North Carolina already had one significant snowfall during December of 2018 and early in 2018, southeast Virginia was struck by a crippling blizzard. Ice, snow, and cold weather can make it extremely difficult to work – especially for construction workers and anyone who works outside. Anyone who walks outside may slip and fall on the ice. Well-known dangers, although rare in our neck of the woods,  include hypothermia and frostbite.

Some examples of outdoor work include:

• Construction work
• Snow cleanup crews
• Police officers
• Firefighters
• Sanitation workers
• Emergency medical technicians
• Highway maintenance crews
• Landscapers
• HVAC Technicians
• Utility Workers
• Refuse and Recyclable Collectors
• Surveyors

Cold weather can be relative. Some climates are known for their cold weather and people there understand what steps are needed to protect roads, pipes from bursting due to freezing, and most of all people. Other climates including southern climates often don’t understand how to respond to cold weather and the city crews with their meager supplies and equipment are quickly overwhelmed when extreme winter weather takes over. It is not their fault; it is simply such a rarity that it is not worth the expenditure to purchase the extra equipment.

The OSHA Cold Stress Guide

As with all worker’s compensation claims, there is no requirement to prove fault. If an accident at work causes the employee to be injured, the employee has a right to demand wage loss benefits and payment for the medical costs to get healthy again. The employer is generally liable even if it did everything it could to prevent the accident.

Employers and employees should both understand the risks of working in cold weather and to how to minimize those risks. The Occupational Safety and Health Administration does have some guidelines on what employers can do to help any worker who works outside in extreme cold or a combination of cold and wet weather.

Still, employers are required to comply with “hazard-specific safety and health standards.” Employers must also “provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.” Employers should also use standards that are commonplace in their industry.

Risk factors for cold stress

Cold weather includes more than just looking at the temperature. It also requires looking at how wind chill makes it feel colder.

In addition to wind, the following factors can make cold weather more difficult to manage, according to OSHA:

• Wet and damp weather
• Employee fatigue
• Not being properly dressed for winter. Workers should wear layered clothing and have protection for their hands, fingers, feet, toes and face.
• Workers who are in poor health or who have certain risk factors such as diabetes, hypertension, and hypothyroidism should stay inside.

Cold weather places stress on the body by shifting blood flow, over time, away from the extremities to the body’s internal organs, the chest, and the abdomen. This shift plus any exposure of the extremities increases the body’s risk for hypothermia, frostbite, and trench foot.

What is hypothermia?

Hypothermia is a dangerous condition which happens “when body heat is lost faster than it can be replaced.” Another factor is that the body’s temperature drops to below 95 degrees F instead of its normal temperature of 98.6 degrees F. Hypothermia normally occurs at very cold temperatures. It can, however, happen even at temperatures above 40 degrees F if other elements exist. These elements include exposure to rain, sweating, or being submersed in cold water such as falling into a lake or pond.

Hypothermia symptoms. Mild symptoms include shivering and stomping one’s feet to try to get the blood circulating. More serious conditions include a falling body temperature. The worker will stop shivering and may become confused and disoriented. He/she may show signs of losing coordination. Workers may not be able to stand. Their pupils become dilated. Their pulse and breathing slow. Workers with hypothermia may lose consciousness. In tragic cases, they may if they don’t get immediate help.

Treatment for hypothermia. Any worker, supervisor, or helper should call 911 or seek immediate medical help. Some of the many common steps OSHA recommends include:

• Moving the worker to a dry, warm location
• Taking off any wet clothes and putting on dry clothes.
• Covering the whole body including the head and neck with blankets – and with “a vapor barrier.” The face should not be covered.
• If medical help is over 30 minutes away, the worker should
  • Be given warm sweet drinks (but no alcoholic drinks) which can help raise the worker’s body temperature. If the person isn’t conscious, then he/she should not be given a drink.
  • Placing “warm bottles or hot packs in the armpits, the sides of the chest, and the groin. Call 911 for additional rewarming instructions.”

If the worker isn’t breathing or doesn’t have a pulse, a call to 911 for emergency help should be made immediately. Additionally, OSHA recommends:

• That the general instructions above, other than being given fluids, should be followed
• The worker should be checked again for signs of breathing and for a pulse. The check should be for 60 seconds.
• A 911 operator or emergency medical service worker should start chest compressions – or direct someone at the site on how to perform chest compressions. OSHA’s cold weather guidelines provide that “Chest compressions are recommended only if the patient will not receive medical care within 3 hours.”

The dangers of frostbite?

Frostbite occurs when the skin freezes and the tissue beneath the skin is affected. The lower the temperature, the greater the risk of frostbite. The hands and face are normally the parts of the body affected. In severe cases, amputation may be required.

Frostbite symptoms include red skin with gray and white patches. There’s numbness in the body part affected. There can be a feeling of hardness in the hand, foot, or body part. In severe cases, there may be blisters.

Treatment for frostbite. Generally, the treatments for hypothermia should also be used to treat frostbite. Additional treatment considerations include:

• Do loosely cover the affected body part and try to protect that part.
• Do give the worker warm sweetened drinks – if they are alert but not if they are unconscious. Don’t give the worker any alcohol.
• Don’t do the following:
  • Don’t rub the frostbitten party of the body. This can cause more harm.
  • Don’t apply water or snow.
  • Don’t break the blisters
  • Don’t try to rewarm the frostbitten area yourself such as by placing the hand or foot in warm water. This can cause tissue damage. Instead, be sure to get medical help. Medical professionals should understand the right way to warm the affected part.

Attorney Joe Miller Esq. fights for injured workers in North Carolina and Virginia. He’s been helping workers get just recoveries for 30 years. Attorney Miller works with your doctors and independent doctors to fully understand your medical needs. To make an appointment, call 1-(888) 667-8295 or fill out my contact form.

According to the Centers for Disease Control and Prevention, nearly 9 people are killed and 1,000 people injured by a distracted driver – each day. Distracted driving is dangerous for three fundamental reasons:

• Distracted drivers aren’t looking the road in front of them
• Distracted drivers don’t have their hands on the steering wheel. This makes it tough to respond to emergencies. Careful drivers have both hands on the wheel.
• Distracted drivers aren’t thinking about how to respond to dangers such as by braking, steering into a different lane, slowing down, or taking other safety measures.

Types of distracted driving

Common examples of distracted driving including

• Texting while driving
• Speaking on a smartphone or cell phone
• Using a GPS system
• Eating while driving
• Adjusting the radio
• Looking at a video
• Conversing with passengers especially those in the back seat
• Personal grooming
• Drinking a beverage such as coffee or soda
• Smoking

Drivers who are tired or who are under the influence of alcohol are also unable to anticipate, control, and respond to emergencies.

A momentary lapse of even a second can be fatal or cause catastrophic injuries. A car travelling at 60mph is travelling 88 feet per second – which is about 4-5 car lengths.

The CDC reports that teenagers have an especially high likelihood of driving while distracted:

• Drivers less than 20 years of age have the highest rate of distraction-related fatal accidents
• In 2015, nearly two in five high-school students said that they sent an email or text while driving in the previous 30 days. Many of these young drivers also admitted that they didn’t wear a seat-belt while they were sending these emails and texts.

Texting while driving laws in North Carolina

North Carolina enacted a strong texting while driving ban that applies to all drivers though it is especially tough on novice drivers. The law provides that adult drivers can speak on their cell phones while behind the wheel but they can NOT text while the car is in motion. The texting while driving ban applies to reading, sending, or composing a text message. It is not illegal to text if the car is stopped or is parked. Violators can be stopped by a police officer and ticketed even if they haven’t committed another traffic offense.

Drivers under the age of 18 (novice drivers) can’t text while driving. They also can’t use a cell-phone (even a hands-free phone). Novice drivers can also be stopped if they haven’t committed another traffic offense.

Bus drivers are also banned from using a cell phone while their bus is in motion – in addition to the texting while driving fan.

Texting while driving in Virginia

In Virginia, it is unlawful for any person to operate a moving motor vehicle on the highways in the Commonwealth while using any handheld personal communications device to:

1. Manually enter multiple letters or text in the device as a means of communicating with another person; or
2. Read any email or text message transmitted to the device or stored within the device, provided that this prohibition shall not apply to any name or number stored within the device nor to any caller identification information.

Fines are $125.00 for the first offense and $250.00 thereafter.

The dangers of driving while tired

Nearly 20 percent of all fatal car crashes are caused by a driver who is too tired – as reported by the AAA Foundation for Traffic Safety, The foundation also found that young drivers, those between 19 and 24, were the most likely to drive while fatigued. While nearly all drivers understand the dangers of driving drowsy, most drivers still drive – even though it puts their lives, the lives of passengers, the lives of other car occupants, and the lives of pedestrians at risk.

Indicators a driver is drowsy

Drivers and occupants of the cars need to know when they need to avoid getting into the car if they’re tired or when to get off the ride if they’re getting sleepy. They’re no reason to risk a life to get somewhere a little faster. Drivers should plan to take regular rest stops. They should know where the hotels are where they can stop and sleep. Some of the signs of drowsy driving include:

• Yawning constantly
• Not remembering the most recent leg of a journey
• An inability to focus
• Shifting into other lanes of traffic
• Tailgating or getting too close to other drivers
• Near misses

• Traveling too fast
• Going through red lights
• Failing to stop for stop signs

Some recommendations for sleepy drivers include:

• Making regular rest stops for every 100 miles or for every several hours of driving time
• Get plenty of sleep before you plan a long drive
• Keep your sleep/awake patterns
• Try to have another driver so you can take turns

• Avoid medications that might make you sleepy
• Avoid relying on caffeine to keep you awake
• Don’t trust that having the radio on will keep you from getting drowsy
• Avoid using cruise control

Some automakers who are aware of the dangers of drowsy driving are working to install technology that senses when a driver is tired. The cars sound alarms and even force the car to stop. Alas, that technology does not currently exist with any reliability. All drivers are responsible for any deaths or injuries they cause due to drowsy driving.

Talk with a respected North Carolina car accident lawyer as soon as possible

In many cases, when a teenager or young driver causes death or injury, the young driver is not the owner of the vehicle. Attorney Joe Miller Esq. can explain when you can also sue the owners of the vehicle in North Carolina under the “Family Purpose Doctrine.”  The car owners are generally the people who have liability insurance to pay for all your damages if the driver caused your injuries or the death of a loved one. If there is not enough insurance to cover you claim, you may be entitled to payment for your pain and suffering and economic losses from your own uninsured or underinsurance policy.

In addition, if you were on-the-clock for your employer or your travel was connected to a business trip at the time of your accident, we can, of course, handle any Workers Compensation aspects to the claim as that is also a specialty of our firm. To make an appointment with an experienced North Carolina car accident attorney, please phone (888) 694-1671 or fill out the contact form.

We are happy to announce that Joe Miller Law has been nominated for the Costal Virginia Magazine’s “Best of” 2018! You can vote for us by following this link.

Joe Miller explains what happens if you’re hurt on the job in Virginia, and your Doctor releases you to light duty.

Who is covered under the Virginia Workers’ Compensation Act?
The Virginia worker’s compensation law covers every person who works in the service of another for hire or as an apprentice. This includes aliens and minors. It includes people whether the contract or apprenticeship is in writing or employed and even whether the contact is legal or not. The only exception is for workers who are not employed in the usual course of the trade, business, occupation or profession of the employer.

What kinds of injuries are covered under the law?
Injuries that can be identified by a single occurrence. Workplace injuries are generally covered in Virginia if:

• They were caused by an accident
• They were work related
• The occurred during work as opposed to away from work and
• The injuries must have been caused by the accident. The injury normally be due to physical change in the body.

Virginia also covers occupational diseases such as respiratory problems or exposure to toxic chemicals. The disease must be due to work though there is no need to show that specific accident caused the disease. Medical doctors usually are called in to show that the diseases were proximately caused by workplace conditions.

Ordinary diseases generally are not covered unless it can be shown with clear and convincing evidence that the disease resulted from work and not caused outside of work, and that one of the following applies:

• The disease was a natural consequence of an actual occupational disease or
• The disease was “an infectious or contagious disease contracted during ones’ employment in a hospital, sanitarium, laboratory or nursing home, or while otherwise engaged in the direct delivery of health care, or during employment as emergency rescue personnel” or
• is characteristic of the employment and was caused by conditions peculiar to the employment.

Carpal tunnel syndrome is most frequently found compensable in Virginia while other types of repetitive stress injuries may be more difficult to prove. Hearing loss is also compensable under the ordinary disease standard.

Common types of occupational illnesses include asthma, mesothelioma, bronchitis, chronic encephalopathy, black lung disease and pneumoconiosis.

What workplace injuries are not compensable under Virginia workers’ compensation law?
Except for carpal tunnel syndrome, repetitive stress injuries such as backaches and neckaches are not compensable. Aside from diseases that do not qualify as occupational diseases; back pain, neck pain, and spinal pain are not compensable unless they relate to a specific identifiable accident.

Are emotional claims compensable?
As with other workplace injuries, if a worker suffers psychiatric or emotional problems due to a specific injury, employees can be treated by a psychiatrist or psychologist – and have the bills paid for. Many workers do suffer emotionally if they, for example, suffer a broken leg. They worry about when they will get better and all the things they can’t do while they’re heal. If there isn’t a traceable accident, psychiatric damages might be compensable if they were a direct natural consequence of some work experience – such as a nurse who sees someone die.

When must Virginia Workers’ Compensation claims be brought?

• For accidents, generally two years from the date of the accident.
• For occupational diseases, generally two years from the time the worker learns of the illness or five years from the date of the last workplace exposure – whichever date is earlier.
  Some exceptions do apply. It is best to consult with an experienced Virginia workers’ compensation lawyer as soon as possible.

Does the employer have any defenses?
Not every workplace injury is compensable. Some employee misconduct can negate the right to benefits. Common defenses include:

Injuries that are self-inflicted such as suicide are not compensable. Other workplace injuries that are not paid in Virginia are:

Willful misconduct such as intentionally ignoring safety law if it’s clear that:

• The safety rule was proper
• The employee knew of the rule
• The rule was meant to protect the employee
• The employee intentionally ignored the rule
• Injuries due to the employer’s use of drugs or alcohol if the employer can show the intoxication or inebriation cause the worker’s injuries.
• Employers do have to give formal notice of any defense in compliance with the law. Attorney Joe Miller Esq. can explain if employers failed to give a proper deadline.

Can employees be punished for fraud or knowingly making false statements or failing to make necessary disclosures?
Employers who knowingly make a false statement may be found guilty of a felony. They may also lose their right to benefits. Claimants who are getting benefits have a duty to notify their employer of any significant changes that might affect his/her right to benefits. Examples include returning to another job, remarriage, being sentenced to jail, or other consequences. Employees who obtained workers’ compensation funds through fraud may be liable for any overpayments.

Can an employer fire me if a file a workers’ compensation claim?
No. Employees have a direct right to file a work injury claim in Virginia. If a worker is fired or an employer threatens an employee, the worker should immediately meet with a Virginia worker’s compensation attorney to understand his/her rights.

What if I’m an independent contractor?
Workers who are not employees cannot generally request workers’ compensation insurance. Whether a worker is an independent contractor or an employee is not always clear. A Virginia work injury attorney can explain whether you might qualify as an employee. Even if the employer says you are an independent contractor, you may be legally an employee and have work injury rights. Some of the factors that can persuade a referee that an employee is really an employee are:

• Does the employer have the right to control when, where, and how the worker does his/her job?
• How is the worker paid, how are expenses paid, who supplies the work tools?
• The general work relationship. Is there a written contract? Did the worker get benefits such as insurance, vacation, or pensions?

Speak with an Experienced Virginia Work Injury Lawyer Today
Virginia workers’ compensation attorney Joe Miller Esq. can answer all of your work injury questions. He has successfully represented thousands of injured workers during his twenty-five plus years of experience. For a free consultation, please call him at (888) 694-1671 or complete our contact form.

Most workers need to show they suffered a specific workplace injury in order to recover workers’ compensation in Virginia. There is an exception for workers who suffer a disease that is due to work. Most occupational diseases occur after months or more normally years of exposure. Many workers may not even know they acquired the disease until decades after the exposure. The delay in seeking treatment for the disease can be problematic for many workers because employers and their insurance companies are likely to initially deny coverage due to the delay and the failure to point to a specific triggering event.

Joe Miller Esq., understands the Virginia occupational illness laws. He fights for workers who suffer these diseases which are often deadly, life-threatening, or disabling. He works with doctors to determine the disease, the cause of the disease, and to show the disease was related to daily work performance. For Virginia worker’s compensation, the last day the employee was exposed is generally considered the formal date of workplace injury.

The Virginia Statutory Definition of Occupational Disease

Here is the state statutory definition of occupational disease. Some exceptions may apply. An experienced Virginia workers’ compensation attorney will know those exceptions.

“Occupational disease” means a disease arising out of and in the course of employment, but not an ordinary disease of life to which the general public is exposed outside of the employment.

An occupational disease shall be deemed to arise out of the employment only if there is apparent to the rational mind, upon consideration of all the circumstances:

• A direct causal connection between the conditions under which work is performed and the occupational disease;
• It can be seen to have followed as a natural incident of the work as a result of the exposure occasioned by the nature of the employment;
• It can be fairly traced to the employment as the proximate cause;
• It is neither a disease to which an employee may have had substantial exposure outside of the employment, nor any condition of the neck, back or spinal column;
• It is incidental to the character of the business and not independent of the relation of employer and employee; and
• It had its origin in a risk connected with the employment and flowed from that source as a natural consequence, though it need not have been foreseen or expected before its contraction.

Hearing loss and the condition of carpal tunnel syndrome are not occupational diseases. Virginia law considers them to be ordinary diseases of life. Now that does not mean they are not compensable. It means that workers who are making claims for those types of diseases must meet a higher standard of proof than the clearly defined occupational diseases. That higher standard of proof is called “clear and convincing evidence.”   

Ordinary Diseases

Generally, a worker who gets an ordinary disease does not qualify for workers’ compensation, unless certain elements of proof can connect it to the workplace, as will soon be explained.  A worker who gets an occupational disease does qualify – so it’s crucial to be able to prove that disease is occupational and not ordinary.

But this does not mean that someone who has an ordinary disease is completely out of luck.  It’s just that the standards of proof are harder, namely, that the elements must be proven by “clear and convincing evidence.” That is a much higher standard of proof than an occupational disease.

Some ordinary diseases may qualify as occupational disease, if the following conditions are clearly met:

1. If the disease can be shown to have arisen out of and in the course of employment and not due to outside causes and if one of the following exists:

a. It follows as an incident of occupational disease as defined in this title; or

b. It is an infectious or contagious disease contracted in the course of one’s employment in a hospital or sanitarium or laboratory or nursing home, or while otherwise engaged in the direct delivery of health care, or in the course of employment as emergency rescue personnel and those volunteer emergency rescue personnel. Essentially, this means people who normally provide some type of healthcare service such as nurses and ER staff and who acquire a disease may qualify for workers’ compensation, or

c. It is characteristic of the employment and was caused by conditions peculiar to such employment.

Common Types of Occupational Diseases
Many of the people who suffer an occupational disease suffer exposure to toxic chemicals. Some of the diseases associated with hazardous chemical exposure are:

• Diseases of the lung. Bronchitis, industrial asthma, lung cancer, asbestosis, and interstitial fibrosis;
• Nerve diseases. Chronic encephalopathy and peripheral polyneuropathy;
• Tuberculosis, hepatitis, Lyme disease, possibly HIV, cancer of the bladder or liver, heart disease.

Mesothelioma, a deadly form of cancer that comes from exposure to asbestos, is another common occupational work disease.  Also, many coal miners suffer from black lung disease.

Repetitive Motion Injuries and Emotional Stress Injuries

There are some occupational illnesses that are not due to exposure – rather they are due to repetitive stress. Workers who do a lot of computer work or repeat work such as assembly work in factories can develop carpel tunnel syndrome and other repetitive stress injuries. Repetitive stress injuries are also called repeated motion injuries. The most common type of repetitive stress injury affects the wrists. If detected in time; rest, rehab, and some medications can help. If not detected in time, repetitive stress injuries can become a lifelong disability. Virginia workers’ compensation law does not recognize repetitive stress injuries as occupational diseases but they are considered “ordinary diseases of life” and would therefore have to conform to the higher standards of “clear and convincing evidence” in order to be found compensable.  Carpal tunnel syndrome is probably the most frequently claimed ordinary disease of life that is found to be compensable.

Other Ordinary Diseases that might be covered.

Conditions that are related to emotional stress such as being continually exposed to traumatic events and suffering from PTSD would not be occupational diseases, but ordinary diseases of life. There have been cases where paramedics and firemen have recovered for that condition due to repeated exposure to traumatic events, as they were able to show it was work-related by clear and convincing evidence.

Other ordinary diseases and conditions such as MRSA infection, tendinitis, HIV, Deep Vein Thrombosis, Frostbite, and Lyme disease have been shown to be compensable in specific cases.

An experienced Virginia workers’ compensation attorney such as Joe Miller can explain when emotional stress related disorders, such as post-traumatic stress disorder, are covered.

Talk to a Virginia Occupational Disease Attorney Now
Virginia work injury lawyer Joe Miller understands workers’ compensation work injury law. He has been helping injured Virginia workers for over quarter of a century. He understands what workers need to prove to qualify for occupational disease benefits. For help now, call Joe Miller at (888) 694-1671 or fill out his online contact form.

Attorney Joe Miller explains a situations in which your workers’ comp might be denied in a recent interview:

The Medical Society of Virginia has new requirements for prescribing Buprenorphine for addiction. These are part of the new Virginia Laws passed in response to the nationwide opioid epidemic and huge uptick in deaths from opioid overdose. Buprenorphine, also prescribed under the brand name Subloxone, is often utilized as a means to treat heroin addiction. While it is a semi-synthetic opioid, and does produce some of the same euphoric effects as heroin and morphine, it is found that at low doses, administration of this drug allows the addict to discontinue heroin or morphine while reducing— and in some cases even eliminating— the severe symptoms of withdrawal that can be so debilitating for addicts.

There are eight steps that physicians should follow before prescribing Buprenorphine:

Step one

Prescriptions should be waivered by the Substance Abuse Mental Health Services Administration (SAMHSA), registered with the Drug Enforcement Agency, and comply with the federal and state laws for prescribing buprenorphine. Nurse practitioners and physician assistants must also be waivered and have a practice agreement with a waivered physician.

Step two

Before buprenorphine can be prescribed for opioid treatment, the physician should conduct and document a patient assessment that covers the following:

• A complete psychiatric and medical history
• A substance abuse history
• A family history review and a review of the patient’s psychological supports
• A physical examination
• A urine drug test
• A pregnancy test for women who are of childbearing age
• Testing for HIV, Hepatitis B, Hepatitis C, and tuberculosis if clinically indicated

Step three

The physician should query (ask for results of a patient search) from the Prescription Monitoring Program before starting any treatment and during treatment.

Step four

Prepare a treatment plan that includes the following:

• The reasons for choosing to use medication assistance
• An education plan for the patient
• A written informed consent from the patient
• How counseling of the patient will be achieved
• A signed agreement that details of both the patient and the physician

Step five

During the induction phase:

Initiate treatment with no more than 8mg of buprenorphine, except when medically indicated if properly documented in the medical record.
The patient should see the doctor once a week

Step six

During the stabilization phase, the prescriber should increase the dosage of buprenorphine in safe and small increments to achieve the lowest dosage without causing intoxication, withdrawal, or significant drug craving.

Step seven

During the course of treatment:

• Ensure that the patient is getting counseling
• Limit the strength of the prescription
• Dosages of more than 16 mg of buprenorphine should be documented in the medical record
• The prescriber should not prescribe more than 24mg of buprenorphine per day
• Require that the patient take urine drug tests and serum medication level tests every three months for the first year of treatment and every six months thereafter
• Incorporate relapse prevention strategies into counseling or make sure they are addressed by a mental health service provider as defined by Virginia Code
• Take steps to reduce the changes of buprenorphine diversion by:
• Using the lowest dosage possible
• Having an appropriate frequency of office visits
• Counting pills
• Checking the Prescription Monitoring Program

Step eight

Make sure the medical record includes the following documentation:

• Records should be legible, timely, accurate, and readily accessible so they can be reviewed
• The informed consent and treatment plan should be in place
• The document should meet the state code confidentiality requirements
• The documentation should comply with the Board of Medicine Regulation

Special Considerations

The prescriber should refer the patient to a mental health service provider as defined by the Virginia Code Section 54-1-2400.1 for counseling or should provide counseling to the patient and document the counseling in the record.

Prescribers should NOT prescribe buprenorphine if the patient is already taking any of the following medications (unless there are extenuating circumstances and a tapering plan to achieve the lowest possible documentation is properly documented):

• Benzodiazepine
• Sedative hypnotics
• Carisoprodol
• Tramadol

Limitations for prescribing buprenorphine mono-products

• Buprenorphine should not be prescribed without Naloxone (also known as Narcan—used to reverse the effects of opioids) unless:
  -The patient is pregnant
  -The prescriber is converting the patient from methadone to buprenorphine containing naloxone for not more than seven days
• Buprenorphine mono-tablets can be prescribed directly to patients in federally approved opioid treatment programs but, with the exception of the above conditions, only the buprenorphine product containing naloxone shall be prescribed or dispensed for use offsite from the program
• If buprenorphine mono-tablets are prescribed, the evidence for prescribing them should be put into the medical record

How to work with the following special treatment populations

• Pregnant women. They should be treated with buprenorphine mono-products that have a dosage level of 16 mg or less each day
• Patients who are less than 16 years of age. Prescribers should not approve the use of buprenorphine for treating addiction unless authorized by the Food and Drug Administration
• Patients with chronic pain. Assess the progress of patients with chronic pain by “reduction of pain and functional objectives which can be identified, quantified, and independently verified.”
• Patients with medical comorbidities. Evaluate by taking a patient history, a complete physical exam, take the right laboratory studies, and be aware of how buprenorphine interacts with other prescription medications
• Patients with psychiatric comorbidities which aren’t stable. Do not undertake buprenorphine treatment. Prescribers should refer the patient for a psychiatric evaluation and treatment before stating any prescription medication treatment program.

Speak with an experienced Virginia workers’ compensation lawyer now
Many workers who are injured are prescribed medications to manage their pain. Attorney Joe Miller works with caring qualified physicians and with the legal community to understand the latest requirements that physicians must follow. He has helped thousands of injured workers get a just recovery. To make an appointment now, please call Joe Miller Esq. by phoning him at (888) 694-1671 or using his contact form.

Attorney Joe Miller explains what mediation is and how it can be helpful:

At the Law Offices of Joe Miller Esq. and the Work Injury Center, we are very aware of the expanded use of opioids to treat work injury pain and other pain causes. As part of our continuing effort to keep informed and keep our clients and working partners informed, we are writing to advise of the latest guidelines developed by the Centers for Disease Control in Atlanta (CDC) for prescribing opioid medications. We have previously written about the new Virginia Laws on prescribing Opioids, which pretty much track the previously enacted CDC rules.

As we have reported previously, while we certainly support law enforcement and any and all efforts to curb this horrific national epidemic of opioid deaths, we are concerned that the passing of these laws and guidelines in response primarily to the actions of criminals and thugs will adversely affect our law-abiding injured worker clients. Many of our clients have suffered extremely serious injuries and opioids are often the best and only way to substantially decrease their pain after major surgeries or surgery failures.

The Centers for Disease Control in 2016 developed new guidelines in response to the opioid prescription crisis. Opioids are chemicals that work on nerves in the brain or the body to reduce the severity of pain. They are either derived directly from the seed pods of the poppy flower papaver somniferum , which is also used to make heroin, morphine and opium, or from synthesized derivatives of the plant or synthesized chemicals.

Sadly, many people are becoming addicted, overdosing, or abusing their prescriptions. The guidelines are specifically aimed at helping primary care doctors known when to prescribe the drugs and when and how to monitor their patients. The guidelines apply to patients who have pain that lasts three months or more. The guidelines do not apply to patients who take the opioids for cancer treatment, end-of-life care, or palliative care.

According to the CDC, opioid prescription use has quadrupled since 1999. Over 183,000 people have died due to their use or misuse of opioid prescriptions since that year. The recommendations are designed to provide standard current guidelines for clinical practices. Specifically, the guidelines target the choice of opioids that are prescribed, the proper dosage, how long the drugs should be used, what sort of follow-up doctors should do, and when the prescriptions should terminate.

The full guidelines can be seen here – Guidelines for Prescribing Opioids for Chronic Pain

The purpose of the guidelines

The purpose is help physicians make recommendations when they treat chronic pain. They are a “best practices” set of standards for responsible prescribing.

Non-opioid remedies are suggested such as exercise and cognitive behavior therapy. Non-opioid drugs such as anti-inflammatories are encouraged. The guidelines state the opioids should not be the routine recommendation. Even when opioids are prescribed, the doctor should combine their use with the other non-drug therapies for maximum benefit.

Doctors are advised to prescribe the lowest possible effective drug dosage and begin the treatment by using immediate-releasing opioids instead of opioids that are extended-release or long-acting. Opioid prescriptions should only be for the time needed to manage the pain duration.

Providers should follow-up with their patients by scheduling regular appointments to see if the benefits of the opioid prescription are causing their patient harm and whether their patients are applying the non-pharmacological treatments that are available.

What’s included in the guideline?

More specifically, the guidelines focus on the following three assessment areas:

• When the doctors should start and when they should continue the prescription of opioids for chronic pain. This includes the selection of non-drug therapies, non-opioid drug therapies, and opioid therapies. The goals of the chronic pain treatment should be established and the doctors and health providers should discuss the pros and cons of the therapies with their patients.
• Doctors should understand the full scope of opioid medication treatment. The guidelines cover which opioid medications should be used, what dosages should be prescribed, how long the treatment should be, and there should be a plan for when the opioid prescriptions will be discontinued
• The health providers should understand the specific ways opioids can harm the patient and what ways there are to minimize the risks. The doctors should review prescription drug monitoring program (PDMP) data. There should be urine testing to examine how much drugs are in the patient’s systems. The guidelines do mention that the doctor should consider what could happen if benzodiazepines are co-prescribed. If the patient develops an opioid use disorder, there should be a plan in place to respond to that disorder.

How do the 2016 CDC opioid prescription guidelines differ from prior guidelines?

There are several key differences:

• Different dosage recommendations. The new dosage recommendations are lower. The higher the dosage, the greater the risk the patient may overdose and die. Even low dosages, the CDC recognizes, the equivalent of 20-50 milligrams of morphine pose increased dangers.
• The prior guidelines focused on just high-risk patients. The new guidelines recognize that all opioid use patients are at risk of abuse or harm. In addition to their own monitoring programs, physicians are encouraged to use state prescription drug monitoring programs (PDMPs) which have the latest technological advances.
• The 2016 guidelines have more detailed suggestions, compared to prior guidelines, for monitoring the patient use of opioids and for terminating the opioid prescriptions when the potential dangers are more than the benefits.

Additional Centers for Disease Control activities to address the opioid crisis

In addition to offering new guidelines, the CDC is attempting to help people suffer less from opioid abuse and helping families not have to bury a loved one who overdoses in the following ways:

1. Enhancing and maximizing the use of prescription drug monitoring programs (PDMPs). These programs are databases run by the states to track the prescribing and dispensing of controlled prescription drugs to patients. The PDMPs are set up to help detect when there is abuse of opioid prescriptions such as for illegal use. The database helps the doctor doing the prescribing and the pharmacist understand the patient’s substance prescription history. In this way, your doctor and the pharmacy can see which patients are high-risk and need more aggressive intervention.
2. Helping the states create better programs though the Prevention for States program. The Prevention for States program helps states address opioid overdoses by providing the state the resources and support they need for more advanced intervention. The CDC chose 16 states to begin participation in the program starting in September 2015 to develop strategies for the safe prescription of opioids and the best way to handle abuse, misuse and overdoses. An additional 13 states, for a total of 29, were added in March of 2016. The 29 approved states include North Carolina and Virginia. The CDC plans to give each state up to $1 million to help advance prevention in four main areas:
   • Maximizing the PDMP through universal registration, making the databases easier to use and access, making the date more timely, expanding the identification and reporting of suspected abuses – all with the aim of getting a better understanding of the opioid overdose epidemic.
   • Community or Insurer/Health Systems Interventions which give technical help to counties and communities that have a high-amount of opioid abuse, improving opioid prescribing interventions for insurers and health systems, and enhancing the use of the guidelines
   • Evaluating the interventions to better understand what helps and what does not
   • A rapid response project to advance prevention of abuse.

The Prevention for States program evaluates how the state’s activities are working including focusing on relevant success stories. How well the program does will determine future national and state efforts.

3. Some of the strategies that have been developed or are being explored – for combatting the opioid crisis at the state level are:

• Finding ways to increase the use of the drug monitoring programs
• Finding ways to help pain clinics reduce the over-prescription of opioids to patients with a risk factor of abuse or problems using opioids
• Evaluating the data to find ways to “assess Medicaid, workers’ compensation programs, and state-run health plans to detect and address inappropriate prescribing of opioid pain relievers, such as through use of prior authorization, drug utilization review, and patient review and restriction programs.”
• Increasing the ability to access treatment services for substance abuse including Medication-Assisted Treatment (MAT)
• Identifying ways to expand first responder access to naloxone, aka narcan, a drug used to reverse overdose.

4.  The CDC is also working to have the states promote the use of the new 2016 CDC guidelines on Prescribing Opioids for Chronic Pain and in putting strong practices to work in the neighborhoods where drug addiction is the norm. The CDC is also working to develop and implement rapid response plans.
5.  Improving the way data is tracked and used to help monitor the crisis

Categories of opioids

The CDC examines these four types of opioids:

1. Natural opioid analgesics, including morphine and codeine, and semi-synthetic opioid analgesics, including drugs such as oxycodone (Percocet), hydrocodone (Vicodin or Narco), hydromorphone, and oxymorphone;
2. Methadone, a synthetic opioid;
3. Synthetic opioid analgesics other than methadone, including drugs such as tramadol and fentanyl; and
4. Heroin, an illicit (illegally-made) opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance from the poppy plant papaver somniferum.

Opioid analgesics (commonly referred to as prescription opioids) have been used to treat moderate to severe pain in some patients. Natural opioids, semi-synthetic opioids, methadone (a synthetic opioid), and some other synthetic opioids are commonly available by prescription.

Fentanyl is a synthetic opioid that is legally made as a pharmaceutical drug to treat severe pain, or illegally made as a non-prescription drug and is increasingly used to intensify the effects (or “high”) of other drugs, such as heroin.

Why the opioid epidemic is growing

Opioid deaths are rising across most every demographic including men, women, all races, and most ages. Over 60% of drug overdose deaths now involve an opioid. Some of the data statistics for opioid use are as follows:

According to the CDC, in 2015 there were nearly 62 deaths each day due to opioid abuse – over 22,000 for the year. This was a increase of 3000 over the number of prescription opioid deaths in 2014. A good part of the increase was due to the use of synthetic opioids other than methadone. One of the leading synthetic opioids that concerns law enforcement and is believed to be causing the increase in deaths is illegally-made or obtained fentanyl or carfentanyl. Carfentanyl has been previously described as a weapon of mass destruction and chemical weapon and is 10,000 times more powerful than morphine and 100 times more potent than fentanyl. The DEA issued a dire warning to the public regarding carfentanyl in 2016. Even casual contact with a small amount of the drug can cause sickness and death.

It can be hard to determine the exact cause of opioid deaths because the data doesn’t distinguish between legally and illegally-made fentanyl. The CDC is trying to address this disparity.

Between 1999 and 2014:

• The 25-54 age range saw the highest rates of overdose deaths
• Non-Hispanic whites, American Indians, and Alaskan Natives had higher rates of overdose deaths than non-Hispanic blacks and Hispanics.
• While men suffer more deaths from opioid deaths than woman, the gap is closing.

In about 20% of drug overdose fatalities, the death certificate does not list the specific drug that caused the death. Adding to the problem of determining which drugs caused an overdose death is that often multiple drugs (such as a prescription opioid and heroin) are found in the patient.

Prescription opioids are involved in more overdose drug fatalities than any other drug. It is believed that the proportion of deaths cause by prescription opioid use is actually higher than is being reported. Two of the reasons for the increase in opioid overdose deaths are believed to be:

1. A 15-year increase in deaths from prescription opioid overdoses
2. Illegal opioid overdoses of which heroin and fentanyl are the leading drivers. Other leaders are methadone, Oxycodone (such as OxyContin®) and Hydrocodone (such as Vicodin®)

Other risks from opioid use besides overdose deaths are abuse, addiction, and abuse

• Nearly 2 million Americans either abused or were dependent on prescription opioids in 2014.
• Nearly 25% of Americans who get prescription opioids for long-term non-cancer pain in primary care settings struggle with addiction.

The prescription opioid epidemic affects more than 1,000 people each day.

Speak with an experienced North Carolina and Virginia workers’ compensation attorney today about opioid abuse
Attorney Joe Miller Esq. has been helping injured workers for over 25 years. He has helped thousands of employees get just recoveries. Part of his work as a workers’ compensation lawyer is helping clients work with skilled medical professionals to get the medical attention and care that is required. To learn more about your work injuries and the issues in treating them, please call (888) 694-1671 or fill out our contact form.