pain, pills, procedures and the wounded worker syndrome william nemeth md cpe texas association of...
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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
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DISABILITY DISABILITY EPIDEMIC!!!!EPIDEMIC!!!!
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Before After
INSANITY!INSANITY!
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""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
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UTILIZATION
UTILIZATIONUTILIZATION v. OUTCOMESv. OUTCOMES
+
OUTCOME
4-6 WEEKS
--DEPENDENCEDEPENDENCE
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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
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HOW DID THEY HOW DID THEY GET THIS WAY?GET THIS WAY?
“MEDICINABLING” SystemENTITLEMENT Attitude“MEDICALIZING” Docs
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SystemMEDICINABLES!MEDICINABLES!
INDEMNIFIES• Chronic Disease• Chronic Pain• Lost Time
PROVIDES• Socioeconomic Safety Net
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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
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Doctors
MEDICALIZE!MEDICALIZE!
• Mis-diagnose• Over-treat• Give work excuses
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MISDIAGNOSIS!!!!!!MISDIAGNOSIS!!!!!!MISTREATMENT!!!!!MISTREATMENT!!!!!
• Denial- PsychosocialDenial- Psychosocial• IgnoranceIgnorance• Medical Economics- Medical Economics-
Profit MotiveProfit Motive• Can’t Say “NO!”Can’t Say “NO!”
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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
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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
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PSYCHOLOGICALPSYCHOLOGICALBEHAVIORSBEHAVIORS
• “ “SOMATIZATION”SOMATIZATION”
• ABNORMAL ILLNESS ABNORMAL ILLNESS
BEHAVIORBEHAVIOR
• ““SYMPTOM MAGNIFICATION”SYMPTOM MAGNIFICATION”
• ““CATASTROPHIZING”CATASTROPHIZING”
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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
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WHAT WHAT CAUSESCAUSESTHE THE PAIN ??PAIN ????
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CHRONIC PAIN IS COMPLEX!CHRONIC PAIN IS COMPLEX!
Biopsychosocial Model
PHYSICAL PAINGENERATOR(ACUTE)
PSYCHOSOCIAL(CHRONIC)
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INJURIES HEALINJURIES HEAL
DISEASES PERSIST!DISEASES PERSIST!
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CHRONIC PAIN IS A BRAIN CHRONIC PAIN IS A BRAIN DISEASEDISEASE
NEUROPLASTICITY
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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
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RISK FACTORSRISK FACTORS•DOI•DUTY•DOB•DOCTOR/ATTY•DIAGNOSIS•DEGENERATIVE DISEASE•DIABETES•DRUGS•DEPENDENCY•DEPRESSION
D10
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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!
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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
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What Doesn’t Work?What Doesn’t Work?
MRIMRIDiscographyDiscography
IDET IDET Repeated BlocksRepeated Blocks
Pain PumpsPain PumpsBack FusionBack Fusion
Disc ReplacementDisc ReplacementMany DrugsMany Drugs
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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
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DISABILITY MANAGEMENTDISABILITY MANAGEMENTID “AT RISK” and CO-MANAGE
MEDICAL/VOCATIONAL REHABILITATION
BENCHMARKSGUIDELINES
TREATMENTPLANNING
FUNCTIONALRESTORATION
DISABILITYMANAGEMENT
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EARLY FUNCTIONAL EARLY FUNCTIONAL RESTORATIONRESTORATION
• Risk Assessment• Early Intervention• Cognitive Behavioral Therapy• Exercise• Adjunctive Care• SAW-RTW
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Why Disability Why Disability Management?Management?
“Because we can’t afford Because we can’t afford
NOT to!!!”NOT to!!!”
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THAT’S IT FOLKS!!!!THAT’S IT FOLKS!!!!
William Nemeth MD
Somi Healthlink LLC
A Pain & Disability Management [email protected]
(512) 695-5599