Guidelines On Guidelines; Guidelines Rule



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|HAMLIN PSYCHE CENTER |

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|Thomas A. Curtis, M.D. |William W. Kaiser, Ph.D. |

|Medical Director |Director of Clinical Services |

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|Lorna Punzalan, Office Manager, ext. 218 |

|Italo Vilogron, Treatment Coordinator, ext. 220 |

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|14531 Hamlin Street | |4300 Long Beach Blvd., #240 |

|Van Nuys, CA 91411 | |Long Beach, CA 90807 |

| |Van Nuys: (818) 780-4409 | |

| |Long Beach: (562) 513-3684 | |

| |Fax (818) 780-4472 | |

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Guidelines on Guidelines; Guidelines Rule

BY THOMAS CURTIS, M.D.

I came home from work one night, sat at the dining room table in my work clothes, and wrote this all out almost verbatim.

Nothing like beginning with a conclusion.

The guidelines are wrong in the areas of benzodiazepenes, minor tranquilizers, sleep medications, and antipsychotic medications.

These medications are beneficial for alleviating anxiety and panic attacks, restoring sleep, improving cognition and controlling disruptive emotions and behaviors.

The guidelines restrict these medications due to side effects, primarily habituation; they recommend short-term use only—2 weeks for sleep medications; 4 weeks for benzodiazepenes such as Xanax, Ativan and Klonopin; 0 weeks or nothing on Fioricet (because it contains a low dose barbiturate); 0 weeks or nothing on muscle relaxers of Soma and Valium (potentially habit forming tranquilizers); and 0 weeks or nothing on the atypical antipsychotics (Seroquel or Risperdal) because such major tranquilizers are not recommended for MTUS Chronic Pain and are approved only for Schizophrenia and Bipolar Disorder. Nada. Nothing. Zero. Not Recommended. UR appeal denied. IMR upholds. The patient cannot have these psyche medications for a year. Case closed.

It had been easier before 12/14, when the following verse and passage mysteriously vanished from the Official Disability Guidelines:

“Benzodiazepines are not recommended for long-term use unless the patient is being seen by a psychiatrist.” [1]

I searched the text for the meaning of the deletion. Had it evaporated like mist in the sand? Then, on 3/25/15, there was what appeared to be a transfer of the text of the benzodiazepene section on chronic pain inserted also into an heretofore empty space now occupied under the benzodiazepene section of the mental health guidelines.

“Not recommended for long-term use because long-term efficacy is unproven and there is a risk of psychological and physical dependence or frank addiction. Most guidelines limit use to 4 weeks.” [2]

My response to these guidelines on the benzodiazepenes is set forth in a stock paragraph in UR Appeal reports from this office.

“It should be noted also that the risk of side-effects such as dependence, tolerance, overdose, cognitive deficits, increased anxiety, increased depression or other such risks should not stand as sufficient evidence to decertify a medication when no evidence of such side-effects has developed from the continued use of this medication by this patient.”

In my experience, complications such as tolerance and addiction can be managed by low dosages and physician advice. At this office, the Ativan, Klonopin and Xanax are held down mostly to low dosages such as 0.5 mg twice a day to be taken only as-needed to avert or soften an impending panic attack or severe sensation of anxiety. Patients are advised that the medication should not be taken regularly or the body will develop tolerance. They are also advised that when tolerance sets in, when the medication doesn’t work as it should, do not increase the dose, instead, just cut back and stop for a few days to get the medication sensitivity back. Then the medication will work better again. This how to avoid addiction.

The real side-effect of the benzodiazepene medications for sleep or panic anxiety is withdrawal seizures on about day two or three after quitting cold turkey on a dose of about 3.0 mg per day or more—doses three times those prescribed by this office. The risk is higher with the concurrent use of medications that lower the seizure threshold, medications such as Wellbutrin and Elavil, or the concurrent stopping of the non-benzodiazepene anti-convulsant medications used for pain such as Neurontin or Lyrica, or the anti-convulsant Bipolar Disorder medications such as Lamictal.

It is mildly amusing in every case where the UR doctor invariably follows the guideline for withdrawal of the Ativan, Xanax and Klonopin over a month when the injured worker could stop such a low dose overnight without adverse consequences. The unnecessary recommendation for withdrawal shows that these doctors are following the cookbook instead of relying upon their knowledge and experience of these medications.

I do not know who is responsible for the changes in the guidelines, presumably a group of eminent Occupational Medical specialists assigned the heavy burden of applying the principles of evidence-based medicine to the population of injured workers.

I believe in evidence-based medicine. Although it was created to serve as a dialogue between doctor and patient to weight the options of different treatment plans, evidence based medicine fits perfectly into the best way to control medical costs through the excision of unhelpful treatments unsupported by research.

The problem arises when practical guidelines have to be applied in areas of little or no research; or of research mainly on one side of the issue, for instance, of the complications rather than benefits from the Xanax, Ativan and Klonopin for panic/anxiety, the sleep medications or other such potentially habit-forming minor tranquilizers such as Fioricet and Soma.

What doctor would risk speaking up for habituating “benzos” at this time of an opioid epidemic caused by criminal physicians. After all, do not these “benzos” have a reputation of “junk medicines” when compared to the more dramatically useful antidepressants and antipsychotics.

It should be emphasized, however, that there is no research on such use of these medications by psychiatrists treating Workers’ Compensation patients in California--none.

In fact, the psychiatric research in the area of treatment of injured workers in California is relatively sparse: a more than 30-year-old study by Robert Cooper, M.D., on the MMPI; writings by Allen Enlow, M.D., eventually leading to the “Psychiatric Protocols” and the eight work functions of Permanent Partial Psychiatric Disability (PPPD) [now superseded by the AMA Guides and the GAF]; an analysis of psychological evaluations for clearance prior to major spinal surgery by a prominent psychologist, name forgotten, who consulted for decades at Orthopedic Hospital. As well, Dr. Solomon Perlo has published deeply on the psychological test confirmation of malingering and estimates of permanent psyche disability. A psychologist at the office of the late Dr. Irvin Savodnik also created a psychological test to detect malingering. There are a few other papers that I cannot recall.

Of particular importance would be the insufficiently supported AME psychiatric criteria for a “catastrophic” injury set forth in 2014 by Drs. Larson, Preston, Gilberg and others.

But that’s about it. That’s all there is on psychiatric literature in California Workers’ Compensation—on benzodiazepenes, nothing; on the major tranquilizers, nothing; on the sleep medication, nothing. There are no such studies on Workers’ Compensation applicants. None.

In my opinion, research on other groups of patients should be considered essentially inapplicable to injured workers who should not be lumped into more neurotic populations of tranquilizer seeking patients consulting with general practitioners, internists, gerontologists and surgeons. Is it not true that anyone can get injured or stressed to the point of panic, anxiety, insomnia and loss of emotional control?

What good evidence could there be that these medications should be restricted to short-timeframes in this population—that sleep medications should be restricted to two weeks, that Xanax, Ativan and Klonopin should be limited to four weeks, that Seroquel and Risperdal should be restricted to Schizophrenia and Bipolar Disorder—or for that matter that Nuvigil should be restricted to narcolepsy and shift workers, that Cerefolin, a “food,” should be restricted only for “nutritional deficiency.”

However, there has been one psychiatric paper on benzodiazepenes and guidelines—an article from the American Journal of Psychiatry entitled “Benzodiazepene Use Among Depressed Patients Treated in Mental Health Settings” (Valenstein, 2004)[3] that showed the high prevalence of the use of benzodiazepenes in an outpatient practice. This study showed one thing: The VA psychiatrists do not follow the guidelines on benzodiazepenes.

The reason that psychiatrists do not follow the guidelines may be reflected in the most recent research. For instance, in a Comment and Response in the Journal of the American Medical Association—Psychiatry in 7/15 under “Benzodiazepenes in Anxiety Disorders”, Giovanni A. Fava, M.D., Richard Balon, M.D., and Karl Rickels, M.D., citing “Efficacy and Tolerability Of Benzodiazepenes Versus Antidepressants In Anxiety Disorders: A Systematic Review And Meta-Analysis” in the journal Psychotherapy and Psychosomatics, reported that

“First, benzodiazepenes provide an effective pharmacological treatment of anxiety disorders. Their use has been in part supplanted by second-generation antidepressant drugs in recent years but this has occurred without any supporting evidence. Indeed, when benzodiazepenes and antidepressants were directly compared in clinical trials, the superiority of benzodiazepenes both in efficacy and adverse effect profile emerged…

Clinicians know that benzodiazepenes, like any other medications, are unlikely to entail permament solutions to chronic anxiety states. However, they appreciate that judicious use of benzodiazpenes can reduce stress, decrease anxiety and tension, and facilitate sleep. Physicians should be free to prescribe them like any other psychotropic drugs.” (Fava, "Benzodiazepines in Anxiety Disorders", p. 734) [4]

There is also a current study that should be relevant to the sleep medication. In The Journal of the American Academy of Psychiatry and the Law, Volume 43, Number 2, 2015, an editorial entitled “Waking Up to the Forensic and Ethics Risks of Systematic Sleep Deprivation[5] [SD] by Michael Seyferrt and Adrienne Berofsky-Seyffert indicated that

“Despite President Obama’s ban on torture when he took office, the United States has done an about-face in adopting Appendix M of the Armed Forces Manual (AFM), permitting the infliction of prolonged sleep deprivation (SD) and other so-called psychological methods. We are particularly disturbed by misinformation surrounding the impact of sleep on morbidity and mortality…Converging lines of evidence from more recent animal and human studies suggest that chronic SD caused irreversible systemic physiological damage involving bioenergetic and neuroimmune dysfunction. The effect involves the release of proinflammatory mediators that increase the risk of chronic vascular, metabolic, and neurdegenerative changes, including obesity, diabetes, cardiovascular disease and dementia…The long-term damage to specific cognitive areas of the brain are not repaired after normal levels of alertness are restored…It is clear that SD has the ability to compromise our experiential states of self-conscious awareness, language, motivated deliberation, and autonomous choice and ultimately can sabotage a sense of self-identity and moral personhood.” (Seyffert, pp. 132-133)

This research may help account for the frequent report by applicants that if they cannot sleep, everything gets worse.

To reiterate, the guidelines restrict sleep medications to two weeks. One need not look far for research that disputes the guideline restriction of two weeks for sleep medications.

According to the Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults in the Journal of Clinical Sleep Medicine Vol. 4, No. 5, 2008[6], it was stated that,

“A subset of patients with severe chronic insomnia may be appropriate candidates for longer-term or chronic maintenance treatment.”

If hypnotic medications are used long-term, regular follow-up visits should be scheduled at least every six months in order to monitor efficacy, side effects, tolerance, and abuse/misuse of medications.” (p. 501-502)

Most importantly, the authors stated that,

“Examples of short-intermediate-acting BzRAs (Benzodiazepene Receptor Agonists) include zaleplon, zolpidem, eszopiclone, triazolam and temazepam. No specific agent within this group is recommended as preferable to the others.” (p. 498)

The reader should note the inclusion of zaleplon (Sonata), zolpidem (Ambien), eszopiclone (Lunesta), triazolam (Halcion) and temazepam (Restoril), the latter two being benzodiazepenes, all recommended for the chronic maintenance treatment of insomnia.

Should I try to personally appeal to the adjusters to save costs by simply authorizing the Xanax, Ativan, Klonopin and sleep medications instead of paying more for UR. Or should I tell the patients to fill my prescriptions privately at Costco for about $15.00 per month per medication. What would you do?

Or should I try to convince the UR doctors that addiction beginning at my office has not been a problem.

While it is generally true that these people, living in varying degrees of desperation, will often try any dose of medication to relieve their pain and suffering, it is also true that the vast majority of injured workers truly do not want to become addicts, and when properly advised, will become cautious and responsible with the medications.

If you were an injured worker, would you want the government to restrict your medications to help prevent you from becoming an addict, or would you prefer to discuss it with your doctor to make your own choice in this area of medical care.

I have other questions.

Would it be fruitless now to appeal to the UR doctors to change course and begin to appropriately certify the benzodiazepenes, sleep medications and atypical antipsychotics?

Can the reviewing doctors override the guidelines on the basis of clinical knowledge and common sense?

Should IMR not be conducted by an ultra specialist, not by just another UR doctor? Should not each specialty be headed by a Board Certified expert with at least 24 months of treatment experience in the field, plus a current academic position? Would this not allow the IMR doctors to interpret the guidelines according to the most updated and best research in the field?

Should psychiatric treatment, both psychotherapy and psychotropic medications, be deferred to specialists in physical medicine, orthopedics, industrial medicine, family practice, internal medicine, pathology, anesthesiology and other non-psychiatric specialties?

Should not all mental health UR decisions be based upon the Mental Health Guidelines, not upon the ACOEM and MTUS Chronic Pain Guidelines? In my experience, even the pain patients attend psychotherapy and take psyche meds not to reduce pain, but to reduce depression, anxiety and insomnia to better adjust to their injuries and changed life circumstances. The stress patients have nothing to do with the MTUS Chronic Pain Guidelines. Their treatment should never be ruled by any pain guidelines.

There may be good news around the corner. The UR doctors may be turning around. The UR pain doctors were always the most understanding. Indeed, some of the pain UR doctors come through with all the medications approved. These appear to be experienced Occupational Physicians who know that disabling pain must be appeased not only with opiates and antidepressants, but also with the Xanax, Ativan and Klonopin for the associated panic anxiety, with sleep medication for insomnia, and with the atypical antipsychotics for depression, anxiety, mental confusion and outrage.

And the UR psychiatrists have loosened up on the withholding of long-term BuSpar for which the guidelines recommend short-term use only. The UR psyche doctors have caught on that the research on BuSpar only studied the short-term use. However, since there are essentially no side-effects, why not allow relief of tension, pressure and nervousness long-term!

There is a glimmer of hope that the UR doctors will wake up on the issue of the positive effects of these medications. Although politically incorrect at this time because of the scandal of opiate and related drug problems caused by prescribing doctors, the UR doctors have the right to override the guidelines, to find a necessary variant or exception to the guidelines, to allow for these necessary medications to relieve panic anxiety and insomnia suffered by disabled injured workers.

Hopefully, the UR doctors will also catch on soon to the atypical antipsychotics such as Seroquel and Risperdal which reduce not only depression, anxiety and thought disorder, but also panic, insomnia, irritability, anger and behavioral acting out (i.e.: potential for violence).

The UR doctors will hopefully gather the courage and experience to override the literal application of the guidelines and allow such necessary medications at low doses to avoid side effects.

It should be kept in mind that the relief of emotional pain and suffering results in increased activity, better cognition and improved sociability—“objective functional improvement.”

After all, is not the goal of reducing pain and suffering the art of medicine itself?

Thomas Curtis, M.D.

P.S.: My last writing on Workers’ Compensation was in about 1983 with a dialogue between a “smart guy” and a “dumb guy,” an attempt at a humorous approach in ridicule of a major political force at that time to compensate psyche injury according entirely to psychiatric diagnosis. Although lampooned at the time, this creative idea of a retired judge will likely eventually be achieved with computerization of multiple check mark forms and programs to provide averages for goals of treatment and disability parameters in the future.

P.P.S.: I have not fully retired! I still work half-time!

8/10/15

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[1] Chronic Pain, Anxiety medications in chronic pain. (2014, November 14). Retrieved November 15, 2014, from odg-

[2] Mental Illness & Stress, Benzodiazepines. (2015, March 25). Retrieved July 23, 2015, from odg-

[3] Valenstein, M., Taylor, K., Austin, K., Kales, H., Mccarthy, J., & Blow, F. (2004). Benzodiazepine Use Among Depressed Patients Treated in Mental Health Settings. American Journal of Psychiatry AJP, 654-661.

[4] Fava, G., Balon, R., & Rickels, K. (2015). Benzodiazepines in Anxiety Disorders. JAMA Psychiatry, 733-734.

[5] Seyffert, M., & Berofsky-Seyffert, A. (n.d.). Waking Up to the Forensic and Ethics Risks of Systematic Sleep Deprivation. The Journal of the American Academy of Psychiatry and the Law,43(2), 132-136.

[6] Journal of Clinical Sleep Medicine, 4(5), 498-502. (2008).

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