Edition
Impact of Litigation
Rating Heart Transplants
Maximum Medial Improvement
Can Acromioplasty Result
in Impairment?
The AMA Guides™ Newsletter
provides updates, authoritative guidance, and AMA
interpretations and rationales
for the use of the AMA Guides
to the Evaluation of Permanent
Impairment
Background
There is an increasingly severe epidemic of overuse, abuse, and death involving
prescription narcotics.1,2 Recent publications have emphasized that this epidemic
is of specific relevance to workers’ compensation, the primary venue for utilization
of the Guides to the Evaluation of Permanent Impairment.1 Impairment evaluators
must be prepared to thoroughly consider the ramifications of this epidemic on the
evaluation process.
This discussion addresses several of those ramifications, primarily involving the issue of
permanent impairment. Given the scientific knowledge base regarding prescription narcotics for chronic benign pain, it is difficult to imagine how any patient could credibly
be considered to have reached maximum medical improvement (MMI) if that patient
has a narcotic prescription in place. This predicament creates an obstacle to credibly
concluding that a presentation of impairment is permanent and, consequently, is also
an impediment to completing an impairment evaluation.
During the creation of this article, members of the Guides Newsletter Editorial Advisory
Board expressed concerns that the obstacles to MMI created by prescription narcotics
will delay the resolution of claims (which could be harmful to the patient, as well as
to other stakeholders). There is also concern that evaluators will confuse the effects of
narcotics with permanent impairment and will consequently create erroneous impairment ratings. These concerns are examples of the issues that are addressed in the
following discussion.
Reasons To Be Concerned that Narcotic Medications Generally
Cause More Harm Than Good
When an evaluator is asked to conduct an impairment evaluation of a patient who has
a narcotic prescription in place, that patient will usually be presenting with complaints
of chronic benign pain. This premise is based on several issues, including: the tendency
© 2011 American Medical Association.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
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AMA Guides Newsletter
Advisory Board
Editor
Christopher R. Brigham, MD
Kailua, Hawaii
Associate Editors
James B. Talmage, MD
Cookeville, Tennessee
for impairment evaluations to be requested when the associated claim has been
going on for quite some time (in other words, it has become chronic) and someone
(such as the referral source) has given up hope of further recovery; if the patient
has a narcotic prescription in place, it is usually because of chronic pain complaints; and chronic pain presentations within workers’ compensation (or other
systems that utilize the Guides) are usually not of a malignant nature (eg, cancer)
or of a nature for which recurrence is expected (eg, sickle cell anemia). Therefore,
this discussion focuses on chronic benign pain.
Scientific Findings Indicate That Narcotics Can Cause Pain To Worsen
Craig Uejo, MD, MPH
San Diego, California
Editorial Board
Gunnar B.J. Andersson, MD
Chicago, Illinois
Marjorie Eskay-Auerbach, MD, JD
Tucson, Arizona
Robert J. Barth, PhD
Chattanooga, Tennessee
Charles N. Brooks, MD
Bellevue, Washington
Lorne K. Direnfeld MD, FRCP(C)
Kahului, Hawaii
Leon H. Ensalada, MD, MPH
Reedville, Virginia
Mark Hyman, MD
Los Angeles, California
Steven Leclair, PhD, CRC
Gray, Maine
Mark Melhorn, MD
Wichita, Kansas
Kathryn Mueller, MD, MPH
Denver, Colorado
Glenn B. Pfeffer, MD
Los Angeles, California
Mohammed I. Ranavaya, MD, JD
Huntington, West Virginia
W. Frederick Uehlein, JD
Framingham, Massachusetts
Scientific findings have indicated that narcotics reliably cause an abnormally
severe sensitivity to pain, termed hyperalgesia. For example, in what was claimed
to be the only prospective study of the effect of narcotic medications on pain sensitivity among chronic low back pain patients, all of the participants demonstrated
increased vulnerability to pain after just one month of utilizing prescription narcotics.3 The participants’ pain thresholds reportedly dropped by an average of 16%,
and their pain tolerance reportedly dropped by an average of 24%.
In subsequent literature, the same researchers warned that the hyperalgesic effects
of narcotic medications might be manifested in ways that include some of the
common perplexing complaints from chronic pain patients, including unexplained
pain reports (which is the essential nature of chronic benign pain), pain complaints that are discrepant from previous complaints, diffuse pain complaints, and
allodynia.4 In a separately published “qualitative systematic” review, members of
the same research team warned of the obvious risk that the hyperalgesic effects of
narcotics will cause a worsening of the specific pain for which the narcotics were
originally prescribed as a treatment.5
This harmful effect of prescription narcotics does not appear to be permanent. For
example, a more recent review has emphasized findings that indicate that pain
presentations demonstrate improvement subsequent to the discontinuation of narcotics.6 The benefit that comes from eliminating narcotic prescriptions appears
to be very reliable. For example, in one sample, 21 of 23 chronic pain patients
reported a significant decrease in pain after they were detoxed from narcotics.7
Such scientific findings indicate that prescription narcotics actually contribute to
chronic benign pain in a harmful manner (a premise that is also supported by much
of the literature that is discussed below) and that the elimination of prescription
narcotics is beneficial for such pain. For the impairment evaluator, this creates an
obstacle to concluding that any patient who has a narcotic prescription in place
has reached MMI. The medication can actually be creating an artificially severe
presentation of pain. The elimination of the medication can lead to an improvement in the pain. Therefore, until the patient’s use of narcotics is eliminated, the
permanence (or lack thereof) of the pain cannot be known, and the patient cannot
credibly be said to have reached MMI. This will be an issue of primary importance
if the evaluation is utilizing a protocol from the Pain chapters of the various editions of the Guides. Additionally, given the Guides current inclusion of subjective
claims of functional impairment in the evaluation protocols, such worsening of
pain caused by narcotic prescriptions could easily contaminate any Guides evaluation process.
Narcotics Expand the Nature of the Patient’s Impairment Beyond Pain.
An additional concern is created by scientific findings that indicate that prescription narcotics cause other significant problems beyond the worsening of the pain.
As is the case with the findings in regard to pain, these findings of other effects
indicate that the patient’s general presentation of impairment could be temporarily
2
AMA Guides Newsletter, March/April 2011
Prescription Narcotics (continued)
worsened by prescription narcotics. Such issues may or may
not be of direct relevance to the diagnosis that is the primary
focus of any specific impairment evaluation. But given the
Guides current inclusion of subjective claims of functional
impairment, such general impairment that is being caused by
narcotic prescriptions could easily contaminate the evaluation process. Therefore, the examiner has additional reason
to conclude that a patient who has such a prescription in
place has not reached MMI.
Endocrine Disruption
One of the most prominently raised concerns in this regard
involves endocrine disruption.
Hypogonadism (central suppression of hypothalamic secretion of gonadotropin-releasing hormone8) is one of the most
well-documented examples of such endocrine disruption. A
review of relevant scientific findings specified that symptoms
of narcotic-induced hypogonadism include loss of libido,
infertility, fatigue, depression, anxiety, loss of muscle strength
and mass, osteoporosis, compression fractures, erectile dysfunction in men, and menstrual irregularities and lactation
irregularities in women.8
This effect has been found to be very reliable among patients
with narcotic prescriptions9,10 in that a large majority of
such patients demonstrated the narcotic-induced hypogonadic effects. For example, 87% of men who reported normal
sexual function prior to their narcotic prescriptions reported
that they developed severe erectile dysfunction or diminished
libido after the initiation of such prescriptions.9
Additional scientific findings have indicated that the adverse
effects of narcotics are also manifested in adrenal insufficiency, growth hormone deficiency, and other forms of
hormonal irregularities.11
Several scientific reports have indicated that the adverse
effects on the endocrine system begin within hours of the initial intake of narcotics.9,12
Fortunately, the effects appear to be reversible through the
elimination of the consumption of narcotics.12
Sleep Abnormalities
An abundance of scientific literature expresses concern about
narcotics being a cause of sleep apnea and other forms of
sleep disturbance.13,14 For example, such reports indicate a
30% rate of central sleep apnea developing after the initiation of a narcotic prescription.13
Fortunately, there are also indications that these adverse
effects of narcotics on sleep-related issues are reversible with
cessation of the narcotic use (thereby providing additional
hope that an patient with a narcotic prescription in place has
a decrease in impairment to look forward to if the narcotic
consumption is discontinued).15
Immune System Compromise
Another harmful effect of narcotics, specifically compromise
of the immune system, has reportedly been recognized scientifically for 100 years and has reportedly been demonstrated
for most forms of narcotic medication.16,17
Cognitive Impairment
Research has also indicated that narcotics are a risk factor
for cognitive impairment, even when the narcotic consumer
does not perceive him- or herself to be sedated. 18,19
Substance Abuse
Readers might note that this discussion has not emphasized an issue that is usually mentioned early in discussions
of prescription narcotics: substance abuse. This issue was not
mentioned yet because several of the adverse effects reported
above actually appear to be more pervasive. But substance
abuse is indeed yet another area in which prescription narcotics appear to be playing a harmful role. For example, one
review reported that substance abuse is common among
patients with such prescriptions, with findings of the association between such prescriptions and substance abuse running
as high as 56%.20
Generalized Ill Health and Disability
The negative effects of prescription narcotics appear to
extend even beyond pain, endocrine problems, sleep abnormalities, immune deficiency, cognitive impairment, and
substance abuse. For example, in a large-scale study involving
almost 2000 participants reporting pain, those who were
utilizing narcotic medications were indeed more likely to
have a current experience of severe pain and were also more
likely to perceive their health as being poor in general, to
be unemployed, to be utilizing the health care system more
extensively, and to report a worse quality of life in all areas.21
Similarly, other research projects have repeatedly produced
results indicating that the prescription of narcotics leads to
dramatically higher rates of disability.22-24
Narcotics Generally Lack Credibility as a Treatment
For Chronic Benign Pain
An evaluator might wonder about a possibility that the
adverse effects described above could be considered a
burden of treatment compliance for any patient for whom
a narcotic prescription is necessary and justified. But such
wondering can be quickly put to rest by a review of the scientific literature, which creates significant generic obstacles
to claiming that narcotics could be necessary or justifiable in
any individual case of chronic benign pain. The professional
literature provides a wealth of discussions of the lack of justification for narcotics as a treatment for chronic benign pain
(examples provided below). This lack of justification takes
several forms.
AMA Guides Newsletter, March/April 2011
3
Prescription Narcotics (continued)
Lack Of Reliably Demonstrated Benefit for Chronic
Benign Pain
One example of the lack of support for narcotics as a treatment for chronic pain is the published reports regarding the
lack of treatment success. For example, one systematic review
utilized meta-analysis of the most well-designed studies in
order to analyze the effects of narcotics for chronic back pain
and found that narcotics did not demonstrate an advantage
in the reduction of pain compared to placebo or non-narcotic
medication.20 That project also involved a review of the most
well-designed studies that provided data on reduction of pain
following a narcotic prescription compared to baseline and
again found that there was not a significant reduction in pain
associated with narcotic use.20
A similar project discovered that, even among the most
well-designed studies, some published claims of a statistically
significant advantage for narcotics had been misrepresented.
Those reviewers also noted that they could not find any welldesigned studies that demonstrated a clinically significant
benefit from narcotics compared to placebo or other forms of
treatment. The reviewers concluded that the available science as a whole failed to provide support for narcotics as a
treatment for chronic back pain.25
Both of the above reviews commented on the incredibly
small number of relevant high-quality studies, the total lack
of long-term studies, and the lack of evidence that narcotics
provide a benefit for quality of life or ability to function for
chronic benign pain patients.
Another review process involved consideration of lowquality research (due to the lack of high-quality research).26
Even though such low-quality research is prone to producing
artificially positive results, the reviewers concluded that even
the findings from the low-quality research did not allow for
any firm conclusions that narcotics were effective for chronic
benign pain in terms of pain relief, improvement of function,
or improvement in quality of life.
Another methodology for reviewing the relevant literature
involved an analysis of several recent clinical guidelines and
the studies on which those guidelines were based.27 The conclusions from that process, in regard to chronic benign pain,
included: research findings have failed to provide a credible basis for concluding that narcotics have a greater benefit
than non-narcotic medications; the evidence indicates that
it is doubtful that the benefit from narcotics will be clinically
meaningful for patients; and even the patients who are most
responsive to narcotics do not report noticeable pain relief.
Such reviews can be taken into consideration with the
large-scale study referenced above,13 which prompted the
researchers to comment on the remarkable nature of the
findings that narcotics do not seem to have even a superficial beneficial effect on any of the key goals of treatment
for chronic benign pain—pain reduction, improvement of
quality of life, or improvement of function.21
4
AMA Guides Newsletter, March/April 2011
The epidemic of prescription narcotics has itself provided a
basis for a quasi-experiment that similarly indicates that narcotics are not a credible treatment for chronic benign pain.
Specifically, a review of the statistics of the prescription narcotic epidemic, combined with a review of clinical outcomes
that are associated in time with that epidemic, concluded
that there has been a 423% increase in expenditures for opioids for back pain but that that dramatic increase has not led
to any population-level improvements in clinical outcomes
or disability rates.28
Because of such findings, treatment guidelines that have been
adopted by numerous workers’ compensation systems warn of
the lack of justification for the routine use of narcotics for the
treatment of chronic benign pain. 1,29 Such guidelines actually have a history of warning that narcotic medications are
the most important impediment to recovery from chronic
pain.30 Similarly, guidelines that were created for purposes
beyond workers’ compensation have a tradition of warning,
even before many of the findings listed in this paper emerged,
that the extended use of narcotics for chronic pain may
worsen the patient’s problems.31
Most Patients Not Compliant with Such Prescriptions
Another example of the lack of justification for the prescription of narcotics for chronic benign pain is the astounding
rate of noncompliance. Two incredibly large-scale research
projects (involving millions of cases) have been published
on this subject.32,33 Both studies revealed noncompliance
rates that exceeded 70% for chronic benign pain patients
who received narcotic prescriptions. The nature of the noncompliance took several forms, including indications that
the patient was not personally consuming the medications (thereby raising concerns that the medications were
being illegally sold or otherwise distributed for recreational
purposes) and indications that the prescription narcotics
were part of a pattern of substance abuse that included
illegal drugs.
Given such strong and reliable evidence that there is a high
probability that any individual chronic benign pain patient
is going to be noncompliant with his or her prescription for
narcotics, it is difficult to imagine how such prescriptions can
be justified (especially given all the other issues that are discussed herein).
The Nature of the Pain and Associated General
Medical Findings Are Not Reliable Determinants of
Such Prescriptions
The scientific findings in regard to predictors of narcotic prescriptions for chronic benign pain are another example of the
lack of justification for such prescriptions.
For example, research results have repeatedly indicated that
the claimed severity of a presentation of chronic pain and
the claimed duration of chronic pain are not predictive of
whether patients will receive prescriptions for narcotics.34-36
Research findings have similarly indicated that general medical findings (eg, physical pathology) are not predictive of
who will obtain a narcotics prescription.36
Factors which actually predict whether a patient will receive
a narcotic prescription include less education,37 lower
income,37 mental illness (specifically including depressive
mental illness, personality disorders, and substance use disorders),28,34,38 smoking,39,40 obesity,39 ethnicity (eg, non-Hispanic
whites are more likely than Hispanics to receive a prescription40, blacks are less likely to receive a prescription than
other ethnicities41), and demonstration of pain behaviors.36
These predictors of who will be given a narcotic prescription include many issues that are actually recognized as
contraindications for such prescriptions.28,42 Therefore, narcotics prescriptions are demonstrating a pervasive pattern of
“adverse selection”—being selectively provided to patients
who are actually at the highest risk for failing to benefit from
the prescriptions and who are at highest risk for adverse
effects from such prescriptions.28,42
This set of circumstances creates another credibility problem
for narcotics as a treatment for chronic benign pain. The
prescriptions appear to be prompted by factors other than
general medical findings or the reported nature of the pain.
In other words, the true motivation for the prescriptions is
misdirected.
The Strong Association Between Prescription
Narcotics and Death
Although not technically relevant to impairment evaluation
(because a person must be alive in order to participate in the
evaluation), this issue should be a tremendous concern to all
in the health care field.
Prescription narcotics have become a leading cause of death
in the United States. For example, scientific findings indicate that prescription narcotics are the leading cause of
death among workers’ compensation claimants who have
undergone back fusions.43 This scientific discovery warrants
emphasis. It indicates that prescription narcotics (in conjunction with workers’ compensation and back fusions) are
actually turning a non–life-threatening issue (back pain) into
the number one cause of death. Equally noteworthy are the
reports that poisoning deaths, primarily involving prescription medications (prominently including narcotics, which
exceed the deaths caused by heroin and cocaine combined44),
have actually overtaken motor vehicle accidents as the top
cause of death among middle-aged Americans.45
The extremely strong association between prescription narcotics and death has been evident for many years,2 and recent
reports have indicated that the rate of death from these medications is continuing to increase.46 In fact, these medications
are the only substantial cause of death that is continuing to
rise in the United States.46
The Actual Nature of the Presentation of Chronic
Benign Pain is Being Ignored
Scientific findings have repeatedly and reliably indicated
that the primary risk factors for chronic benign pain are of a
psychological nature or a social nature.47-52 Given such indications that chronic benign pain is a psychological and social
phenomenon, it is difficult to imagine any justification for
narcotics as a treatment option.
Some of the most robustly established risk factors can be
used as examples of this problem. For example, in the only
relevant prospective research ever conducted, the only participants who developed persistent benign pain complaints
were those who were eligible for compensation.50 Hopefully,
it is obvious that there is no justification for narcotics as a
“treatment” response to compensation eligibility. As another
example, preexisting personality disorders appear to be the
most prominent health care finding among chronic pain
patients,49,52 including a greater than 70% rate of such preexisting disorders among workers’ compensation claimants with
chronic disabling back pain complaints.49 Hopefully, it is also
obvious that there is no justification for narcotics as a treatment for personality disorders.
The Evaluator’s Response
Address the Obstacles to Concluding That MMI
Has Been Reached
Given the issues that have been discussed above, there
are clear obstacles to credibly concluding that a patient
who has a narcotic prescription in place has reached MMI.
Consequently, the impairment evaluator will have difficulty credibly claiming that the patient’s presentation of
impairment is permanent and that the patient is eligible for
impairment evaluation.
The evaluator can respond to this predicament by explaining
the obstacles to concluding that the patient is eligible for
impairment evaluation (as have been reviewed above) and
by recommending that the patient pursue detoxification from
the narcotics (under appropriate clinical supervision). Given
the inherent indication from any prescription of narcotics
for chronic benign pain that the treatment plan has probably
been misdirected, the examiner can also recommend that the
patient seek a scientifically credible response to his or her
complaints. The examiner can offer to resume the impairment evaluation after such recommendations have been
acted on.
This response option causes concern that resolution of the
patient’s legal claim will be delayed. Given the scientific findings that have indicated that involvement in medical-legal
claims is reliably detrimental to the health and well-being
of claimants,53-55 such a delay could actually be harmful to
AMA Guides Newsletter, March/April 2011
5
Prescription Narcotics (continued)
the patient (as well as being harmful to other stakeholders
who could potentially benefit from claim resolution, such as
employers).
Consequently, the examiner could choose to take a more efficient approach, in an effort to help the claimant move more
quickly away from the reliably harmful effects of involvement in a medical-legal claim. The examiner could complete
the evaluation process, including creating an impairment
rating, and document in the impairment evaluation report
that the rating is being provided in spite of the reasons to
be concerned that the impairment is artificially inflated in a
nonpermanent way by the unjustifiable narcotic prescription.
Claims administrators could then make an informed decision
in regard to whether they want to resolve the claim based on
the nonpermanent impairment rating. This is not an abstract
consideration. For example, Tennessee mandates that a
workers’ compensation claimant is considered to be at MMI
no later than two years after the initiation of “pain management,” and this law was created specifically in response to
concerns regarding the tendency for pain management to
prolong claims.
Claims administrators could alternatively respond to the
warnings regarding the nonpermanent nature of the impairment by encouraging the claimant to seek a more credible
treatment course. Such encouragement would carry hope of
making a genuinely permanent impairment rating possible, as
well as hope of the claimant obtaining more credible health
care and a better health outcome. The evaluator could
specify credible treatment options in the impairment evaluation report in an effort to make sure that any actual attempt
to move beyond the noncredible treatment with narcotics
does not lead to another noncredible form of treatment.
Avoid Confusing the Effects of the Prescription
Narcotics with Permanent Impairment
As was discussed above, the detrimental effects of narcotics
should not be considered permanent. Consequently, the
evaluator should take great care to ensure that the effects of
the narcotics do not erroneously factor into the impairment
rating. The efforts of the evaluator in this regard might need
to take the form of apportionment: separating out any effects
of the narcotics from the permanent effects of any injury that
is the specific focus of the patient’s medical-legal claim.
During the course of creating this article, members of the
Guides Newsletter Editorial Advisory Board have reported
tendencies of some evaluators to make misdirected allegations that certain patients will need to consume narcotic
medications permanently and to subsequently claim that
the symptoms (impairment) caused by the narcotics are permanent impairments. Examples provided include all the
nonpermanent effects of narcotics discussed above, plus an
additional effect not discussed above: gastrointestinal dys-
6
AMA Guides Newsletter, March/April 2011
function, typically involving constipation, but also involving
abdominal pain even in the absence of constipation (which
has been identified as part of the hyperalgesia effect of narcotic medications).56,57 Scientific findings have indicated that
there is a lack of support for any such claims. There is a lack
of justification for claiming that narcotic medications need
to be permanently consumed in response to complaints of
chronic benign pain, and there is a lack of justification for
claiming that the effects of such medications are permanent.
Consequently, evaluators should not claim that there is a permanent need for prescription narcotics, evaluators should not
claim that the effects of narcotics are permanent, and evaluators should not allow the effects of prescription narcotics to
be included in an impairment rating.
If an evaluator states that narcotics “needed” for chronic
pain are causing measurable impairments in sleep, cognitive,
sexual, or gastrointestinal function, and other areas, then,
absent clear objective proof of benefit in terms of a measurable increase in function, clearly the medication is causing
harm without benefit and should be discontinued before
impairment rating. Again, the claim may administratively
need to be rated despite this conundrum. The evaluator
should not state that the impairment from side effects of the
opioids is permanent.
The uncommon patient who chooses not to work because
of pain, but chooses to work once provided with opioids, is
the type of patient for whom benefit (in terms of measurable increased function) might justify chronic opioid use for
chronic benign pain. Anecdotally, these uncommon patients
rarely seem to recognize or report side effects from opioids.
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