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Appeals court considers whether workers’ comp should cover an opioid for back pain

If a doctor prescribes medication for an injured worker that generally isn’t recommended, does workers’ comp have to pay for it? 

In 1999, Adonis Holland fell 25 feet from a ladder and suffered back and leg injuries while employed by Oncore Construction Co. in Washington, DC. He was diagnosed with lumbar strain, lumbar disc syndrome and an inflammatory condition affecting the spinal nerve root.

A doctor prescribed home exercise, pain medications, physical therapy, intravenous neural enhancement therapy, trigger point injections and a lumbar brace. None of these treatments gave Holland extended relief from pain.

An independent medical evaluation (IME) in November 2007 said Holland had reached maximum improvement, he could perform sedentary to light-duty work and that no further treatment was indicated.

In January 2011, his treating physician said Holland’s condition had worsened over the years and he could no longer work. The doctor prescribed oxycodone in 2001.

Holland’s original physician died, and a new one continued his oxycodone prescription. He sought to have the oxycodone covered by workers’ comp. His employer challenged the necessity and reasonableness of oxycodone and requested a Utilization Review (UR) report.

The UR report noted the new doctor’s records didn’t contain:

  • a comprehensive evaluation with regard to the nature and sources of Holland’s back pain
  • review of his prior records, imaging studies or EMGs, or
  • referral for appropriate diagnosis and management of his reported chronic pain.

The report also said opioid use “should be monitored closely and restricted.” It stated “the absence of a contract for controlled substances for nearly two years following the initiation of chronic narcotic therapy along with monitoring of urine for potential abuse is … substandard care.” The report also suggested alternative therapies be tried.

The new doctor’s care didn’t meet appropriate guidelines, according to the report, and the use of narcotic pain medication was “not considered a medically appropriate treatment for chronic lumbar pain of this nature.”

An administrative law judge (ALJ) heard the case. Holland testified he’d tried physical therapy, cortisone shots and epidurals under a doctor’s supervision, but none of those options provided relief. Holland also said he’d signed a controlled substances consent form and the new doctor conducted random urine testing. The oxycodone was necessary, according to Holland, so he could participate in everyday activities.

The ALJ found Holland’s testimony “very credible.” Nevertheless, the ALJ concluded Holland’s continued use of oxycodone wasn’t reasonable or necessary, therefore shouldn’t be paid for by workers’ comp. The ALJ based his ruling on the UR. The Compensation Review Board (CRB) upheld the ALJ’s decision. Holland took his case to a DC appeals court.

The appeals court found the previous order failed to:

  • account for evidence that alternative therapies had been unsuccessful, and
  • consider the use of opioids in Holland’s unique circumstances.

The court noted the ALJ found Holland’s testimony to be credible, and that he had listed the previous therapies he tried that didn’t provide relief from the back pain. Also, the IME indicated no further treatment was needed.

The court said this contradicted the UR report suggesting that alternative treatments were reasonable and necessary.

The ALJ had also accepted the general conclusion that the use of controlled substances on a regular basis for non-cancer pain is considered to be a “substandard approach.” The appeals court said the ALJ was required to weigh the evidence in the record that showed oxycodone had alleviated Holland’s pain and that he hadn’t suffered any substance abuse issues. In other words, general medical conclusions can’t always be applied for every patient.

The appeals court overturned the previous decision. The employer couldn’t deny coverage for oxycodone for Holland under workers’ comp.

(Adonis Holland v. Oncore Construction Company, District of Columbia Court of Appeals, No. 16-AA-0846, 6/21/18)

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