MSRB: Past, Present and Possible Future Issues Beth Baker, MD, MPH - - PowerPoint PPT Presentation

MSRB: Past, Present and Possible Future Issues

Beth Baker, MD, MPH Specialists in OEM SFM MCIT

MSRB

 Past Chair MSRB: 2003-2012  Jeff Bonsell, DC- Current Chair  William Lohman, MD

Medical Director- MN DOLI

MSRB- What does it do?

 Advise DOLI about medical issues  Liaison between DOLI and medical community  Authority to sanction medical provider after OAH

hearing (never?)

 Draft treatment parameters

 Select topics to study  Literature review  Change in prior parameters or new draft

MSRB

 1983: MN Statute  2 chiropractors  1 RN  1 PT  1 OT  6 physicians (different

specialties)

 Commissioner Designee  1 labor representative  1 employer/insurer  1 public  1 hospital administrator  Alternates  DOLI staff

2010- Medications

 5221.6105  Non-steroidal anti-inflammatory drugs (NSAIDS)

 Start with generic nonselective NSAID  1 week trial of ibuprofen or naproxen  Cox-2 inhibitor if:

 Age >60  History of peptic ulcer disease or gastrointestinal bleed  History of GI side effects with other nonselective NSAID  If increased risk of cardiovascular disease or on ASA- don’t use

Cox-2 inhibitor- use NSAID plus gastro protective med

Opioids

 Start with generic opioid

 Codeine, hydrocodone, oxycodone, morphine

 Meperidine is not indicated  Transcutaneous opioid only if documented disorder that

prevents adequate oral dosing

 Oral transmucosal or buccal preparations

• nly if

documented disorder that prevents adequate dosing with swallowed medication

Muscle Relaxants

 Start with generic

 Carisoprodol, chlorzoxazone, cyclobenzaprine,

methocarbamol, trizanide

 Benzodiazepine not indicated as muscle relaxant

 Diazepam or valium

2013 Rule Making

 Spinal Cord Stimulator  Intrathecal Drug Delivery System  Rulemaking docket  Request for preliminary comments:

February 11, 2013

Spinal Cord Stimulator

 Electrical generator that delivers

pulses to targeted spinal cord area

 Leads implanted by:

 Laminectomy= permanent  Percutaneous= temporary or permanent

 Source of power: Implanted battery

• r radio-frequency transmitter

SCS

 If persistent disabling radicular pain following surgery and no

evidence of compressed nerve root: discuss risk and benefits of spinal cord stimulator (weak recommendation)

 Shared decision making recommended because of high rate of

complications

 25% or more develop complications

 Electrode migration, infection, wound breakdown, generator pocket

related complications, electrode migration

 No trials comparing SCS to intensive chronic pain program

 Chou et al. Intervention Therapies, Surgery, and Interdisciplinary

Rehabilitation for lbp: An Evidenced-Based Clinical Practice Guideline from the American Pain Society. Spine 2009 (34) 10: 1066-1077

SCS

 Severe persistent leg and back pain  Appropriate psychological screening  Successful percutaneous trial (2-60days)

> 50% decrease in pain

 Stable or improved pattern of medication use  If nonresponders implanted anyway- none were a success  North. Spine 2002: 27(22): 2584-2591.

SCS Proposed Parameter

 Very limited application  At least 50% relief during trial lasting at least 3 days  Trial screening period only if:

 Intractable pain  Not a candidate for other surgery  No untreatable major psychological or psychiatric comorbidity

that would prevent patient form benefiting

 Provider shall refer for psychological/psychiatric evauation.

 Second opinion (from outside practice) confirms need for SCS

Intrathecal Delivery System Proposed

 Very Limited Application  At least 50% relief during trial lasting at

least 24 hours

 Trial screening period only if:

 Intractable pain  Not a candidate for other surgery  No untreatable major psychological or psychiatric comorbidity

that would prevent patient form benefiting

 Provider shall refer for psychological/psychiatric eval.

 Second opinion (from outside practice) confirms need for SCS

2013 Lumbar Fusion Fact Sheet



On MN DOLI website



What injured workers should know about lumbar fusion surgery as a treatment for degenerative disc disease



What injured workers should know about lumbar fusion surgery as a treatment for degenerative disc disease



This information sheet is for injured workers with a Minnesota workers’ compensation claim who are considering lumbar fusion

• surgery. It does not provide medical advice. Whether lumbar fusion

is right for you is a choice you must make with your doctor.



What is lumbar fusion surgery?



Lumbar fusion surgery is performed as treatment for a number of different conditions that affect the structural integrity of the spine (for example, certain spinal fractures). Lumbar fusion surgery is also sometimes performed for treatment of severe chronic low back pain in patients with degeneration of one or more lumbar discs.

2013 Lumbar Fusion Sheet

 Lumbar Fusion Information Sheet 2013  Addresses fusion for chronic lbp due to degenerative

disc disease  1/2 injured workers get better (1/3 poor results)  Some studies show fusion patients do better than usual

treatment but same results as intensive med management and rehab

 10-20% complication rate  ¼ will have another lumbar surgery  < 50% return to work  Most continue to require strong pain meds

2013 Lumbar Fusion Sheet

 You are allowed a second opinion  Current lumbar fusion parameter

 Incapacitating low back pain > 3 months  Positive discogram at one more more levels  Need preauthorization for surgery unless emergency

2013 Lumbar Fusion Sheet

 American Pain Society 2009  “shared decision making regarding surgery for

nonspecific low back pain…… the fact that the majority

• f such patients who undergo surgery do not

experience optimal outcome”

2013 Lumbar Fusion Sheet

 American Association of Neurological Surgeons 2005  “Lumbar fusion is recommended as a treatment for

carefully selected patients with disabling low back pain due to one or two level DD without stenosis or spondylolisthesis…. an intensive course of PT and cognitive therapy is recommended as a treatment

• ption for patients with lbp in with home conventional

medical management has failed”

2013 Lumbar Fusion Sheet

 Internal Society for the Advancement of Spine Surgery

in 2007

 Fusion only indicated for chronic lbp and DDD if "the

patient has not shown significant improvement from a minimum of 6 consecutive months of structure conservative care” and “subsequently not shown sufficient improvement from a program of intensive multidisciplinary rehab”

How MSRB makes recommendations

 Lumbar fusions  Literature review by Dr. Lohman  Presented to MSRB  Preliminary recommendations

 2013 Lumbar fusion sheet

 Final recommendations

 ? Revise prior lumbar fusion treatment parameter

2013 Work Comp Bill

 MSRB may be asked to provide advice regarding:  Commissioner of labor and industry will implement:

 2 year patient advocate program for back fusion surgery  Ensure injured workers understands treatment options

and receive tx. according to accepted medical standards

 Services provided by patient advocate shall be paid from

special compensation fund

Current topics: Lumbar fusion

 Minnesota data review

 Back surgery costs 16% above national average  Fusion costs up to $80,000  Fusion cost increased 500% between 1992-2003  Fusions are 47% of total spine surgeries  2010: 265 spinal fusions (MDH inpatient data)  81% spinal fusions in Twin Cities

Methodology issues

 Multiple types of fusions

 Posterior lumbar interbody fusion (PLIF)  Posterolateral fusion (PLF)  Anterior lumbar interbody fusion (ALIF)  Transforaminal lumbar interbody fusion (TLIF)

 Can be done with or without instrumentation  Varying types of instrumentation used

Fusion better than nonsurgical tx.

 29% Much better in fusion group

 17% surgical complication rate  9% life threatening

 14% Much better in nonsurgical group  Compared fusion vs. usual treatment  Pain improved most in first 6 months and then

gradually deteriorated  Fritzell et al, Spine 2001, Spine 2004

Fusion versus Cognitive intervention and exercise

 Equal improvement

 70% success with fusion

 18% surgical complication rate

 76% success with cognitive. tx + exercise

 Randomized prospective study

 Brox et al, Spine, 2003

Outcome of Lumbar Fusion

 Nguyen 2011  Ohio Work Comp data  Fusion vs. non-operative tx for chronic lbp  RTW at 2 years: 26% fusion, 67% non-op  Repeat surgery 27%  Surgical complications 36%  Opioid mean dose increased 41% after fusion

 76% fusion subjects remained on opioids

Spinal Fusions in US

 Rajaee, Spine 2012  1998-2008  National cost of fusions increased 7.9 X  Mean total hospital changes for fusions increased 3.3 X  Number of fusion surgery discharges increased 137%

Discogram

 Provocative discogram lacks evidence of ability to

predict successful fusion outcomes  Chou Spine 2009

 Discogram appears to accelerate risk in next 10 years

• f:

 Future DDD  Serious lbp- 3 X  Medical visits- 5X  Work loss 3 X  Carragee Spine 2009

Future topics

 Epidural injections- ? Is it worth revising old treatment

parameter

 Literature review completed 2011

 Results mostly align with current treatment parameters

 1995 Treatment Parameters, updated prn

 Therapeutic Injections  Repeat injection only if positive response to first injection  Maximum allowed:

 Nerve root block ( 2 per site) now often called

transformational epidural

 Epidural injection- 3 injections

Epidural injections

 Recommendations vary  Some reviews include only randomized controlled trials

(RCTs)

 Diagnostic vs. therapeutic  Guided by imaging techniques?  Steroids vs. anesthetics vs. other meds  Lumpers vs. splitters

Epidural injections

 Deliver drug into epidural space  Various approaches: caudal, interlaminar,

transforaminal

Cochrane Review 2009

 No strong evidence for or against use of any type of

injection therapy for sub acute or chronic lbp without radicular pain

 Small studies (only 3 had > 100 patients)  Injection sites, drugs used and outcomes measured

varied greatly

 Generally safe?  Staal et al. Cochrane Database of Systematic Review:

3: 2009

American Society of Interventional Pain Physicians (ASIPP)

 Caudal epidural



Strong evidence for short term relief (< 6 weeks)



Moderate for long term relief in chronic lbp and radicular symptoms

 Interlaminar epidural

 Strong evidence for short term relief (< 6 weeks)  Limited for long term relief of lumbar radiculopathy and chronic back pain

 Transforaminal epidural

 Strong evidence for short term relief (< 6 weeks) and moderate for long

term improvement in lumbar nerve root pain



Boswell et al. Pain Physician 2007: 10: 7-111



Boswell et al. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician 2007: 10: 7-111

2013 Chronic Pain Parameter?

 Previous version 2008-2009  Not adopted by DOLI  2013 Work comp bill

 “Criteria for long term use of opioids and other scheduled

medications to alleviate intractable pain and improve function”,

 “Including the use of written contracts between injured

worker and the health care provider who prescribes the medication”

Drafting Chronic Management for opioids

 Opioids daily for more than 3 months  Not indicated unless meet A-E:

 A. Patient selection criteria

 Can’t maintain function at work, ADLs  Pain not solely psychiatric in origin  All other reasonable options exhausted  Hx of compliance and reliable prescription med use  No current substance abuse or dependence

Chronic Opioids Parameter

 Not indicated unless:

• B. No potential contraindications

 Respiratory depression on opioid  Pregnant or planning on becoming pregnant  Hx of substance abuse or substance dependence  Suicide risk  Poor impulse control  Bipolar disorder  Characterological or personality disorder  Regularly engages in activity that would be unsafe for patient

using opioids

Chronic Opioids

 Prescribing MD must obtain appropriate specialty

consultation

 C. Must be part of integrated program of treatment

 Sign written formal treatment agreement  Fixed schedule  Written plan for breakthrough or episodic pain  Must inform prescribing HCP if opioids are given by other

HCPs

 Prescribe by single health care provider or proxy  Filled at single pharmacy

Chronic Opioids

 D. Written treatment agreement

 Patient with comply with all treatment  All meds for injury from HCP or proxy  Fill at one pharmacy  Lost or stolen won’t be replaced  Not renewed prior to schedule  Provide coverage for break through pain  Terminate opioids if violates agreements

Chronic Opioids

 E. Monitoring

 Regular follow-up visits

 At least quarterly first year  Then at least annually

 Refer to pain specialist

 Sudden or progressive increase in dose  Condition deteriorates  Goals not met