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Independent medical and impairment evaluations often involve a patient who is taking chronic opioids. Therefore, evaluating physicians need to understand the current science pertaining to opioid therapy and how this impacts patients and these assessments. This article reviews recently published additions to the medical literature, including: The efficacy of chronic opioid therapy for chronic non-cancer pain; The outcomes of weaning chronic opioid-therapy patients off opioids; The basis for opioid-induced hyperalgesia (chronic opioid use can worsen
Editorial Comment The opioid epidemic is tragic and has been particularly widespread in the workers' compensation and personal injury arenas in which many impairment assessments are performed. Therefore, evaluating physicians may be asked to rate opioid use disorders. This article provides insights to this process. The AMA Opioid Task Force recognizes the need for increased physician leadership, a greater emphasis on overdose prevention and treatment, and the need to coordinate and amplify the efforts and best practices that are already in place
Spinal cord (dorsal column) stimulation (SCS) and intraspinal opioids (ISO) are treatments for patients in whom abnormal illness behavior is absent but who have an objective basis for severe, persistent pain that has not been adequately relieved by other interventions. Usually, physicians prescribe these treatments in cancer pain or noncancer-related neuropathic pain settings. A survey of academic centers showed that 87% of the responding centers use SCS and 84% utilize ISO. 1 These treatments are also performed frequently in nonacademic settings
from 2020. More than 70% of these fatalities were caused by opioid overdose, most involving synthetic opioids other than methadone. Cocaine and psychostimulants also contributed to increasing drug overdose deaths (approximately 17% of the total in 2021). For the first half of 2020, there were almost 3,000 fatal overdoses owing to benzodiazepines, with 92.7% also involving opioids. 3 The enormous surge in morbidity and mortality associated with drug use and addiction piqued our curiosity. The characterization of drug addiction as a chronic, relapsing disease of the
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
Pete's story. Despite a difficult childhood, Pete had made a good life for himself. He had a wife, two sons, and a landscaping job for a school district in a Sun Belt state. Then an accident left him with severe back pain. His employer didn't want him back until he was “100 percent.” Chronic pain led to spine fusion surgery, which did not relieve the pain. Pete lost his job. His neuro-surgeon's advice: “Don't even bother looking for another job.” The only thing Pete's doctors offered was opioid (narcotic) pain relievers. His new life was lying in a
Abstract
Spinal cord (dorsal column) stimulation (SCS) and intraspinal opioids (ISO) are treatments for patients in whom abnormal illness behavior is absent but who have an objective basis for severe, persistent pain that has not been adequately relieved by other interventions. Usually, physicians prescribe these treatments in cancer pain or noncancer-related neuropathic pain settings. A survey of academic centers showed that 87% of responding centers use SCS and 84% use ISO. These treatments are performed frequently in nonacademic settings, so evaluators likely will encounter patients who were treated with SCS and ISO. Does SCS or ISO change the impairment associated with the underlying conditions for which these treatments are performed? Although the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not specifically address this question, the answer follows directly from the principles on which the AMA Guides impairment rating methodology is based. Specifically, “the impairment percents shown in the chapters that consider the various organ systems make allowance for the pain that may accompany the impairing condition.” Thus, impairment is neither increased due to persistent pain nor is it decreased in the absence of pain. In summary, in the absence of complications, the evaluator should rate the underlying pathology or injury without making an adjustment in the impairment for SCS or ISO.
