MD SPEAK. To fuse or not to fuse? By Summit Medical Director Kenneth G. Phillips, M.D., MPH, FACOEM, FAIHQ, CIME

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1 NEWS FOR SUMMIT S PROVIDER COMMUNITY FALL 2012 MD SPEAK The last issue of The Heritage News highlighted a study on the success rates of lumbar discectomy among professional football players. The study analyzed postoperative player performance and showed some exciting results. For those players who returned to the game, there was no significant difference in performance when comparing pre-injury and post-injury performance statistics. 1 This time around, we are sharing a study on the more intensive spinal fusion surgery, titled Long-term outcomes of lumbar fusion among workers compensation subjects: a historical cohort study. 2 The study included 725 fusion cases, and matched them with a control group of 725 randomly-selected, non-surgical, chronic low back pain cases. Each group was evaluated after two years (after surgery for the fusion group, and after injury for the control group.) At evaluation, 26 percent of the fusion cases had returned to work, compared with 67 percent of the controls. Fusion cases saw an 11 percent permanent disability rate while controls saw only 2 percent. In addition, the total number of days off work was 1,140 for fusion cases and only 316 days for controls. The fusion cases also had a 27 percent reoperation rate, a 36 percent complication rate and a 41 percent increase in daily opioid use. To fuse or not to fuse? By Summit Medical Director Kenneth G. Phillips, M.D., MPH, FACOEM, FAIHQ, CIME The study concluded that lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a workers compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status. Clearly, while the discectomy study showed exciting results, this study of spinal fusion highlighted much poorer outcomes. At Summit, we base our treatment authorization decisions on the Official Disability Guidelines (ODG). When this research was published in early 2011, ODG included its findings in their treatment recommendations. Continued on page 5 Quick reference Back conditions and surgery terms 3 Discectomy The surgical removal of the damaged portion of a herniated disk in the spine. Spinal fusion Surgical removal of entire damaged disks, permanently connecting two or more vertebrae in in the spine and eliminating motion between them. Spinal stenosis A narrowing of the open spaces within the spine, which can put pressure on the spinal cord and the nerves that travel through the spine. Spinal stenosis occurs most often in the neck and lower back. Spondylolisthesis A spinal disorder in which one vertebra slips forward and onto the vertebra below it. Industry News...2 Managing Prescriptions...3 Return-to-Work.. 4

2 Industry NEWS O pioid-induced hyperalgesia: an age-old problem, coming to light For more than a century, medical practitioners have noted a curious phenomenon in relation to prolonged opioid use: the potential for increased, rather than decreased, pain. In one of the earliest known notations on the subject, 1870s medical practitioner Clifford Albutt describes this paradoxical complication. At such times I have certainly felt it a great responsibility to say that pain, which I know is an evil, is less injurious than morphia, which may be an evil. Here experience is needed. Does morphia tend to encourage the very pain it pretends to relieve? in the cases in question, I have much reason to suspect that a reliance upon hypodermic morphia only ended in that curious state of perpetuated pain. 4,5 The latest research indicates Albutt was onto something. Today, we call it opioid-induced hyperalgesia (OIH), and new information is coming to light about this often overlooked but potentially detrimental condition. Defining the problem Researchers define OIH as a state of nociceptive sensitization caused by exposure to opioids. 6 As you know, when nociceptors (pain receptors in the nervous system) detect potential tissue damage, they send a corresponding signal to the brain, which is then translated as pain. In the case of OIH, opioids interfere with, and increase, the nociceptive signal transmission. The exact chemical mechanism is still unclear, but many researchers believe that opioids can sensitize the nerve pathways, exacerbating the damage signal sent to the brain and ultimately increasing the painful experience. 5 Diagnosis The Official Disability Guidelines offer the following as guidelines for diagnosis if you suspect OIH. Attempt to determine if pain has increased over that which was pre-existing (in the absence of apparent disease progression). Attempt to determine if the patient has previously responded to opioids but now has worsening pain. Attempt to determine if the patient has never had improved pain with opioids. If disease progression is ruled out, determine if there is evidence of possible opioid tolerance or opioid hyperalgesia. Evaluate pain: In cases of opioid hyperalgesia, pain may spread and become more diffuse and less well-defined in quality, beyond what would be expected from the preexisting pain state. This is generally not an acute but an insidious process. Psychological issues such as secondary gain, exacerbation of underlying depression or anxiety, and the development of addictive disease should also be ruled out. (ODG) 7 Distinguishing OIH from tolerance When patients on opioid therapy present with increased pain, and their physical condition has not worsened, many physicians believe the culprit is simply a developed tolerance to the drug. Tolerance, in pharmacological terms, is simply a lack of response to a drug, and is usually resolved by increasing the dosage. 6 However, because OIH is an actual sensitization to pain caused by the drug, it cannot be resolved by increasing the dose. In fact, pain is likely to worsen as the dosage is increased and can only be improved by reducing or eliminating the drug. 5 Treatment options If a patient has previously seen successful pain reduction from opioids, but later experiences an increase in pain while undergoing opioid therapy, ODG suggests the following course of treatment. It is not unreasonable to give a trial of opioid dose escalation to see if pain and function improves. If pain improves, the diagnosis is probable tolerance. If pain does not improve or worsens, this may be evidence of opioid hyperalgesia, and the opioid dose should be reduced or weaned. Another option to consider is opioid rotation. Use of adjuvant pain medications is recommended when there is evidence of either tolerance or hyperalgesia. When there is no evidence of pain improvement after opioid dosage is increased, further evaluation by a specialist with additional expertise in psychiatry, pain medicine or addiction medicine should be considered. 7 (continued) 2

3 Managing PRESCRIPTIONS Potential treatment challenges In his paper on the subject 5, Dr. Sanford Silverman spells out a number of treatment challenges related to OIH. Opioid weaning can result, of course, in withdrawal, transient pain and frustration (for the doctor as well as the patient). In addition, he warns that the hyperalgesic effect may not be mitigated until a certain critical dose of opioid is reached. To ensure a successful pain management experience, Dr. Silverman believes the physician and patient should address potential complications, including OIH, before beginning any opioid therapy. A written, comprehensive agreement, including a treatment exit strategy, should be established between the patient and the treating physician. While this may not eliminate future problems, it does establish realistic expectations and lay out a response plan should complications arise. If you have patients exhibiting signs of OIH or simply unexplained pain, we are here to help. Please contact one of our medical directors for more information on opioidinduced hyperalgesia or for a referral to a specialist in your area. More information To read more from Dr. Silverman on pain management, see the Summer 2011 edition of The Heritage News. For further insights on chronic pain and opioid dependence, see the Summer 2012 edition. These and all previous editions of this newsletter can be found in the Provider Resources section of our website, under News and Notifications. Protecting patients from drug interactions We know that patient safety is a top priority for doctors and pharmacists. We also understand that it can be diffi cult to monitor drug history, potential interactions and compliance issues when you must rely largely on the patient for this information. Many patients are unaware that certain medications, when combined, can deliver dangerous levels of drugs such as acetaminophen or opioids. In an effort to address these potential issues and to promote safety, we take advantage of a program from Express Scripts, our pharmacy benefi t manager. Express Scripts systematically reviews the prescription fi ll patterns of our injured workers and fl ags potential problems. When combined opiate or acetaminophen levels reach a point of concern, one of our medical directors will send a notice to your offi ce. If you receive one of these letters, please review your records, take any applicable steps to ensure your patient s safety, and contact us so that we can update our fi les. Also, please remember that this monitoring system does not include all prescription and nonprescription drug sources, so it is still vital to question patients on their medication use. Prescription home delivery available! We re pleased to offer home delivery from the Express Scripts Pharmacy for all patients covered by one of our workers compensation programs. This voluntary program offers these great benefi ts for your patients. Convenience. Patients can order up to a 90-day supply of medication, then order refi lls easily online or by phone. Shipping is free. Safety. Pharmacists check every prescription for accuracy and potential drug interactions. Privacy. Patients can speak confi dentially to a pharmacist 24 hours a day, every day. Satisfaction. J.D. Power and Associates ranked the home delivery service from the Express Scripts Pharmacy higher than retail chain pharmacies in its latest customer satisfaction report. We hope that you will encourage your workers comp patients who are insured by Summit-managed programs to participate. To enroll, patients can call (8:00 a.m. to 5:00 p.m., Central time, Monday through Friday). Express Scripts will then contact your offi ce for prescription details and authorization. 3

4 Working with WORKERS COMP Return-to-work programs will soon see a popularity spike Every year, eligible businesses in most states are assigned an experience modification factor (or mod) based on their claims history. It s somewhat like a credit score but instead of creditworthiness, the mod measures the cost of claims the business has incurred compared to other businesses in their industry. This number is then factored into the rate the business pays for their workers compensation insurance. Needless to say, smart business owners strive for a good mod in much the same way they try to maintain a good credit score. What s the big change? If you haven t already, you re likely to see employers become much more interested in returning injured workers to the job. That s because most of the states in which Summit operates have adopted a major change to the formula for calculating workers comp experience modifications and return-to-work programs (or lack thereof) will play a major role in how much businesses pay in insurance premiums. In short, this change means safety and return-to-work programs will have a much greater financial impact than ever before. What does that mean for you and your patients? Employers who are concerned about this issue (and most will be) are likely to become much more involved in a patient s recovery, with an increased desire to return the patient to work as soon as possible. The keys to handling this intense interest will be open communication, clear medical restrictions, and an emphasis on what the patient can do, rather than what he cannot do. Through Back2Work, Summit s return-to-work program, we have specially trained return-to-work coordinators and claims adjustors available to help you navigate this challenge. We re always available to offer ideas and facilitate communication between you and your patient, and the patient s employer. If you have questions about a case or would like us to work with you and a patient s employer to establish a return-to-work plan, please give us a call. For the first time in 20 years, the agency that calculates mods, the National Council on Compensation Insurance (NCCI), has proposed a major change to the formula. Currently, only the first $5,000 of a lost-time claim is included in the mod formula at 100 percent. Costs above $5,000 are included in the formula at different weightings, depending on the size of the risk. That $5,000 cap is called the split-point. Beginning in 2013, that split-point cap will be increased annually until it reaches roughly $17,000 in That means that by 2015, employers could be held accountable for more than three times the claims costs they are responsible for today. And, they won t get to start from scratch in Because the calculation takes into consideration claims history for several years, claims from as early as 2009 will be factored into the 2013 calculation. For more detailed information about this topic, referred to as the NCCI split point change, check out the September 2011, Spring 2012 and Summer 2012 editions of our newsletter for employers, COMPpress. To view the newsletter, visit our website and click on Employer Resources and then Print Materials. 4

5 To fuse or not to fuse? (continued) As it stands now, ODG lists the following as their position on spinal fusion. Patients with on-thejob injuries are three to five times more likely as other patients to have a bad outcome from spinal fusion (Harris-JAMA, 2005). A recent study of workers comp patients in Ohio who had lumbar fusion found that only 6 percent were able to go back to work a year later, 27 percent needed another operation, and over 90 percent were in enough pain that they were still taking narcotics at follow-up (Nguyen, 2007). Until further research is conducted, there remains insufficient evidence to recommend fusion for chronic low back pain in the absence of stenosis and spondylolisthesis. 7 In light of this recommendation, we ask that when you submit an approval request for spinal fusion, you include objective evidence of stenosis or unstable spondylolisthesis (see box on page 1). If you feel a case warrants fusion surgery without such evidence, please give me or Dr. Olson a call. We re always glad to discuss any case with you. Ready to try ODG? To get your 30-day free trial of the online Offi cial Disability Guidelines, visit com/orderformtrial.htm. Then, when your trial expires, use the coupon code Summit T22 when purchasing. You ll receive a discounted annual rate of $166 per user ($159 off the usual rate). To learn more about the Offi cial Disability Guidelines, visit Becoming an ODG-trained provider opens doors for you and your practice and makes working with Summit even easier. Learning how to use ODG is quick and simple. To view an online presentation from Summit about ODG, its benefi ts to you and how to fi nd the training resources you need, visit the Provider Resources section of our website. Click on Official Disability Guidelines and then About ODG to fi nd the link to the presentation. For Your INFORMATION ICD-10 rollout date changed to October 1, 2014 The Centers for Medicare and Medicaid Services announced in August yet another change in the compliance date for the ICD-10 transition. The new compliance date is October 1, Rest assured, whatever the date, Summit will be ready to handle the shift to ICD-10. In fact, we re in the implementation process now. If you have questions about how ICD- 10 may impact your patients in Summit-managed insurance programs, please don t hesitate to call us. Do you offer o nline access to medical records? If your practice offers online medical record access, we want to know! Online medical records can often help save your staff members precious time when they are working with us. This is because online medical records can help our nurse case managers move patient claims forward quickly, with less involvement from your staff. In some cases, we have been able to make immediate decisions regarding approval of treatment, simply by having access to the most current and complete documentation. If you offer this service, please let us know by calling and asking for a Heritage network representative. Reminder: Louisiana requires authorization form As of April 20, 2012, Louisiana requires medical providers to use the LWC FORM 1010 to request authorization for treatment from a workers comp carrier. In compliance with state law, we have established an address and fax number specifically to receive this form from you. You can LWC 1010 forms to us at la1010@summitholdings.com or fax them to If you need a copy of the form, you can download it from our website. Visit click on Provider Resources, then Provider Forms. 5

6 References Who is Summit? 1. Statistical performance in National Football League athletes after lumbar discectomy. (Jason W. Savage, Wellington K. Hsu, Clinical Journal or Sport Medicine, September 2010). 2. N guyen TH, Randolph DC, Talmage J, Succop P, Travis R. Long-term Outcomes of Lumbar Fusion Among Workers Compensation Subjects: An Historical Cohort Study. Spine (Phila Pa 1976) Feb 15;36(4): September 14, 2012 Diskectomy Spinal Fusion, Definition Spinal stenosis, Definition Spinal Fusion, Why it s done DSECTION=why%2Dits%2Ddone 4. On the abuse of hypodermic injections of morphia. Albutt C. Practitioner 1870; 5: Opioid Induced Hyperalgesia: Clinical Implications for the Pain Practitioner. Sanford M. Silverman, MD, Pain Physician 2009; 12: A Comprehensive Review of Opioid-Induced Hyperalgesia, Marion Lee, MD, Sanford Silverman, MD, Hans Hansen, MD, Vikram Patel, MD, and Laxmaiah Manchikanti, MD, Pain Physician 2011; 14: We base our medical procedure authorization decisions on the Official Disability Guidelines (ODG), a comprehensive review of scientific evidence. All references in this newsletter: Official Disability Guidelines, (Work Loss Data Institute), available at odgtwclist.htm. Note: Any minor grammatical edits to the text cited have been made with the express approval of the Work Loss Data Institute. Holiday office closures With more than 30 years of experience, Summit is a leading provider of workers compensation insurance products and services to employers throughout the Southeast. Summit includes Summit Consulting Inc. and its subsidiary, Heritage Summit HealthCare Inc., along with its affiliated insurers, Bridgefield Casualty Insurance Company and Bridgefield Employers Insurance Company. Summit is also the managing general agent of BusinessFirst Insurance Company, Retailers Casualty Insurance Company, and RetailFirst Insurance Company. How to Contact Us Heritage Summit HealthCare Inc. P.O. Box 3623 Lakeland, FL Summit Claims Center P.O. Box 2928 Lakeland, FL hour injury reporting If you know of a provider who may be interested in joining our network, please give us a call or send an to provider.leads@summitholdings.com. All Summit offi ces will be closed this holiday season in observance of the following holidays: Thanksgiving Thursday, November 22, and Friday, November 23, 2012 Christmas Day Tuesday, December 25, 2012 New Year s Day Tuesday, January 1, 2013 If you have any questions or comments about the content of this newsletter, please send an to heritagenews@summitholdings.com. 10/12 (12-127) Even on holidays, injured workers or their employers can report injuries 24 hours a day, 7 days a week on our website or by calling our injury reporting line at We wish you and your staff a happy, healthy holiday season and new year Summit Consulting Inc. 6