Jeffrey Fujimoto claimed that he suffered a continuous trauma psychiatric injury while employed as a body technician for Caliber Collision Centers. The parties agreed to use Myron L. Nathan, M.D., as the AME in this case. Dr. Nathan attributed 90% apportionment of the causation of the Applicant’s psychological injury to work-related stress. After a hearing in the case, the WCJ instructed the parties to obtain a definitive report from the AME, regarding factors of causation pursuant to [Rolda v. Pitney Bowes. Inc. (2001) 66 Cal. Comp.Cases 241, 247 (Appeals Board en banc)].”

Specifically the WCJ instructed Dr. Nathan as follows. “[P]lease provide a supplemental report that describes in detail, in accordance with Rolda, all the workplace and all the non-industrial related events and/or issues that combined caused the Applicant’s psychological injury. You are then to assign a percentage of causation separately to each individual work-related and/or non-industrial event(s) and/or issue(s) that, when combined, equal 100% of the causation of the Applicant’s psychological injury. You are not to combine percentages as to any multiple factors and/or issues, either industrial or non-industrial.

It will ultimately be up to me to decide which workplace activities are actual events (i.e., which of the event(s) described by the Applicant happened or not) and whether those events that I have deemed to be actual events are otherwise legitimate, non-discriminatory, good faith personnel actions. Based on this, I can determine if the actual events of employment, if added together, will result in them being the predominant cause (i.e., more than 50%) of the Applicant’s psychological injury and, whether those actual causes were substantially caused (i.e., 35% to 40%) by lawful, nondiscriminatory, good faith personnel actions.” The instruction provided the format for the AME to list and number each industrial and non-industrial event and assign a separate percentage of causation to each numbered event.

In response to the WCJ’s correspondence Dr. Nathan provided a list of 13 separately listed stressful events, and the percentage of causation of each event. After reviewing the evidence, and the 13 item list. the WCJ found that only item number 4 pertaining to a graffiti incident was an “actual event of employment” and this item caused 4% of the psychiatric injury according to the opinion of Dr Nathan. The WCJ issued his Findings of Fact and Order and Opinion on Decision finding that, in accordance with Labor Code § 3208.3(b)(1) and Rolda, that the Applicant did not sustain industrial injury to his psychological system.

The applicant’s Petition for Reconsideration was denied in the panel decision of Jeffrey Fujimoto v Caliber Collision Centers; Hartford Accident and Indemnity Company.

A WCJ is not compelled to blindly accept the testimony of any witness deemed to be untruthful given that he or she is the ultimate finder of fact and is entitled to make his or her own credibility determinations. [Garza v. Workmen’s Comp. Appeals Bd. (1970) 35 Cal. Comp. Cases 500, 505] While the WCAB may reject the findings of a WCJ and enter its own findings on the basis of its review of the record, [Labor Code § 5907] when a WCJ’s findings are supported by solid, credible evidence, they are to be accorded great weight and should be rejected only on the basis of contrary evidence of considerable substantiality. [Lamb v. Workers’ Comp. Appeals Bd. (1974) 39 Cal. Comp. Cases 310, 314]

The multilevel analysis to establish compensability for claims of injury based on personnel actions, in accordance with Rolda v. Pitney Bowes. Inc. (2001) 66 Cal. Comp. Cases 241, 247 (en banc), is as follows:
(1) whether the alleged psychological injury involves actual events of employment, a factual/legal determination;
(2) if so, whether such actual events were the predominant cause (i.e., accounting for 51% or more) of the psychological injury, a determination which requires medical evidence;
(3) if so, whether any of the actual employment events were personnel actions that were lawful, nondiscriminatory and in good faith, a factual/legal determination; and
(4) if so, whether the lawful, nondiscriminatory, good faith personnel action were a “substantial cause” (i.e., accounting for at least 35% to 40%) of the psychological injury, a determination which requires medical evidence.

Having reviewed all of Dr. Nathan’s reports and considering the Applicant’s lack of credibility in his testimony, the WCJ could not conclude that any of the Applicant’s claimed employer actions, except the graffiti were ‘actual events.’

Reuters News reports that U.S. regulators just approved a portable device to treat painkiller overdoses that people without medical training can use in emergency situations, a move to combat the rise of deaths from the abuse of opioids, including heroin. The Food and Drug Administration said making the cellphone-sized device with the recovery drug naloxone available for wider use could help save lives as opioid drug overdoses increase. The approval means emergency responders or even family members could have an easy-to-use treatment in cases of suspected overdose of opioids, which include pain drugs like oxycodone, morphine, codeine and hydrocodone as well as heroin. “It’s really an effort to make this very usable,” FDA Commissioner Margaret Hamburg said.

More than 16,000 people die each year from prescription opioid overdose in the United States, according to the FDA and the device’s maker, privately held drugmaker kaleo Inc. Opioid overdoses are mostly tied to those addicted to painkillers and heroin, but they can also happen accidentally in patients using the prescription medicines legitimately to treat pain.

The hand-held device is called Evzio and automatically delivers a set dose of naloxone, a drug ingredient already approved to treat overdose patients that works by quickly restoring breathing. Naloxone is now typically given through a nasal spray or a syringe that must be injected under the skin or into the muscle, and has been limited mostly to medical professionals at hospitals and emergency rooms as well as a growing number of police officers and other emergency responders. The version approved on Thursday is small enough to be carried in a pocket, the FDA said. Relatives and caregivers would still need training and practice on how to use the device, and several doses may be needed to revive someone, the agency added. “Making this product available could save lives by facilitating earlier use of the drug in emergency situations,” Bob Rappaport, head of the FDA division that reviews such products.

Health experts and other advocates trying to combat the effects of drug addiction welcomed the device’s approval in a conference call with the FDA, and some even suggested doctors prescribe it along with initial opioid painkiller prescriptions. But some also worried the injector could cause some people to dismiss the risks of opioid use because an antidote would be easier to access. FDA and other federal drug officials said Evzio was not a substitute for medical care and that it was essential that people who overdose still get quick medical attention.

It was not immediately clear how much the injector would cost or whether health insurance companies, including the government’s Medicare and Medicaid programs, would cover it. The device will require a prescription and will be available at pharmacies this summer, the company said, adding it had not yet set a price. Meghan Ralston of the Drug Policy Alliance advocacy group, expressed concern in a statement about costs and said people should use “whichever form of naloxone is most convenient and affordable for them.” She called on manufacturers to ensure affordability.

A growing number of municipalities have stocked other naloxone treatments and have begun training firefighters, police officers and other emergency medical personnel on how to deliver the antidote. Separately on Thursday, New York Attorney General Eric Schneiderman said the state would equip every law enforcement officer in the state with naloxone to help fight a surge in heroin overdoses. The effort would be funded with $5 million recovered from drug traffickers. Schneiderman cited data from police in Quincy, Massachusetts, which began requiring officers to carry naloxone in 2010. Since that time, the police department has used the drug 221 times and reversed overdoses in 95 percent of those cases. Last week, Massachusetts Governor Deval Patrick, in a speech declaring a public health emergency stemming from the abuse of opioids, said his state would also make naloxone more widely available.

A new survey released by Aflac found that 42 percent of all companies providing access to voluntary accident and disability insurance reported declines in their workers’ compensation claims.

The Aflac Workers’ Compensation Report, an online survey conducted by Lieberman Research Worldwide on behalf of Aflac, asked 600 employers from small, medium and large U.S. companies if they provided employees with access to accident or disability insurance and, if so, whether they noted a corresponding decline in workers’ compensation claims. When responses were broken down by company size, the survey found that 55 percent of large companies that provide access to accident insurance experienced declines in workers’ compensation claims, while 34 percent of small- and medium-sized companies each reported declines. These findings are important considering workers’ compensation benefits paid to injured workers in 2011 rose, costing American employers $77.1 billion.

“For years, insurance agents and brokers have heard anecdotal rumors linking voluntary accident and disability insurance to reduced workers’ compensation claims, and we learned the anecdotes are true based on our recent study results,” said Tye Elliott, Aflac vice president of Core Broker Sales. “These findings confirm the correlation between accident and disability insurance and reduced workers’ compensation claims. Employers can now weigh the potential positive financial effects of offering accident and disability insurance against the costs of workers’ compensation claims.”

This study has been reported in main stream media, most of the insurance journals, and the Wall Street Journal. Unfortunately, the study does not provide a financial analysis. Assuming the declines in workers’ compensation claims reduced employer costs, on the other side of the equation, providing voluntary accident and disability insurance to all employees would be an increased cost for employers who do not provide this benefit. The analysis needs to determine if the additional cost is offset by the projected savings. If there is no savings, the concept seems more like cost shifting than cost savings.

Workers’ compensation has seen a steady increase in prescriptions for topical compounded preparations, and prescriptions for sterile compounded drugs are appearing as well. In fact, the use of compounded drugs in workers’ compensation has increased nearly five-fold in the past five years. Along with increased use, the prices charged for compounds have risen, dramatically.

The quality of the preparation and the safety and efficacy of these “custom” compounds are largely unknown. Usually formulated with four to six different ingredients, compounded medications can come with staggeringly high costs, running into thousands of dollars per prescription. Compound pharmacy marketing materials tout numerous benefits of topical compounds. Compounders claim that applying topical drugs to the site of the injury theoretically avoids systemic absorption and subsequent side effects, and that combining multiple agents into a single preparation reduces the number of tablets or capsules needed and helps patients who have trouble swallowing oral preparations. Compounds can omit ingredients that cause an allergic or other adverse reaction in the patient.

Workers’ compensation payers are questioning the cost of compounds and struggling with how to assess their efficacy and appropriateness and determine appropriate reimbursement. Professionals from CompPharma’s pharmacy benefit managers (PBMs) sought answers to questions regarding compounded drugs, and just published its 41 page report on compounding.

The most common compounds in workers’ compensation are “topicals” – creams, gels or ointments that are applied to the skin and are intended to manage pain. Despite their prevalence, the report says there is very limited evidence to support the use of these preparations. Sterile products are occasionally prescribed for injured workers. Most medications billed through PBMs within this population are for implantable pain pumps. The most common medications used include clonidine, morphine, bupivacaine, hydromorphone, fentanyl, and baclofen.

In recent years some compounding pharmacies have begun pushing the boundaries by marketing new uses for existing medications. The Internet abounds with compounding companies making “therapeutic” claims for their special topical formulations. These claims have no supporting evidence of safety and efficacy. Some feature anecdotes and testimonials, but none provide suitable references. This is especially true of compounded topical pain medications. Specific formulations are claimed to be effective for neuropathic pain, inflammation, and so on. In this respect, compounding pharmacies are acting more like manufacturers without the burden of having to conduct clinical drug trials to provide evidence to back their claims.

The determination of whether a compounded medication is being appropriately used requires a comprehensive understanding of information that needs to be gathered from a variety of stakeholders. Cooperation and input from prescribers, patients, pharmacists, and claims handlers are often necessary when determining the appropriateness of compounds.

CompPharma’s research has not revealed any evidence that topical compounds are safe or effective. In fact, the evidence indicates that there is significant variation between the stated potency of a compounded product and the actual ingredients. As long as there are no regulatory requirements related to testing and post-dispensing safety surveillance, the procurement of compounded medications is indeed a situation where the prescriber must beware. While a lack of information does not prove a lack of efficacy, the lack of research suggests that ineffective topical compounded drugs are being used instead of FDA-approved drugs that have been shown to be safe and effective. The data presented also begs the question: if no strong clinical research supports the use of compounded medications, is a custom compound the right thing to do for the patient?

The battle over control and safety of compounding drugs has pitted the FDA against state boards of pharmacy. On one side, the FDA seeks to regulate the compounding of drugs that go beyond traditional compounding (individually based, specific to patient needs) into the realm of mega, non-prescription compounding. On the other, the states, spurred on by the compounding drug industry, seek to keep control by issuing new rules and passing new regulations.

Not prescribing opioids first or as a long-term therapy for chronic, non-cancer pain and avoiding MRIs, CTs and X-rays for low-back pain are among the tests and treatments identified by American Society of Anesthesiologists (ASA) that are commonly ordered but not always necessary. As part of the ABIM Foundation’s Choosing Wisely campaign, ASA today released its second list of five targeted, evidence-based recommendations that can support conversations between patients and physician anesthesiologists about what care is really necessary.

ASA’s list identified the following recommendations:

1. Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain. Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids.

2. Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient. Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in co-prescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.

3. Avoid imaging studies (MRI, CT or X-rays) for acute low-back pain without specific indications. Imaging for low-back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.

4. Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice. * Intravenous sedation, such as with propofol, midazolam, or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, should not be used as the default practice. Ideally, diagnostic procedures should be performed with local anesthetic alone. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain-relieving effects of the procedure and the potential for false positive responses ASA Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.

5. Avoid irreversible interventions for non-cancer pain that carry significant costs and/or risks. Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain.

The ASA Committee on Pain Medicine was charged with developing the Choosing Wisely list on pain medicine. Committee members submitted recommendations for the campaign, and from this list voted on which should be included in the Choosing Wisely list. The literature was then searched to provide supporting evidence. Once approved by the committee, the Choosing Wisely list was reviewed by ASA’s Chair of the Section on Subspecialties, Vice President for Scientific Affairs, Executive Committee, and Administrative Council. The American Pain Society (APS) has endorsed ASA’s Choosing Wisely list on pain medicine.

To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit ChoosingWisely.org.