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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, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. 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. References 1. American College of Occupational and Environmental Medicine. ACOEM’s Guidelines for the Chronic Use of Opioids. American College of Occupational and Environmental Medicine, 2011. Available at http://www .acoem.org/Guidelines_Opioids.aspx. 2. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363(21):1981-1985. 3. Chu LF, Clark DJ, Angst MS. Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: a preliminary prospective study. J Pain. 2006;7(1):43-48. 4. Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: molecular mechanisms and clinical considerations. Clin J Pain. 2008;24(6):479-496. 5. Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104(3):570-587. 6. Bannister K, Dickenson AH. Opioid hyperalgesia. Curr Opinion in Supportive and Palliative Care. 2010;4(1):1-5. 7. Baron MJ, McDonald PW. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Management. 2006;2(5):277-282. 8. Katz N, Mazer NA. The impact of opioids on the endocrine system. Clin J Pain. 2009;25(2):170-175. 9. Daniell HW. Hypogonadism in men consuming sustained-action oral opioids. J Pain. 2002;3(5):377-384. 10. Daniell HW. Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. J Pain. 2008;9(1):28-36. 11. Merza Z. Chronic use of opioids and the endocrine system. Horm Metab Res. 2010;42(9):621-626. 12. Aloisi AM, Aurilio C, Bachiocco V, et al. Endocrine consequences of opioid therapy. Psychoneuroendocrinology. 2009;34 Suppl 1:S162-S168. 13. Teichtahl H, Wang D. Sleep-disordered breathing with chronic opioid use. Expert Opin Drug Saf. 2007;6(6):641-649. 14. Wang D, Teichtahl H. Opioids, sleep architecture and sleep-disordered breathing. Sleep Med Rev. 2007;11(1):35-46. 15. Ramar K. Reversal of sleep-disordered breathing with opioid withdrawal. Pain Pract. 2009;9(5):394-398. 16. Sacerdote P. Opioid-induced immunosuppression. Curr Opin Support Palliat Care. 2008;2(1):14-18. 17. Budd K. Pain management: is opioid immunosuppression a clinical problem? Biomed Pharmacother. 2006;60(7):310-317. 18. Meares S, Shores EA, Batchelor J, et al. The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury. J Int Neuropsychol Soc. 2006;12(6):792-801. 19. Ersche KD, et al. 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Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine. 2008;33(2):199-204. 25. Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low-back pain. Cochrane Database Syst Rev. 2007;(3):CD004959. 26. Noble M et al., Long-term opioid management for chronic non-cancer pain [>6 months]. Cochrane Database Systematic Review, 2010; (1): CD006605 27. Stein C, Reinecke H, Sorgatz H. Opioid use in chronic noncancer pain: guidelines revisited. Curr Opin Anaesthesiol. 2010;23(5):598-601. 28. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22(1):62-68. 29. Denniston PL (President), Kennedy CW (Medical Editor). ODG Treatment in Workers Comp, 2011. 9th ed. Work Loss Data Institute. 2011. 30. American College of Occupational and Environmental Medicine. Occupational Medicine Guidelines. 2nd ed. OEM Press, 2004. 31. King SA. Pain disorders. In: Hales RE, Yudofsky SC, eds. The American Psychiatric Publishing Textbook of Clinical Psychiatry. 4th ed. Washington, DC: American Psychiatric Publishing, 2003:1023-1043. 32. Block A, et al. Results of Random Drug Testing in Chronic Back Pain Patients Managed with Pain Medication. Proceedings of the NASS 23rd Annual Meeting. Spine J. 2008;8:25S-26S. 33. Couto JE, et al. High rates of inappropriate drug use in the chronic pain population. Popul Health Manage. 2009;185-90 34. Breckenridge J, et al. Patient Characteristics Associated With Opioid Versus Nonsteroidal Anti-inflammatory Drug Management of Chronic Low Back Pain. J Pain. 2003;4(6):344-350. 35. Fillingim RB, et al. Clinical characterisitcs of low back pain as a function of gender and oral opioid use. Spine. 2003;28:143-150. 36. Turk DC, Okifuji A. What factors affect physicians’ decisions to prescribe opioids for chronic noncancer pain patients? Clin J Pain. 1997;13:330-336. 37. Luo X, Pietrobon R, Hey L. Patterns and trends in opioid use among individuals with back pain in the United States. Spine. 2004;29(8):884-890. 38. Sullivan MD, Edlund MJ, Zhang L, Unutzer J, Wells KB. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med. 2006;166:2087-2093. 39. Fanciullo GJ, Ball PA, Girault G, Rose RJ, Hanscom B, Weinstein JN. An observational study on the prevalence and pattern of opioid use in 25,479 patients with spine and radicular pain. Spine. 2002;27(2):201-205. 40. Stover BD, Turner JA, Franklin G, et al. Factors associated with early opioid prescription among workers with low back injuries. J Pain. 2006;7(10):718-725. 41. Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010;151(3):625-632. 42. Sullivan MD. Who gets high-dose opioid therapy for chronic non-cancer pain? Pain. 2010;151(3):567-568. 43. Juratli SM, Mirza SK, Fulton-Kehoe D, Wickizer TM, Franklin GM. Mortality after lumbar fusion surgery. Spine. 2009;34(7):740-747. 44. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15(9):618-627. 45. Centers for Disease Control. Quickstats: Motor vehicle traffic and poisoning deaths by age – United States, 2005-2006, Morbidity and Mortality Weekly Report, July 17, 2009; 58:753. 46. Fiore K. Deaths from Rx Painkillers Still Rising, CDC Says. Medpage Today, February 17, 2011. 47. Sanders SH. Risk factors for chronic, disabling low back pain: an update for 2000. Am Pain Soc Bull. 2000. 48. Linton SJ. Psychological factors for neck and back pain. In: Nachemson AL, Jonsson E (editors). Neck and Back Pain. Philadelphia, PA: Lippincott, Williams & Wilkins; 2000. 49. Dersh J, Gatchel RJ, Polatin P, Temple OR. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine. 2006;31(10):1156-1162. 50. Carragee E, Alamin T, Cheng I, Franklin T, Hurwitz E. Does minor trauma cause serious low back illness? Spine. 2006;31(25):2942-2949. 51. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010;303(13):1295-1302. 52. Weisberg JN. Studies investigating the prevalence of personality disorders in patients with chronic pain. In: Gatchel RJ, Weisberg RJ (eds). Personality Characteristics of Patients With Pain. American Psychological Association, 2000. 53. Rohling ML, Binder LM, Langhinrichsen-Rohling J. Money matters: A meta-analytic review of the association between financial compensation and the experience and treatment of chronic pain. Health Psychol. 1995;14(6):537-547. 54. Harris I, Multford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery. JAMA. 2005;293:13:1644-1652. 55. Australasian Faculty of Occupational Medicine and Royal Australasian College of Physicians, Health Policy Unit. Compensable Injuries and Health Outcomes. The Royal Australasian College of Physicians, Sydney 2001. 56. Grunkemeier DM, Cassara JE, Dalton CB, Drossman DA. The narcotic bowel syndrome: clinical features, pathophysiology, and management. Clin Gastroenterol Hepatol. 2007;5(10):1126-1139. 57. Holzer P. Treatment of opioid-induced gut dysfunction. Expert Opin Investig Drugs. 2007;16(2):181-194. AMA Guides Newsletter, March/April 2011 7