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The Faces Behind Narcotics:
A Nurse Case Manager’s Perspective

By Sue Bowers, RN-BC, BSN, CCM
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Sue Bowers is the president of Choices Case Management, Inc. , a case management company in Brentwood, CA. She was interviewed here in “The Nurse Case Manager” In this article she examines how medicating pain can cause unintended consequences
In our world today where we live with instant gratification, why would the need for instantaneous pain control be considered any different? In our world of “I hurt”, why should patients have to wait when they have escalating pain or chronic pain becomes an issue affecting their lives? The resounding words of our patients continue to echo into the ears of nurse case managers working with injured employees, “Can’t my doctor just give me something? This medication isn’t working”.

We are in an ever increasing chasm of escalating and rampant narcotic use in addressing pain at varied and ongoing pain levels. Narcotics are being prescribed for medical conditions, new and old injuries, surgical control, simple strains and sprains, and ever increasingly for chronic pain conditions in which patients are being managed with potent and addictive medications which often present difficult and challenging circumstances for many patients and their families today.

Narcotics in workers’ compensation, account for 38% of pharmaceutical costs today. Prescription costs increase as the claims age and become more costly. But what about the patient? What happens to the patient when medical care, costs, utilization review, and expectations of daily life continue when pain medication does not provide the relief? Or the patient becomes dependent or addicted and they are unable to function or participate in normal life? Can narcotics create dependence/addiction and be life altering for these patients?
Narcotics in workers’ compensation account for 38% of pharmaceutical costs today (Prescription Drug Studies Focus Key Workers’ Comp Cost Drivers; Workforce; By Roberto Ceniceros April 26, 2012)
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The answer is a simple “yes”. The purpose of this article is to provide a personal introduction to the reader of two patients whose lives have been affected by the use of narcotics. These patients are the “Faces behind Narcotics”- real life worker’s compensation stories of injured employees whose lives have been affected and changed from the use of narcotics. In these studies, these patients were assigned nurse case managers to assist in the coordination of care in addressing detoxification and rehabilitation programs from the reduction or elimination of narcotics. Two stories, two lives, two different outcomes following detoxification from today’s most commonly prescribed medications: narcotics.

Narcotics are being used commonly to treat patients with minor injuries, such as back strains, failed back surgeries, or injuries that have morphed into “chronic pain” conditions (pain lasting over 6 months). To understand the potency and potential for dependence and addiction, one must have a basic understanding of the chemical components and the chemical reactions and make up of narcotics. Narcotics work on opiate receptor sites in the central nervous system (brain and spinal cord) and attach to these receptor sites to decrease pain. Common side affects of narcotics include: decreased respiratory rate, euphoria, drowsiness, changes in mood, mental clouding, deep sleep, nausea, vomiting, decreased cough reflex, low blood pressure, itching, flushing of face, red eyes, acid reflux, spasms, constipation, and even respiratory arrest. Narcotics are not meant for long term pain management, however, with today’s culture of instant gratification (which includes pain relief), narcotics are easily and readily being made available.

Common side affects of narcotics include: decreased respiratory rate, euphoria, drowsiness, changes in mood, mental clouding, deep sleep, nausea, vomiting, decreased cough reflex, low blood pressure, itching, flushing of face, red eyes, acid reflux, spasms, constipation, and even respiratory arrest. (Health.com: Tips for Managing the Side Effects of Narcotic Painkillers)
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Who are the “Faces behind Narcotics”?

Case # 1:

Meet Mr. X. He is a 54-year old man (former local transit driver) who suffered a debilitating back injury 9 years prior to a nurse being assigned to assist and coordinate a drug detoxification and functional restoration program Mr. X was dealing with chronic pain issues with carrier reported prescription costs ( at the time of this referral) of $24,000.00/month. Pharmaceutical costs to date on this claim total $398,000.00. Mr. X ‘s regimen of pharmaceuticals at the time of referral included: Vicodin, Oxycontin, Fentanyl, Flexeril, Soma, Catapress; Celebrex; Duragesic, Effexor, Lisinopril, Neurontin, Terazosin, Baclofen, and Percocet. Mr. X had previously completed a detoxification program 2 years prior to this referral, which was successful in and of itself.

However, a tragic event occurred in his home life two weeks after discharge from this program. No post program support was available. No resources were available to assist him in coping with the tragic event that occurred in his family. Unfortunately, Mr. X could not cope with the event, returned to the primary treating physician (who had been prescribing all of the previous medications), and was again started on the same medications he had just been detoxed from. The dependence/addiction cycle began again and Mr. X was unable to tolerate pain with increasing and escalating narcotic dosages and pharmaceutical costs.

This was the mitigating factor for the carrier to engage the case management process. Pro-active research was completed for an appropriate, supportive, and restorative detoxification program for Mr. X which would offer the best outcomes and support post program. With the assistance of the nurse case manager, Mr. X was successfully admitted to a program where Suboxone was initiated and all other narcotics were discontinued. Mr. X was able to return to some level of pre-injury functioning and has maintained a non-dependence on narcotics. He continues to function at a level previously unobtainable. Today, he is actively participating in a gym program which has allowed him to return to some level of life and function.

Case # 2:

Meet Ms. Z, a 51 year old Registered Nurse. This case was referred to assist with opiate detoxification. At the time of referral, Ms. Z had injured her back 8 years previously. The back had been unsuccessfully treated with two back surgeries and high doses of opiates. She had not worked for over 5 years. Carrier reported pharmaceutical costs (at the time of this referral for case management) were $15,000.00 per month. Within 6 months of being assigned this file, Ms. Z had completed opiate detoxification, yet was still having difficulty with chronic pain management. Pro-active research was completed to identify programs for Ms. Z which would offer the best outcomes in addressing chronic pain management and return to function without opiates. The nurse facilitated and supported completion of a rehab program by a local physician that supported chronic pain management without opiates.

Ms. Z successfully completed a 6 week return to work rehab program. Ms. Z returned to work full duty and managing chronic pain without opiates: Positive outcomes were obtained through the development of rapport, ongoing support and education with Ms. Z regarding detoxification from opiates, management of chronic pain and successful return to work. Ongoing communication with medical providers, examiner, and Ms. Z resulted in timely authorizations and completion of the medical treatment plan.

Two stories, two lives, two different outcomes following detoxification from today’s most commonly prescribed medications: narcotics.
Narcotics have the potential to pose a real threat to the health and safety of our injured employees. As dosages escalate upward, prescription quantities increase, additional medications are added to an already overwhelming barrage of medications, and when safety and judgment are at risk, we have to ask ourselves if this kind of treatment provides the best option and potential outcome for our clients? Do our injured employees control their pain or does their pain control them? Does narcotic management offer them the best quality of life? How do we manage and support the injured employees on narcotics?

From a case manager’s perspective, these tips are some of what we look at when asked to provide our expertise when narcotics are of a concern or costs are an issue for the carrier.

When narcotics are used long term:
  • Physicians should be addressing alternative medications with specific goals in place to reduce or eliminate the narcotics with a projected end date in place or targeted goal date set

  • Patient contracts should be in place to review and monitor narcotic use

  • Patient contracts and usage should be reviewed monthly or at every office visit (violations to the contract should prompt the physician to explore medications and compliance more thoroughly)

  • Random and routine drug toxicity screens should be ordered and reviewed by treating physicians

  • Physicians should routinely be asking their patients if other physicians are prescribing medications

  • CURES reports (Controlled Substance Utilization Review and Evaluation System) should be requested by treating physicians to be aware of other prescribing physicians and medications

  • Routine liver function studies testing should be done every 6 months to assess liver function

Clear and written instruction from physicians regarding the use of alcohol and other medications while using narcotics.

Do our injured employees control their pain or does their pain control them?
From a nurse case management perspective, narcotic dependence/addiction has become increasingly prevalent and detrimental in the lives of many of our workers’ compensation claims. Fortunately, in the two case studies shared, there were successful outcomes by reducing or eliminating narcotics which allowed our patients to return to “life”. While these “Faces behind Narcotics” were successful, there are countless others whose “Faces” are painted in shadows of despair, dependence, addiction, and poor quality of life. In many instances, these patients are “existing” – living life waiting from one prescription to the next. These “Faces behind Narcotics” are the cases in which a voice is needed; an advocate of the process is needed- specifically a nurse case manager.

While the impression today for many is that the nurse is the “enemy” or is there “to take things away and make things more difficult,” the truth is the right nurse case manager can be an instrumental asset in the life changing outcomes of some of these cases. Earlier intervention in these workers’ compensation cases would almost certainly impact the patient, their quality of life, the medical treatment, pharmaceutical concerns and expenses, and the overall outcome of the case. Ideally, these “Faces behind Narcotics” would merely be success stories of positive interventions which prevented chronic pain and narcotic issues from spiraling out of control.

Narcotic dependence/addiction has become increasingly prevalent and detrimental to injured workers.
Sue Bowers, RN, BSN, CCM, is the president and cofounder of Choices Case Management, a case management company providing quality and expert nurse case management services for Workers’ Compensation in Northern California.

Choices Case Management
1145 2nd Street, Ste. A #315
Brentwood, CA 94513
Phone: 925-516-3901
Fax: 925-516-3905



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