Continuing Medical Maintenance

Continuing medical maintenance (CMM) is the latest hot topic in Oklahoma workers' compensation. Usage of generic and designer drugs is on the rise. Thanks to the ubiquitous marketing campaigns of the drug companies, patients can now tell their doctors what to prescribe for their ailments.

In the workers' compensation world this translates into escalating use of narcotics to control chronic non-cancer pain. Unfortunately the pain relieving effect brings the risk of side effects that alter the emotional and mental status of the patient. They also may increase the patient's pain sensitivity. Besides the risk to the patient, there is an ever increasing expense to the insurance carrier.

Judges must weight these costs and benefits while complying with the legal intent of CMM to provide stability to the injured worker's condition after he has reached maximum medical improvement. We are concerned that the Physican Advisory Committee Guidelines for Prescription of Opioid Medications is not followed after a CMM order is issued with the resulting escalation of narcotic strength and dosage. It should be noted that the Guidelines require the physician to wean the patient from narcotics if there has not been an improvement in physical functioning. I seldom see this happening after a CMM order.

How can we balance the needs and risks? There are no guidelines that establish fact patterns justifying a CMM order. Case law requires medical evidence before a time limitation can be imposed, and statements that CMM "should be limited to ___ months" are conspicuously absent from the medical reports. Current orders used by all the judges allow the parties [insurance carriers, this includes you] to modify or review the CMM order at any time, but they never do.

So, what can we do? As usual there isn't just one approach to solving the problem. We can wait for an appellate decision that settles the issue, or we can wait for the legislature to enact restrictions, or . . . .

Rather than waiting, I have revised my standard CMM orders.

If the claimant is expected to receive narcotics, my order will automatically review the case in six months to decide whether he and his physician are complying with the Guidelines. If there is no improvement of function over the baseline, weaning may be ordered; or the review may be rescheduled until I am satisfied that continued dispensing of narcotics is justified.

If the claimant is not expected to receive narcotics, there is no review; and narcotics may not be prescribed without a subsequent court order.

This approach imposes limitations that protect the injured worker and assures Court review. Let's not allow the cure to be worse than the injury.