CAAA 2009 Summer Convention The Effects of Substance Abuse on the WHOLE LAWYER

1. CAAA 2009 Summer Convention The Effects of Substance Abuseon the WHOLE LAWYER Ira B. Fishman, M.D.,Q.M.E.Board certified internal medicine Albany, CA 94706 irafishmanmd.com irafishman@irafishmanmd.com Please see website for some details about me; can always be contacted via emailPlease see website for some details about me; can always be contacted via email

2. AMA GUIDES STUDY OF SUBSTANCE ABUSE NARCOTICS Sexual dysfunction Reduced alertness Constipation Fatigue Decreased cognition and concentration Sudden death NSAIDs Acute myocardial infarction Ischemic stroke Hypertension GI side effects Renal side effects Briefly discuss certain classes of drugs and then touch on rating some drug induced complications, conclude with brief discussion of AlamarazBriefly discuss certain classes of drugs and then touch on rating some drug induced complications, conclude with brief discussion of Alamaraz

3. irafishmanmd.com STIMULATION: Cocaine Amphetamines Ephedra Caffeine Provigil Nicotine MOOD ALTERATION Marijuana Alcohol Will not have enough time to discuss all; will be here for afternoon session and also tomorrow morning�s session; feel free to ask questions after the presentation Will not have enough time to discuss all; will be here for afternoon session and also tomorrow morning�s session; feel free to ask questions after the presentation

4. irafishmanmd.com NARCOTIC induced Sexual dysfunction: Central hypogonadism: altered function of hypothalmus, reduced levels of pituitary stimulatory hormones, decreased production of gonadal hormones: testosterone and estrogen. Decreased libido, amenorrhea, erectile dysfunction, decreased vaginal lubrication Particularly common with long acting narcotics such as oxycontinParticularly common with long acting narcotics such as oxycontin

5. RATING NARCOTIC INDUCED SEXUAL DYSFUNCTION Page 342: Table 13.21 Criteria for rating neurologic sexual impairment Class1: 1%-9% WPI score; Sexual function is possible but with difficulty of erection or ejaculation in men or lack of awareness, excitement or lubrication in either sex. Age adjustment (page 156): Increase percentages by 50% for men younger than 40, and decrease percentages by 50% in men older than 65. Successful treatment with PDE5 inhibitors may decrease the degree of impairment (Try all three presently available if first does not work) Nocturnal tumescence study (NTS) for objective verification; no equivalent test available for women. Labs: Serum free and total testosterone, LH, FSH, Prolactin. Look for comorbid conditions: diabetes, hypercholesterolemia, hypertension, peripheral vascular disease, alcoholism, tobacco addiction. Two methods available: one neuro, one local organ: for higher degrees of dysfunction class 2 of local organs may be more specificTwo methods available: one neuro, one local organ: for higher degrees of dysfunction class 2 of local organs may be more specific

6. RATING NARCOTIC INDUCED SEXUAL DYSFUNCTION Page 156: Table 7-5 Criteria for rating permanent impairment due to penile disease Class 1: Similar to neurologic rating on p. 342. Class 2: 11%-19% WPI score: Sexual function possible with sufficient erection but with impaired ejaculation and sensation. Page 163: Table 7-9 Criteria for rating permanent impairment due to vulval and vaginal disease Class 2: 16-25% WPI score. Sexual intercourse possible only with some degree of difficulty. No objective testing for female sexual dysfunction available in routine clinical settings Examples cite penile trauma but for severe narcotic induced sexual dysfunction may analogize. Class 2 on p 342 does not specifically mention erections. Page 342 does not specifically mention sexual intercourse. Examples for women have to do with localized vaginal conditions that also alter birth canal. Examples cite penile trauma but for severe narcotic induced sexual dysfunction may analogize. Class 2 on p 342 does not specifically mention erections. Page 342 does not specifically mention sexual intercourse. Examples for women have to do with localized vaginal conditions that also alter birth canal.

7. Treatment of prescription medication addiction (opioid dependence) with newer agents: Suboxone and Subutex; no known effect at this time on hypothalmic gonadotropin releasing hormones. Less side effects than methadone; more expensive. Doesn�t affect pleasure centers, less potential for addiction, both induction and maintenance can be administered by qualified private physician in outpatient setting as opposed to needing �methadone clinic�. Subutex: Induction; sublingual tablet of buprenorphine, a partial mu-opioid agonist;Schedule III Suboxone: Maintenance: sublingual tablet of buprenorphine and naloxone. ?Reduce sexual dysfunction side effects of chronic narcotic therapy. Currently underutilized in chronic pain management setting.

8. Rating narcotic induced reduced daytime alertness Impact on cognition: neuropsychiatric evaluation (use other rating tables in Chapter 13). Page 309: Table 13-2 Criteria for rating impairment of consciousness and awareness (organic brain disease NOT for sleep disturbances) Use of Provigil (modafinil) to increase daytime alertness. Moving beyond Epworth Sleepiness Scale. Aggravation of obstructive sleep apnea (OSA); need for overnight polysomnogram. Multiple sleep latency test (MLST): Speed at which individual falls asleep during the day when instructed not to resist falling asleep. Maintenance of wakefulness test (MWT): Individual asked to stay awake in a quiet room while observed. MLST and MWT done following overnight polysomnogram. For reasonable fee of $800 (on top of $1600-1800 for polysomnogram) add MSLT and MWT.For reasonable fee of $800 (on top of $1600-1800 for polysomnogram) add MSLT and MWT.

9. Obstructive sleep apnea (OSA) is a very important disease state for consideration of adjunctive industrial treatment and/or derivative injury in: Traumatic brain injury (TBI) Asthma Upper airway disorders Hypertension Depression resistant to drug treatment Narcotic dependency Weight gain

10. Rating narcotic induced reduced daytime alertness Page 317: Table 13-4. Criteria for rating impairment due to sleep and arousal disorders. Class 2 does not mention sleep pattern as does Class 1: 10-29% WPI score: reduced daytime alertness interferes with ability to perform some activities of daily living. Underrating individuals who on chronically maintained on narcotics by pain management specialists: both with regard to sexual dysfunction and reduced daytime alertness. Underrating individuals who on chronically maintained on narcotics by pain management specialists: both with regard to sexual dysfunction and reduced daytime alertness.

11. Rating narcotic induced constipation Accompanying symptoms: abdominal pain, bloating, pain with defecation, hemorrhoids (document presence), diverticulitis. Page 128: Table 6.4 Criteria for rating permanent impairment due to colonic and rectal disorders. One of few tables available in AMA Guides with specific description of pain (e.g. moderate, periodic, continual, severe persistent) Class 2 10-24% WPI score: mild GI symptoms with occasional disturbances of bowel function, accompanied by moderate pain; mild symptomatic therapy may be necessary. (Per Alamaraz, ?dispense with objective evidence requirement if for example: no hemorrhoids).

12. Cardiovascular side effects of NSAIDs 3 criteria to qualify for monetary award under 11/9/07 Merck settlement terms for Vioxx civil suits. 1. Occurrence of heart attack or ischemic stroke. 2. At least 30 pills of Vioxx must have been dispensed in a 60 day period. 3. There must be evidence that the claimant used Vioxx within 14 days of the alleged injury. ALL NSAIDs have same PDR �black box� warning 5 billion dollar settlement. Irony is that all NSAIDs have this risk. 5 billion dollar settlement. Irony is that all NSAIDs have this risk.

13. NSAIDs : PDR �black box� warning (example Naprosyn: Cardiovascular risk) NSAIDs may cause increased risk of serious cardiovascular thrombotic events, myocardial infarction and stroke which can be fatal. Risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk. Warnings: All NSAIDs, both COX-2 selective and non-selective agents may have a similar risk. PD Rating: page 36: Table 3-6a Criteria for rating permanent impairment due to coronary heart disease and Table 3-6b: Maximal and 90% of maximal achievable heart rate, by age and sex.

14. Almaraz considerations (1): Adequate rating tables for internal medicine (IM) disease states often available in the AMA Guides,5th edition. Could even have a reverse rating effect; for example decreasing 30% WPI score for mild asymptomatic LVH in controlled hypertension. Areas of IM where Alamaraz potentially useful: Type 2 diabetes, industrially induced weight gain, irritable bowel syndrome, GERD, nonulcer dyspepsia, drug induced nausea and vomiting, fibromyalgia. For some of these conditions, one could potentially analogize to an AMA Table that contains specific descriptive language of pain and impact on ADLs. Most likely, this would provide a more accurate permanent impairment rating in keeping with Almaraz guidelines.

15. Almaraz considerations (2): Ferris vs. United Airlines: not a panacea. Functional somatic syndromes: more accurate ratings that include pain descriptions. Type 2 diabetes: accounting for insulin therapy. Dr. Kneapler analogized to hernia table because the pain was located in the abdomen and specifically interfered with lifting.Dr. Kneapler analogized to hernia table because the pain was located in the abdomen and specifically interfered with lifting.

16. irafishmanmd.com Dr. Fishman�s take home points on this fine summer afternoon: Suboxone for treatment of chronic opioid dependency Narcotic induced sexual dysfunction affects men AND women; no objective testing for women. All NSAIDs can be associated with myocardial infarction and/or ischemic stroke. Obstructive sleep apnea linked to many diseases. Add daytime alertness studies to polysomnogram. Cover letters do matter.