11/23/2015

The Land of “Just Right”

Finding the appropriate and best balance between less and more in workers' compensation outcomes.

By Mark Pew

The U.S. has long been known as the “land of plenty,” which often refers to natural resources and seemingly limitless possibilities. And with human knowledge doubling on average every 13 months—as opined by futurist R. Buckminster Fuller in 1982—“plenty” is in increasing supply. But is that a good thing? Are there some areas where less might actually mean more?

(Not) PRN – Often, visits to doctors’ offices are focused on prescription drug refills, many for “PRN” prescription drugs, especially short-acting opioids and antacids that come with 30 to 60 pills each time. From the Latin pro re nata, PRN generally means “for an occasion that has arisen, as circumstances require, or as needed.” Unfortunately, many patients misunderstand and decide that if they have 30 pills, they should take one each day; 60 pills should be two each day, etc. What PRN really means is to take a pill when conditions warrant, and so dispensing and using the same number of pills every month is not PRN. It has been reported that physicians wait just an average of 18 seconds before interrupting the patient’s symptom narrative, and 40-80 percent of medical information provided by health care practitioners is forgotten immediately by the patient. That is a deadly combination that contributes to the epidemic of prescription drug misuse. Pharmacists can be helpful intermediaries by explaining proper utilization, but, ultimately, the doctor-patient relationship should be strong enough so that no misunderstandings lead to inappropriate use.

What does this mean for workers’ compensation? Monitor usage of PRN drugs closely, and be wary of the same dispensed pill count upon each office visit.

Portion Control – A good meal should result in a feeling of fullness but not to the point of needing to loosen the belt a notch. Unfortunately, many restaurants do not understand that dividing line and provide larger portions than necessary. For members of the “clean plate club,” this results in a temptation to eat more than needed or food ends up wasted. The answer should be “no” when given the opportunity to supersize a meal. Dictionary.com has two different definitions of the word “satiate” that demonstrates this dividing line: “(1) to satisfy to the full; (2) to supply with anything to excess, so as to disgust or weary.” The epidemic of obesity could be affected positively by the simple act of portion control combined with more nutritious choices and higher levels of activity.

What does this mean for workers’ compensation? Educate injured workers (or employees as part of a wellness program) on proper eating habits, including portion control and proper nutrition.

Weekend Warriors – Gyms are filled on weekends with people trying to fulfill their full week’s goal of physical activity. Then they walk funny on Monday. It is generally accepted that a physically fit person will take at least 10,000 steps each day, but that doesn’t mean taking 70,000 steps on Saturday will make up for a lazy week. A truly physically fit person figures out a way to include activity to the point of raising his heart rate on a daily basis, whether it’s walking vigorously up/down the stairs instead of taking the elevator, or doing the “scientific seven-minute workout.” An active lifestyle often is a conscious choice, involving decisions to prioritize movement over lethargy and walking the longer rather than shorter distance between two points consistently throughout the week. Every human being has 86,400 seconds in each day; the difference is how they’re apportioned. If being active is not a priority, the overuse of drugs and overeating compound the negative consequences of inactivity.

What does this mean for workers’ compensation? Encourage injured workers and employees toward an active lifestyle, in words and dollars.

Just One More – Given the dire repercussions for mixing alcohol with prescription drugs like opioids and benzodiazepines, inquiring as to the level of alcohol consumption for someone on a polypharmacy regimen should be mandatory. When mixed with opioids, alcohol can increase drowsiness and dizziness, increase the risk for overdose, slow or create difficulty in breathing, impair motor control, and cause unusual behavior or memory problems. Granted, some people will obfuscate the truth. Patients often self-identify as “social drinkers,” which is a purely subjective term. To some, having a glass of wine with dinner would qualify. To others, binge drinking on the weekend qualifies because they are being sociable. The scale and scope of alcohol consumption is absolutely pertinent and relevant because it increases the possibility of unintended death, which case law in multiple jurisdictions now says is a compensable diagnosis for workers’ compensation. Even if the answer is untruthful, due diligence requires that the question at least be asked.

What does this mean for workers’ compensation? Alcohol abuse can be predictive of drug abuse or addiction; be wary of even nominal amounts of alcohol in the presence of a polypharmacy regimen.

It Takes a Village – According to a Spring 2015 study by Microsoft, humans now have an attention span of eight seconds. It has been reported previously that goldfish have an attention span of nine seconds. Oops. The decline from 12 seconds in 2000 has been attributed to electronic gadgets. Multitasking skills improved, but the ability to focus for extended periods of time has eroded. Not only are there no “unknowns” at the dinner table anymore thanks to smartphones and Google, but also there is less discussion and personal interaction. With expectations of 24/7 access from both employers and family, it increasingly is more difficult to focus on personal time that builds relationships. Many psychologists suggest periodic electronic holidays. That may not solve the issue of reduced attention spans, but it might allow more time to build a stronger sense of community. The biopsychosocial model, which is so important to returning to health and function, opines that what happens in the head and at home is as important as what happens to the body. Having real relationships with real people and taking real time to discuss real problems is a key to better management of life and pain.

What does this mean for workers’ compensation? Encourage a support system for injured workers in dealing with the health, financial, and life-changing circumstances that come from the work injury.

A balanced life with appropriate priorities and discipline can yield not only better clinical outcomes for injured workers, but also better financial outcomes for employers and payers. In some cases, that means a change in approaches by injured workers and employers. Having more is not necessarily bad, but sometimes more is less, which means sometimes less is more. And when the appropriate balance is found, everyone becomes a citizen of the land of “just right.” 



Mark Pew is senior vice president for PRIUM. He has been a CLM Fellow since 2011 and can be reached at mpew@prium.net, www.prium.net.

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