Legislature Approves Privatization In this issue of SCF ... · operating as a mutual insurance company that ... information on AWCCA sponsors or contact information for AWCCA Executive

T H E O F F I C I A L P U B L I C AT I O N O F A W C C A , I N C .

In this issue

In something of a surprising turn of events, the Arizona State Legislature passed Senate Bill 1045 which will privatize SCF Arizona as of January 1, 2013. On that date, SCF will go from functioning as a “quasi-governmental” entity to operating as a mutual insurance company that is wholly owned by its policyholders.

Pursuant to statute, all Arizona state agencies or quasi-governmental entities must have their statutory authorization periodically re-approved by the legislature to avoid cessation of operations via “sunset” provisions. SCF’s current operating authority was scheduled to “sunset” this July. However, in advance of anticipated renewal of its operating authority, SCF underwent a review by the Auditor General’s Office, with the results being a favorable audit. SCF then underwent a “sunset hearing” before the House and Senate Committees of Reference (COR) in the fall of 2009. With the Auditor General Office’s report on SCF being positive, the COR recommended that SCF be granted a ten-year continuation. A bill to continue SCF was introduced in the House of Representatives and passed without issue. However, the bill was never assigned to a committee in the Senate.

Senate President Bob Burns eventually made it known that he wanted to see legislation that would privatize SCF Arizona rather than continuing it for another ten years in its current form. A strike-all amendment was crafted to SB 1045, transforming it from a bill that

would make a technical correction relating to the transmission of a budget report from the Governor to the legislature into a bill that would privatize Arizona’s largest provider of workers’ compensation insurance.

Early discussions about the privatization bill indicated that it could become effective as early as 2011 or possibly 2012. Ultimately, however, the final version of SB 1045 provided that SCF would become a mutual insurance company as of January 1, 2013. This extended time period will allow for plans to be made to ensure a smooth operational transition for SCF, as well as for revision of numerous state statutes that make specific reference to the “compensation fund” and for discussions to be held on issues such as handling of insolvent carrier claims for the ICA Special Fund—a responsibility currently assigned to SCF pursuant to statute.

The new legislation also says that as of July 1, 2014, the successor mutual insurance corporation that will be created from SCF Arizona will be precluded from using the term “state compensation fund” or “SCF” in its new name or logo.

SCF Arizona began as the Arizona State Compensation Fund when it was created by the legislature in 1925 as part of the state’s original workers’ compensation insurance act. It existed as part of the Industrial Commission of Arizona (ICA) until January 1,1969, when

Legislature Approves Privatization of SCF ArizonaBy Jim Gill, Editor, The Examiner

Continued on page 7…

Legislature Approves Privatization

of SCF Arizona ..................... Page 1

AWCCA Contributes

to 3 Charities ....................... Page 2

Need Any Hot Leads for

Your Summer Job Search? ..... Page 3

President’s Message .............. Page 4

You Know Times Are Getting

Hard When… ....................... Page 7

AWCCA Welcomes New

Officers ................................ Page 8

Economic Woes in Arizona Increase

Loss of Earning Capacity

Rearrangement Requests: What

to Look for in a Labor Market

Assessment ........................... Page 9

Kathy Oster Confirmed as

Newest Industrial Commission

of Arizona Member .............Page 12

Fred Brick Memorial Foundation

Rehabilitant of The Year

2010 Recipients ..................Page 13

ICA Approves Average Monthly

Wage Increase ....................Page 16

PAIN CONSULT - Stephen

Borowsky M.D. ....................Page 18

Spring 2010

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www.awcca.orgIf you’re looking for news about AWCCA membership, upcoming events, past issues of

The Examiner, information on AWCCA sponsors or contact information for AWCCA ExecutiveCommittee Members, be sure to visit

www.awcca.org.Please remember to save www.awcca.org in your Internet Explorer “bookmarks”!

AWCCA Executive Committee Members Sam Lloyd and Liz Florez present a donation check to

Marcia Reck of Arizona Adoption and Foster Care.

At its May meeting, the AWCCA Executive Committee voted to make donations to three Valley-based charities: Kids’ Chance of Arizona, Phoenix Children’s Project and Arizona Adoption and Foster Care.

Pursuant to its Revised Constitution and Bylaws, at the end of each meeting year, AWCCA is required to donate excess operating funds to various charitable organizations. This year, AWCCA donated $10,000 to Kids’ Chance of Arizona, a college scholarship fund for the children of employees who were killed or seriously injured in on-the-job injuries. AWCCA also donated $8,000 to Phoenix Children’s Project, an all-volunteer, Phoenix-based charity that assists underprivileged children with a variety of basic needs. Additionally, AWCCA made an $8,000 donation to Arizona Adoption and Foster Care, an Arizona-based charity that assists in the placement of abused or neglected children into temporary or permanent care in out-of-home environments.

AWCCA Contributes to 3 Charities

Mary Frieling of Phoenix Children’s Project receives a donation check from AWCCA Treasurer Helen Olson

(not pictured).

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Need Any Hot Leads for Your

Summer Job Search?

Are you a claim manager whose top ad-juster just went on vacation…and never came back? Are you an MO Adjuster looking for the chance to move to an indemnity desk? Has your nurse case management business increased so much that you need to add a new RN to your staff? Or, are you a labor mar-ket expert who just moved to Arizona wondering where the hot jobs are in the workers’ compensation industry? If you answered “yes” to any of these questions, Joe Strange, the AWCCA’s Job Referral Coordinator, is waiting to help.

The AWCCA offers an excellent, cost-free way to match up qualified employ-ees with job opportunities in the Ari-zona workers’ compensation industry. So, if you’re an adjuster, nurse case manager, voc rehab specialist, private investigator or other industry profes-sional looking for a new employment opportunity, or if you’re a manager for an insurance carrier, TPA or other professional organization hoping to attract that perfect candidate to your staff, contact AWCCA Job Referral Coordinator Joe Strange via e-mail at [email protected] or, by phone at 480-483-4323.

AWCCA,

Thank you so very much for last year’s donation to Arizona Adoption and Foster Care. Due to our economic challenges last year, we did not take our foster families to camp in Heber but we put part of the amount in an account so we could go to camp this year which we are doing in July. Our families are thrilled that we are going to be able to offer this again. It is the best thing we do all year for our foster children and we couldn’t do it without your help.

The second half of last year’s check went for new clothes for foster children as you can see in the photo I have attached. Thank you so much from our staff and our families for all you have done to make this possible. We will take more pictures at camp and send them to you so you can see the happy smiles of our kids at camp. You truly have made a difference.

Marcia Reck, DirectorArizona Adoption and Foster Care

Thank You!

AWCCA Mission Statement:The purpose and objectives of this association shall be to promote the general

welfare of its members by developing close relationships among those engaged

in the handling of workers’ compensation claims; to promote cooperation by

mutual exchange of experiences and information and discussions thereon

and, to educate its members.

The Examiner is published quarterly by the Arizona Workers’ Compensation

Claims Association, P.O. Box 44941, Phoenix AZ , 85064-4941. All articles

appearing in this publication contain the opinions of the authors and not

necessarily the opinions of the AWCCA, its officers or editors. The AWCCA

encourages the submission of new ads and articles, subject to editing. Signed

letters to the editor are welcome. AWCCA seeks to provide a forum for the

free exchange of ideas and opinions.

NEW AWCCAP.O. BOX #

Don’t forget, the AWCCA changed

its mailing address last year. All

mail correspondence including

checks, membership applications,

Letters to the Editor of The Examiner

and other items addressed to the

organization or its officers should

be sent to:

AWCCAP.O. Box 44941

Phoenix AZ 85064-4941

Editor’s Note: As many of you are aware, the AWCCA’s outgoing President, Jim Gill mysteriously disappeared following the May dinner meeting and hasn’t been heard from since. Police are baffled and the applicants’ bar has disclaimed responsibility. Just as mysteriously, the “President’s Message” below was electronically transmitted from an unknown source to The Examiner. (We were going to notify Robert Stack until we realized he’d died in 2003…).

***

Dear AWCCA Members:

Greetings from the year 2027! I’m not exactly sure how I ended up here in the future or whether I can ever get back to 2010. If you’re a Lost fan, you’re probably thinking it had something to do with the cosmic ripples that were sent pulsing through the space-time continuum when Locke moved the island. Or, if you’re a Vonnegut fan like me, you may believe I’ve become “unstuck in time” like Billy Pilgrim in Slaughterhouse Five and that I’ll keep bouncing aimlessly through the eons forever and ever. Who knows…maybe someday I’ll end up on Tralfamadore

fathering children with Valerie Perrine. In any case, it looks like that “Voted Most Likely To Time Travel - Class of 2090” t-shirt was more than just a joke!

So what’s it like here in 2027? Well, first of all, everyone’s not driving rocket cars or flying around with jet packs on their backs like all of us 20th century fossils thought we’d be doing. Nope. Since transporter technology made teleportation the transit means of preference, all of that circa-1950s Flash Gordon stuff went the way of Green Stamps and clothes pins. Of course, from a work comp standpoint, the firefighters have been lobbying for legislation that would make MDR Cs (Molecular Deconstruction/Reconstruction Carcinomas) presumptively compensable ever since they shunned fire trucks in favor of beaming themselves to blaze locations. But, what’s new, eh?

There have been some interesting developments in the past 17 years and 2027 is sure a great time to be alive. It’s amazing how the energy worries of 2010 have become a distant memory with the advent of the Gulf Gulf Solution® ‚‚‚‚‚‚‚‚‚‚‚‚‚‚. When BP finally went bankrupt trying to stop the

big “Gusher of Ought 10” (as historians like to call it), Gulf Oil bought them out and came up with the great idea of simply pumping all the water out of the Gulf of Mexico and letting the whole basin fill up with bubblin’ crude, thereby, creating the world’s biggest above-ground oil reservoir. Of course, Cuba, Haiti and the Dominican Republic weren’t very happy when their countries were surrounded by oil and started smelling like the inside of a Pontiac crankcase. But on the plus side, gas prices went back down to 20¢ a gallon and America’s energy problems were solved for decades to come, not to mention the fact that “sludge surfin’ “ became all the rage among the beach kids living along the Texas and Louisiana coastlines.

Of course 2027 computer technology is nothing short of amazing. Ten-million-terabyte intrauterine mini-computer chips are prenatally implanted into all unborn babies so that they can instantly wi-fi themselves into the web as soon as the cord is cut. Kids today are literally born online. Televisions are ancient relics, having given way to holographic projectors. And, they’ve

President’s MessageBy Jim Gill, AWCCA President

Continued on page 5…

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even figured out a way to make an electric wine opener that really does spit out the cork when you hit the “reverse” button!

From an entertainment standpoint, computerized rap—“C-RAP” as the kids call it—seems to be all the rage among the young folks. I don’t like it much but I sure think it’s appropriately named. For geezers like me, there’s lots of great stuff to look forward to this year. The Rolling Stones just launched their 2027 “Re-Animation Tour”, and Sports Illustrated is saying this may be the year that Dick Van Arsdale, Charles Barkley and Steve Nash lead the Avatar Suns to their first NBA championship! Oh—did I mention avatars? It turns out that James Cameron wasn’t far off the mark when he made that old movie about transferring the consciousness of humans into cloned bodies. Of course, our clones aren’t blue and they don’t have yellow eyes or tails with tips that look like they need a good de-worming. Since our 2027 avatars are created from each person’s own DNA, they look just like each of us, only they can create them to replicate each of our physiques at any age we choose! In the case of the Avatar Suns, with a 26-year old “Flying Dutchman”, a 28-year old “Sir Charles” and a 29-year old “Nash Rambler” leading our 2027 team, this may actually be the Suns’ year if we can just get by the Avatar Lakers… As for me, I’m thinking of being reconstituted as a 30-year old as soon as I sign up for the government-funded “Free Avatar Assistance Program”. I mean, why pay for artificially re-creating myself in my own image when I can plead poverty and do it on the taxpayer’s dime? (Can you tell the Democrats are once again in office?).

I could go on and on about food sustenance pellets, anti-gravity boots and the new illegal alien legislation (I still don’t see why the Space Police can’t ask Andorrans for their Milky Way ID cards without getting those galactic civil rights advocates all revved up). But, I know what you’re really wondering:

“what’s workers’ comp like in 2027?”

Gosh…where should I start? First, claim costs have really gone up ever since they increased the maximum average monthly wage to $25,000. Of course, compensability disputes have dwindled down to virtually nothing ever since the Rodin vs. Industrial Commission decision of 2017. That’s the one where the Arizona Supreme Court ruled that if an injured worker was even thinking about their job at the time of injury, there was some benefit to the employer and therefore, the employee was deemed to be within the course and scope of employment. Of course, the insurance industry has lobbied for years in favor of using forensic memory technology to capture and analyze injured workers’ thought history so that some measure of objectivity could be applied to the compensability process. But, with opposition from labor and the applicant’s bar, legislative efforts have been stonewalled.

Naturally, alleged bad faith claims have been on the rise ever since the family of a prominent bad faith lawyer from early in the century had his frozen head thawed and transferred from the tuna can next to Ted Williams onto a new cyborg body. Fortunately, “The Bad-Faith `Borg” (as he calls himself in his holo-commercials) has yet to win a case. But, with an atomic power supply that can keep him suing for at least as long as the half-life of plutonium, he’s not likely to stop trying anytime soon.

So, you might ask, how is the AWCCA doing in 2027? Well, after I’d served my term as President back in 2010, the organization flourished for many years. Donell Hewett did a terrific job as President during the 2011-2012 meeting year, increasing member participation and maintaining the professional image that Cheryl Altman, Tara Shields, Helen Olson and I had worked hard to build for the

AWCCA when we ran for office together back in 2008. Tara succeeded Donell as President in 2012 and continued to take the organization to new heights with her hard work, foresight and leadership. Josie Leonard was a welcome new addition to the AWCCA Executive Committee during the 2010-2011 meeting year and her involvement inspired many adjusters who had never before been involved in AWCCA to become active in the organization. Helen Olson and Cheryl Altman remained very active in AWCCA for years and were pleased to have been a part of the organization’s growing success. Everyone from our old Executive Committee was extremely proud of the tens of thousands of dollars AWCCA continued to raise for a number of worthy charitable organizations including Kids’ Chance of Arizona, the Fred Brick Memorial Foundation, Arizona Adoption and Foster Care and Phoenix Children’s Project. Thanks to the efforts of Sam Lloyd and Bernie Cook, the Annual AWCCA Charity Golf Tournament was hugely successful for another decade, with Sam and Bernie (and later, their cloned avatars) having continued to run the event until 2020. Liz Florez continued to do such an exemplary job of organizing the AWCCA Spring Seminar that by 2016, it had become a two-day event attended by over 1,000 people annually. Debbie Hill, Grace Nolan, Michelle Pauley, Denise Young and Joe Strange continued to work tirelessly on the monthly dinner meetings and various AWCCA committees for many years as they continued to generate enthusiasm for the organization and to dedicate their expertise to its success.

But as is the case with many organizations, success is always easier to achieve than it is to maintain. And, in recent years, the AWCCA has once again fallen victim to many of the problems that had sometimes

… President’s Message continued from page 4

Continued on page 6…

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plagued it in the past— lack of new people willing to step into leadership roles, compromising quality for expedience in the selection of monthly dinner speakers, Boards that strayed from the Constitution and Bylaws, and a general feeling of apathy and ambivalence about the future.

Last week, at a reunion of our 2010 Executive Committee that took place on the Las Vegas Lunar Colony, we all talked about the current state of AWCCA affairs here in 2027, and we wondered aloud whether we should step in as a group once again to try to steer the organization back in the right direction. But the fact is that it’s time for new people to start stepping up to the plate. Each of you who are reading this message from the future presently makes their living in the work comp industry. Each of you should have a vested interest in being part of an organization that has worked hard to promote industry quality, professionalism, education, and value to

the community in which we all live and work. And each of you should realize that you can’t always rely on someone else to carry on the legacy of that organization. Here in 2027, our group can look back on years and years of having done its part. Now it’s time for that someone else to be you.

So here I am, 17 years after my second term as AWCCA President ended, and 34 years after the close of my first term back in 1993. I’m kicking back in a nice holo-pub along with the rest of your 2010 AWCCA Executive Committee, sipping on some vino made from grapes that weren’t even grown at the time you’re reading this, wondering who is going to step up and become the next generation to lead our organization into the future. Our group would like to believe that the work we did for the AWCCA back in your time was worthwhile enough for someone to want to continue, and that someone reading this

back in 2010 won’t wait until 2028 to start getting involved.

Either way, on behalf of your 2010 Executive Board, I truly want to thank each of you, our Regular and Associate AWCCA members, for your support and encouragement throughout the meeting year.

And I personally want to thank Cheryl, Tara, Helen, Donell, Sam, Liz, Joe, Bernie, Michelle, Denise, Grace and Debbie for your patience when I was a jerk, for your loyalty when I probably didn’t deserve it, for your extra effort when you’d already busted your behinds, and for your dedication and sheer stamina when our monthly Executive Committee meetings seemed like they’d never end. I sure had a great time and I couldn’t have asked to work with a better group of people!

… President’s Message continued from page 5

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Page 7

the legislature separated the Fund from the ICA. As of November, 2008, SCF was structured as two entities: SCF Arizona and the much smaller SCF Premier Insurance Company.

According to the April, 2009 Auditor General’s report, as of 2007, SCF Arizona reported providing workers’ compensation insurance coverage to 55,000 businesses, representing more than 1 million employees and 58 percent of Arizona’s employers. However, a May, 2010 press release posted on the SCF Arizona website placed SCF’s scope of coverage at 35,000 Arizona businesses representing a 40 percent share of the state’s workers’ compensation market.

Per a May, 2010 article in the Phoenix Business Journal, SCF Arizona has more than 500 employees and $3 billion in assets. However, SCF’s premium revenue has been hurt by Arizona’s slumping economy. In 2009, SCF reported $11 million in net income on $275 million in premium revenue compared with $15 million in net income on premium revenue of $408 million in 2008.

That decrease notwithstanding, premium volume written by SCF Arizona and SCF Premier Insurance Company dwarfs the premium volume of each of Arizona’s remaining workers’ compensation carriers. According to statistics cited by the Phoenix Business Journal, the SCF companies’ 40 percent market share is followed by Travelers’ 4.3 percent market share, New Hampshire Insurance Company’s 3.4 percent market share, Zurich American Insurance Company’s 3.2 percent market share and the 2.6 percent market shares of Twin City Fire Insurance Company and Liberty Insurance Company respectively. Market

shares of each of the state’s remaining workers’ compensation carriers were all 2 percent or less.

Speaking to the Phoenix Business Journal, SCF Legal Division Vice President Jim Stabler indicated that the privatization of SCF Arizona follows a countrywide trend that has led to 26 other state compensation funds being privatized, beginning with Minnesota’s state fund in the 1990s and including the most recent state fund privatization in West Virginia. Stabler also said that privatization will allow SCF Arizona to become licensed to write coverage in other states, thereby allowing it to compete on a national basis with larger multi-state commercial workers’ compensation carriers. In communications with stakeholders prior to passage of SB 1045, Stabler had also pointed out that SCF’s privatization would put it on a more even competitive playing field with commercial insurers in that it would now have to underwrite to a profit the same as commercial carriers do.

… Legislature Approves continued from page 1 You Know Times Are Getting

Hard When… by Michael A. Nathe,

Certified Surveillance Expert,President, Nathe & Nathe Investigations

During the middle of March, the handle on my office microwave broke and the supply company guy said the plastic replacement handle would cost $43.00, as all parts were now “GE.” I explained that the microwave was not General Electric, and he expound-ed, “No, you misunderstand. I said GE… as in generally expensive. It’s a sign of the tough economy.”

I remembered this conversation recently as I was scratching out one of many, many fu-ture checks to the IRS and realized you know times are getting hard when:• Motel 6 has stopped leaving their lights

on for you.• A truckload of Americans was caught

sneaking into Mexico… twice.• You order the “quarter-ouncer” at Mc-

Donald’s.• You call your bank after receiving a check

marked “insufficient funds” and ask them if they meant you or them.

• The mafia is laying off judges while the oil companies are laying off congress-men.

• You take your clients out for an afternoon round of miniature golf.

• The people in Haiti are donating money to Americans.

• The kid behind the counter at the fast food restaurant asks, “Can you afford fries with that?”

• You get a pre-declined credit card in the mail.

• The parents in Beverly Hills are learning their children’s names after firing their nannies.

Over the summer months, the Executive Committee will be seeking candidates to fill the openings for up to three Regular Member-At-Large positions and up to four Associate-Member-At-Large positions. Individuals interested in any of the open Member-At-Large positions should contact any of the elected officers. Contact information for each of the elected officers is available on the AWCCA website at: www.awcca.org.

Also at the May dinner meeting, the regular members in attendance voted to approve a number of changes to the AWCCA Constitution and Bylaws. If you are interested in receiving a copy of the AWCCA Constitution and Bylaws as amended, please contact any member of the AWCCA Executive Committee.

Page 8

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Yvonne Smith RN, C, BS Community Liaison Arizona Mobile (602) 319-0025 Home Office (623) 362-4094 [email protected]

Rebecca Lollich MA, CRC

Vocational ConsultantLabor Market Expert

office 480-451-5228fax 480-515-1576e-mail [email protected] E. Bell RoadSte. 107, Box 505Scottsdale, AZ 85260

Tara Shields, Sr. Risk Manager for Circle K Stores, Inc., was elected Vice President of the AWCCA at the May 11th dinner meeting. Tara had served for the past two years as AWCCA Secretary. She has been an AWCCA member since the 1980s and previously served as the AWCCA President from 1998 to 1999, and as Treasurer from 1999 to 2000. Per the AWCCA Constitution and Bylaws, Tara will service as Vice President for the 2010-2011 meeting year and then as President for the 2011-2012 meeting year.

Josie Leonard, Claims Compliance Specialist for SCF Arizona, was elected to fill the position of AWCCA Secretary. Josie has been with SCF Arizona since 1987, having previously worked for SCF in various

AWCCA Welcomes New Officersadministrative, information technology, customer service and claims adjusting positions. Josie will serve a two-year term as AWCCA Secretary.

Tara and Josie are joined on the AWCCA Executive Committee by President Donell Hewett, Sr. Claims Examiner for Republic Indemnity, and Treasurer Helen Olson, also a Sr. Claims Examiner for Republic Indemnity. Donell served as AWCCA Vice President during the 2009-2010 meeting year. Helen is completing her third year as AWCCA Treasurer. She was previously AWCCA Secretary in 1998 and 1999, after which she served as AWCCA Vice-President and President during the 1999-2000 and 2000-2001 meeting years respectively.

Page 9

In these times of high unemployment, businesses turning insolvent and competitiveness for employment increasing, Arizonans are seeking as many financial resources as are available to sustain their livelihood. In turn, workers’ compensation insurance carriers have been experiencing an increasing number of petitions for rearrangement on Loss of Earning Capacity (LEC) entitlements. It stands to reason that, in a down economy, an injured worker who was previously found to be sustaining a loss of earning capacity is more likely to relate their difficulty finding employment to their industrial injury vs. a member of the general public.

But for the fact that the majority of the public is experiencing difficulty finding and maintaining employment because of the state of the economy in Arizona, the injured worker’s reasoning may have more validity.

This article is meant to bring to light some important considerations when evaluating a claim for rearrangement potential.

ARS 23-1044 (F) states “For the purposes of subsection C of this section, the Commission, in accordance with the provisions of section 23-1047 when the physical condition of the injured employee becomes stationary, shall determine the amount which represents the reduced monthly earning capacity and upon such determination make an award of compensation which shall be subject to change in any of the following events:

1. Upon a showing of a change in the physical condition of the employee subsequent to such findings and award arising out of the injury resulting in the reduction or increase of the

employee’s earning capacity.

2. Upon a showing of a reduction in the earning capacity of the employee arising out of such injury where there is no change in the employee’s physical condition, subsequent to the findings and award.

3. Upon a showing that the employee’s earning capacity has increased subsequent to such findings and award.”

An injured worker who receives a Loss of Earning Capacity award and entitlement to Permanent Partial Disability benefits has been granted such through a Findings and Award for Unscheduled Disability Benefits through the Industrial Commission of Arizona (ICA), either from the ICA Claims Division, or following an ICA Administrative Law proceeding.

In determining an injured worker’s employability, some of the factors to be considered include: age; education; occupational history; previous disabilities; nature and extent of the physical disability; residence at the time of injury; rehabilitation efforts; job availability, including the number of applicants who have applied for the job, the number of positions available and information as to whether the injured worker would be equally considered with other non-disabled applicants; any wages received for work performed subsequent to the injury; and criminal convictions.

An undisputed Findings and Award for Unscheduled Disability Benefits issued by the ICA remains in place until that time at which there is a change in the injured worker’s condition relative to the industrial injury, or in some cases as a result of a significant change in earning

capacity related to labor market access. Rearrangement requested as a result of change in the medical condition, requires a physician’s opinion documenting an objective worsening or change in the condition of the industrial injury.

Under ARS 23-1061 (H) the law states that in “a claim that has been previously accepted, an employee may reopen the claim to secure an increase or rearrangement of compensation or additional benefits by filing with the Commission a petition requesting the reopening of the employee’s claim upon the basis of a new, additional or previously undiscovered temporary or permanent condition, which petition shall be accompanied by a statement from a physician setting forth the physical condition of the employee relating to the claim. A claim shall not be reopened if the initial claim for compensation was previously denied by a notice of claim status or determination by the commission and the notice or determination was allowed to become final and no exception applies under section 23-947 excusing a late filing to request a hearing. A claim shall not be reopened because of increased subjective pain if the pain is not accompanied by a change in objective physical findings.”

The ICA requests that a petition for rearrangement or readjustment of compensation contain the following: (a.) Names of the employee, employer, and insurance carrier; (b.) Claim identification; (c.) Income and employment history; (d.) Medical history; and (e.) Statement of the basis for the increase or decrease in earning capacity.

“Economic Woes in Arizona Increase Loss of Earning Capacity Rearrangement Requests:

What to Look for in a Labor Market Assessment”By Lisa Clapp, MA, CRC, CEA

Continued on page 10…

Similar to the required conditions for reopening a claim for additional medical treatment, where “A claim shall not be reopened because of increased subjective pain if the pain is not accompanied by a change in objective physical findings”, conditions which do not warrant rearrangement or readjustment of permanent disability benefits are enumerated. Those conditions are as follows: (1.) Deterioration due to a non-industrial condition; (2.) The aging process; (3.) Rising cost of living; (4.) Moving to an area where work is not available; and (5.) A change in economic conditions affecting work availability.

A party requesting rearrangement or readjustment of compensation must meet their burden of proof demonstrating a greater or lesser earning capacity.

Ultimately the trier of fact, in most instances the Administrative Law Judge, will be the decision maker as to whether or not this has occurred.

From the earning capacity standpoint, there are key elements that must be demonstrated. Those include whether or not the reduction in suitable and available jobs is solely related to the injured worker’s reduced ability to perform essential job functions, or if the reduced labor market access is as a result of economic conditions affecting the entire labor force.

Assuming there is no objective medical evidence to demonstrate a change or worsening of an injured worker’s functional ability to perform work-related activities, the next area of investigation should be the relative labor market conditions.

If an injured worker had returned to gainful employment post claim closure, but was subject to a reduction in force along with other able bodied workers as a result of an economic downturn, the chances of prevailing in a request for increased loss of earning capacity benefits are decreased.

An employer consultation regarding the circumstances under which employment was severed is imperative. Additionally, identifying the nature of the work the injured worker was performing may be critical. If modifications were being made by the employer that might be considered overly burdensome for a similar employer in the open and competitive labor market, the past employment may be considered “sheltered” and thus not representative of the injured worker’s true earning capacity.

Dr. Nassar provides comprehensive orthopedic foot and ankle care for the injured

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Page 10

… Economic Woes in Arizona Increase Loss of Earning Capacity – continued from page 9

Continued on page 11…

permanent partial disability award, more must be considered than a Worker’s Report of Annual Income. In addition to the considerations mentioned in this brief article, there are endless other legal arguments concerning the factors to be considered in determining an injured worker’s post-injury earning capacity. These include, but are not limited to conflicting medical opinions, the worker’s pre-injury commute to their place of employment, the nature by which the average monthly wage was established, etc.

Where the need arises for labor market research relative to an earning capacity dispute, the above-cited criteria is extremely important to the substance of the findings representing an injured worker’s employability as viewed by the trier of fact. This is particularly true when the dispute is brought before the Administrative Law Division of the ICA. More information is necessary than simply referencing wage survey statistical data alone. Identifying job postings and the wages being advertised for those positions, without actually contacting the employer and confirming that the injured worker meets the criteria to sustain the burden of proof on earning capacity, falls below the defined standard necessary to demonstrate suitable and reasonably available employment upon which an earning capacity determination can be made.

Page 11

…… Economic Woes in Arizona Increase Loss of Earning Capacity – continued from page 10

Determining this requires labor market research to query other employers relative to the essential functions of the job category relative to the injured worker’s vocational and medical profile.

Geographic considerations are also important. Most commonly, the labor market in which the injured worker was residing and/or working at the time of the industrial injury is considered in determining the post-injury earning capacity. However, there are exceptions. For instance, if the relative date of injury labor market is a remote area with little employment opportunity, and an injured worker relocates to a healthier labor market where suitable employment exists, consideration can be given to increased labor market access in the new residential venue. This is demonstrated through labor market research whereby the vocational/medical profile of the injured worker is presented to potential employers and the results document the earning capacity in the open and competitive labor market.

In a 1988 decision from the Supreme Court of Arizona regarding the matter of John C. Zimmerman vs. Industrial Commission of Arizona, the fact finders ruled “Existence of workers’ compensation claimant’s earning capacity is shown by evidence that there is employment reasonably available which claimant could reasonably be expected to perform, considering his physical capabilities, education and training…existence of residual earning capacity of a workers’ compensation claimant can only be established by evidence of job opportunities that are both suitable, i.e., type claimant could reasonably be expected to perform in light of his impaired physical or mental condition, and reasonably available.”

The Zimmerman decision found earning capacity to be a two-pronged inquiry. First, the job opportunities must be suitable,

meaning the type the injured worker could reasonably be expected to perform given the impairment. Second, the job opportunities must be reasonably available.

Suitability of employment speaks to that for which the injured worker has the physical ability, required education and/or previous experience. Thus prior to completing labor market research, the injured worker’s qualifications should closely match those being sought by the employer advertising a vacancy. Employer contact can then take place with a person who has knowledge of requirements considered desirable for new employees in order to determine if the injured worker would be equally considered with other applicants for the position. This line of questioning with the potential employer parlays into the second area of investigation regarding reasonable availability.

Availability, defined here as the “determination of the injured worker’s ability to sell his services in a competitive, open market” requires specific evidence regarding the number of positions available, the competition for those positions, the regularity and permanency of the positions, and the likelihood of the prospective employer giving the injured worker as much consideration for the position as a person who has no industrial injury.

In summary, oftentimes when evaluating the rearrangement potential for a

Longtime workers’ compensation industry member Kathy Oster was confirmed by the Arizona State Legislature as the newest member of the Industrial Commission of Arizona. Kathy had been appointed to the position by the Governor’s Office toward the end of April and was officially confirmed by the Senate Commerce Committee and later by the full Senate during the last week of April.

From 2008 until the present, Kathy has worked as a risk management consultant specialized in multi-state worker’s compensation programs. Prior to starting her own consulting business, she was a Senior Consultant for AON Global Risk Consulting for 12 years after having worked as Workers’ Compensation Claim Manager for Tristar Risk Management for three years and as Claim Supervisor for Lumbermen’s Underwriting Alliance for four years. Other

prior claims supervision and adjusting experience included positions with Self-Insurers Service, Transamerica Insurance and Beech Street.

In addition to her longtime involvement with AWCCA, Kathy is on the Advisory Board of Kids’ Chance of AZ and a prior Board Member of the Arizona Self Insureds Association (ASIA).

Page 12

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Thank you to all who participated in the Fred Brick Memorial Foundation Rehabilitant of the Year Award process. The Fred Brick Memorial Foundation board would like to express its sincere gratitude to AWCCA, AZ IARP, and everyone who helped in fundraising events this year! The 15 nominees were a record number. Our review committee was comprised of five community members including Giles Bronson, MA, CRC; Marilyn Kinnier, CRC, CDMS; Jo Zingg, Esq.; Susan Stockdell, OTR-L; and Patricia Treharne, MD, MPH. Thanks to each of them for their time and consideration in evaluating the nominees! Every one of the nominees is due recognition. The 2010 nominees were the most difficult yet to evaluate as each was an outstanding candidate. The nominees represented a large variety of work settings and injuries. However, after due deliberation the results were provided. Because of limited space, a summary of the top three is included in this article, and the honorable mentions are listed. If you would like more information concerning a nominee in the honorable mention category, please contact me at [email protected], and their summary can be provided.

First Place: Vincent Quiroz (Phoenix, Arizona); nominated by Patty Lewis and Pam Sutherin. Mr. Vincent Quiroz was injured on February 13, 2008 while working as traffic control specialist for Highway Technology. He was setting out barricades on a highway when a car traveling at a high rate of speed hit his work vehicle causing his vehicle to hit him. On impact Mr. Quiroz was thrown over 25 feet

and onto the side of the road where rescue workers were not initially able to find him. He sustained a closed head injury and a right shoulder injury. Mr. Quiroz spent time in the intensive care unit, and Health South Rehabilitation, eventually being discharged to start a challenging recovery. Mr. Quiroz found his memory deficit caused difficulty in word search, short term memory and thought processing. The father of four and family breadwinner, he had lost confidence as decision-maker and leader at home and as a supervisor at work. Depression, anger, memory and significant word search problems forced this fun-loving, outgoing man to re-define himself. He returned to work despite the difficulty in communicating his intended thoughts. Having to start back with the basics, he managed his days with copious humor. His wife was taxi driver, translator and biggest support system. She had the patience and respect to allow him time to find his words—not interrupting or speaking for him. Over time his sense of direction and word searching improved with the use of aids learned in therapy. With repetition he

regained confidence at work and was finally able to work his way back into supervision. Then he suffered a seizure.

Placed off work and on lifetime seizure medication, Mr. Quiroz’s driving privileges were again revoked until he could be medically cleared. Throughout the ups and downs of his closed head injury rehabilitation, Mr. Quiroz maintained a sense of humor and ability to laugh at situations and himself when need be. Mr. Quiroz reported to one of his final medical appointments and said “I got it back!” Everything had started clicking. Mr. Quiroz was committed to his family to return as an integral part. He also stayed very committed to returning to his employment role as a leader and supervisor. Mr. Quiroz did not allow this experience to make him a victim and for all his efforts he is recognized as a success story for his remarkable recovery.

Second Place: Saad Ahmed (Glendale, Arizona) was nominated by Shanna Estes, nurse case manager for Genex and Dan Bonaroti, physical therapist at Touchstone Rehab. Mr. Ahmed sustained multiple traumatic injuries due to an IED explosion on 4/25/2007 while working as a translator for American troops in Iraq. His injuries included traumatic brain injury, persistent coma and significant cognitive deficits, bilateral lower extremity injuries and left hand burns. He underwent multiple surgeries ultimately resulting in bilateral lower extremity amputation. He was seen initially at a United States military field hospital. He was transferred to Al-Khalid Medical Center. He developed multiple complications requiring tracheostomy

Page 13

Fred Brick Memorial Foundation Rehabilitant of The Year 2010 Recipients

By Lisa Clapp, Director, Fred Brick Memorial Foundation

Continued on page 14…

Fred Brick Memorial Foundation Board Member Lisa Clapp looks on as Saad Ahmed

addresses AWCCA members at the May dinner meeting after being honored as a Fred Brick Memorial Rehabilitant of the Year recipient.

Page 14

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and mechanical ventilation, intravenous antibiotics and gastrostomy. He was brought to the United States under refugee status in July 2008 for further medical management and has recently moved from Maryland to Arizona as of December 6, 2008. Mr. Ahmed is currently being treated by specialists in the fields of physical medicine and rehabilitation, urology, gastroenterology, neuro-ophthalmology, ear, nose and throat, psychological therapy, rehabilitation and artificial limb and hand surgery. Mr. Ahmed overcame significant obstacles in order to achieve success in his rehabilitation effort through working extremely hard, progressing from a power wheelchair to part time ambulation. He has progressed with occupational and speech therapy. He often wears a shirt to rehabilitation that reads “There is no ‘off season’”. Mr. Ahmed overcame both physical and mental challenges and

the difficult process of integrating into a new country. He underwent multiple surgeries for explosive burns and impact injuries. Although his traumatic brain injury impaired his high level cognitive function, he overcame extremely difficult obstacles to relearn simple tasks and now is advancing to more complex tasks of daily living. Although Mr. Ahmed requires ongoing support from multiple caregivers, friends and family, he has consistently been appreciative for the continued support he receives and despite several delays in his rehab process is making continued strides to independent living.

Third Place: Crystal Rezzonico (Phoenix, Arizona) nominated by Justin Frear of Avizent. Ms. Rezzonico, fire captain for the Phoenix Fire Department, and was traveling with her fire crew to an emergency call when struck broadside by another

vehicle. Upon impact she was ejected from the truck, and flew approximately 40 feet in the air before striking the asphalt and coming to a stop. Ms. Rezzonico was taken emergently to John C. Lincoln Hospital where she underwent emergency treatment for extensive head trauma, bilateral ankle, and knee, hip, and shoulder injuries. She underwent multiple surgeries in an effort to preserve her life. Her chances for survival were calculated on a day-to-day basis, without certainty whether or not she would ever recover from her injuries let alone ever step foot inside a fire station again.

Amazingly, less than two weeks post injury, Ms. Rezzonico was transferred to inpatient rehabilitation at St. Joseph’s Hospital. Her head trauma resulted in extensive deficits in speech, cognitive reasoning, reading,

… Fred Brick Memorial Foundation continued from page 13

Continued on page 15…

nominated by Mirna Payan Arizona Vocational Consulting & Forensic Services, Inc.

• Alejandro Carrera (Phoenix, Arizona) was nominated by Charlene Ramsey, RN Genex Services.

• Duane Brown (Phoenix, Arizona) was nominated by Shanna Estes, nurse case manager, Genex Services.

• Stephen Aitken (Chandler, AZ) was nominated by Jonathan Bock, physical therapist STI, Inc.

• Patrick Parks (Phoenix, Arizona) was nominated by Karen Christiana, Care Meridian.

• Carl E. Corona (Glendale, Arizona) was nominated by Nancy Hoffman, RN, Keene Medical Management, Lesia Fejarang of Avizent, and Ruby Williams of Pinnacle Risk.

• Thomas Ovante (Phoenix, Arizona) was nominated by Diane White of Rehab Without Walls.

• Chad Jenkins (Casa Grande, Arizona) was nominated by Jeannie Craig, nurse case manager Genex Services and Carlos Reeberg, physical therapist CORE Physio.

• William Weigt (Tolleson, Arizona) was nominated by Cathleen Castro Wirth RN, case manager.

• Daisy Ramos (Apache Junction, Arizona) nominated by Kathy Bullock RN, Encore Unlimited.

Page 15

… Fred Brick Memorial Foundation continued from page 14

writing, vision, hearing, etc. Early in the program her participation and compliance reflected her full intention to overcome the handicaps. By six weeks post accident Ms. Rezzonico’s physician felt she had progressed sufficiently to be discharged home with further care coordinated via Rehab Without Walls. Ms. Rezzonico received full range of rehabilitation including physical therapy, speech therapy, cognitive therapy, psychological treatment, occupational therapy and vocational rehabilitation. By eight weeks post accident, Ms. Rezzonico’s therapist and physicians noted that she was making huge gain in her recovery and was diligent in the prescribed therapy. She obtained flash cards with firefighting related items to help with her memory and work finding and performed research via the internet to further develop the vocabulary necessary to return to her role as a fire captain.

Ms. Rezzonico’s dedication to recovery paid off. By January 2010 her physicians and therapists were shocked by her progress. Cognitive testing showed minimal deficits and when tested on fire/rescue scenarios, her decisions were dead on as delineated by three other fire captains. She was allowed to return to part-time light-duty work as of January 21, 2010 while continued the rehabilitation process. Her physicians went so far as to state that given her extensive

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progress and dedication to recovery they had no doubt she would ultimately return to her pre-injury occupation. This was a far cry from the medical opinion entered shortly following the original accident.

Ms. Rezzonico continued to show her drive by working closely with team members to develop and polish skills necessary to transition back to her role as a fire captain. One month later on February 24, 2010, as a result of her continued progress in both the rehabilitation and occupational arenas, with coordinated efforts of her rehabilitation team and the Phoenix Fire Department personnel, Ms. Rezzonico returned to her normal position as a Phoenix fire captain on a fire truck. This is an amazing feat given the fact that her life hung by a thread less than six months previously. She has overcome a multitude of physical, mental, emotional and vocational obstacles in her recovery and it by her dedication and persistence that she has experienced a remarkable recovery.

Honorable Mentions:• Michael Hill (White river, AZ) was

nominated by Jeanne Rawlins, RN of Orchard Medical Consulting.

• Robert Adams (Yuma, Arizona) was nominated by Rene Canute of Canute Medical Management.

• Juan Blanco (Prescott, Arizona) was nominated by Cindy Wendt, RN.

• Mary Cruff (Phoenix, Arizona) was

Page 16

On June 2, 2010, the Industrial Commission of Arizona (ICA) adopted a new maximum average monthly wage for 2011.

According to a posting from ICA Claims Manager Noreen Thorsen on the ICA website (http://www.ica.state.az.us/Claims/Claims_About_Wage_Statutory_Maximum.aspx), the new wage maximum for injuries sustained on or after January 1, 2011 will be $3,920.75. The current maximum average monthly wage is $3,763.44 for injuries sustained on or after January 1, 2010.

According to the ICA website posting, “When the Legislature amended the average monthly wage statute in 2007, see A.R.S. § 23-1041, the Legislature added a provision that provided for an annual adjustment (“indexing”) of the average monthly wage for injuries occurring on or after January 1, 2010. This provision directed the Industrial Commission to adopt an amount that reflects the annual percentage increase in the Arizona mean wage and to increase the average monthly wage by that amount. The Commission

is directed to adopt such an amount by August 1 of each year to be effective for the following calendar year. This indexing provision adjusts the maximum average monthly wage using Bureau of Labor occupational employment statistics coded for all occupations.”

The ICA website also provides the chart below, listing Arizona’s maximum average monthly wage history dating back to 1948.

ICA Approves Average Monthly Wage Increase

Wage MaximumFor Injuries Sustained

On or After Through

$3,763.44

$3,600.00

$3,000.00

$2,400.00

$2,100.00

$1,800.00

$1,650.00

$1,325.00

$1,250.00

$1,000.00

01-01-2010

01-01-2009

01-01-2008

08-07-1999

07-01-1991

07-01-1989

01-01-1988

07-31-1980

08-27-1977

11-22-1948

12-31-2010

12-31-2009

12-31-2008

12-31-2007

08-06-1999

06-30-1991

06-30-1989

12-31-1987

07-30-1980

08-26-1977

Page 17

Page 18

Current treatment of pain has become a quagmire of conflicting issues, issues related to under-treatment and over-treatment, drug abuse and diversion, with regulating agencies watching in the background. Physicians are caught between the WAR ON PAIN and the WAR ON DRUGS.

Arizona has a serious problem. Prescription medications in their parents’ medicine cabinets appear to be a safer alternative to street drugs for adolescents. One out of four Arizona 12th graders abuse prescription pain relievers, a statistic twice the national rate.

QUESTION - What tests are recommended or are appropriate to be performed on patients prescribed long term medications for pain and related issues? The answer to this question covers several areas of importance, one being urine drug testing to monitor compliance, and two, the various tests used to detect any systemic effects, e.g. cardiac, liver, kidney, produced by the medications.

1. URINE DRUG TESTING

We have an obligation to appropriately treat pain, and that frequently involves the use of controlled substances such as opioids (narcotic pain medications). We also have an obligation to prevent opioid abuse, diversion and addiction. Thus, we are caught between the war on pain vs. the war on drugs.

Once a patient qualifies for treatment with opioids, it then is our obligation to monitor the prescriptions and their use or abuse. Appropriate expected findings on urine drug testing help support the validity of the original assessment and diagnosis that

qualified the patient to receive opioids, and, thus supports patient advocacy.

However, if the drug test detects undisclosed substances, whether prescription or illicit, then the original decision to treat with opioids becomes questionable. We must ask, is this drug abuse, addiction or diversion?

45 percent of urine drug tests are abnormal, with 20.2 percent detecting illicit substances, 14.5 percent detecting additional undisclosed drugs, and 10.2 percent detecting missing prescribed opioids.

Urine drug testing can be “point of care” testing, by dipstick in an office, but this test only detects categories and not specific drugs. It can be billed for by the physician and requires documentation as would any lab test. The cut-offs are high, so that small dosages of opioids will not be detected. This testing does not detect drug metabolites. The presence of the drug itself and its metabolite, e.g. oxycodone and its metabolite, oxymorphone, indicates that this medication has been taken regularly. Whereas, the presence of the drug alone, and not its metabolite, indicates the probability that this medication was taken prior to testing and not on a regular basis.

Thus, with a more sophisticated form of urine drug testing, such as with one of the national labs that have sprouted up to meet the demand, one can detect the drug and its metabolites, detect the presence of small dosages, detect specific drugs and not just categories, such as methamphetamines vs. amphetamines prescribed for ADHD vs. over-the-counter decongestant-pseudoephedrine.

The Internet offers the non-adherent patient numerous ways to try to beat the test and scam the prescriber. The full lab urine drug test will identify whether the specimen is actually urine, and whether adulterants have added to the specimen in order to attempt to hide an illicit substance. The urine container has a built-in temperature gauge, so that you would expect the appropriate warm specimen rather than a cool specimen, coming from a hidden container carrying someone else’s “clean” urine specimen.

It is most useful to have the patient give the specimen in your office bathroom, rather than at an outside lab, so that when you announce your request, you can observe any excuses, delays or last minute disclosures. Of course, every patient has just gone to the bathroom just prior to the appointment.

Urine drug testing should be unannounced, and a part of the signed patient prescription agreement. The number of urine drug tests per year depends on the patient, their compliance, their previous drug tests, their drug history and the prescriber’s suspicions. Some physicians use the credo: No urine, No prescription, No exceptions.

2. METHADONE – EKG Testing

Deaths related to use of opioids have increased substantially by 129 percent while deaths related to cocaine increased by 16 percent and heroin by 23.7 percent.

While methadone is most known for its use in drug abuse programs, it is an opioid pain medication and is used to treat chronic pain. It is inexpensive compared to the

PAIN CONSULTby Stephen Borowsky M.D.

Continued on page 19…

Page 19

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branded extended release medications, but it comes with unique risks.

Methadone can linger in the body for up to 72 hours, long past the point its pain relief has worn off. If the patient assumes that pain relief has worn off, and has not been properly instructed or exhibits aberrant behavior, and takes more methadone, respiratory depression, coma and death can ensue. A not uncommon scenario is that of a patient experiencing little or no relief with the first dose of methadone, or the benefit wears off in hours, then takes another dose, and later another, and two days later is found dead.

Methadone has significant cardiac effects, specifically prolongation of the cardiac QT interval (a measure of the time between

the start of the Q wave and the end of the T wave in the heart’s electrical cycle ) and torsade-de-pointe arrhythmia, a variant of ventricular tachycardia, which can be fatal.

A recommended guideline is performing an EKG before initiation of methadone, and at 24 hours and at four days into treatment.

3. LABORATORY BLOOD TESTS

NSAIDs - blood count, EKG, liver and kidney function tests.

All NSAIDs (non-steroidal anti-inflammatory drugs) have the same boxed warnings regarding cardiovascular and gastrointestinal risks, specifically:

• Cardiovascular Risk - Non-steroidal

anti-inflammatory drugs (NSAIDs) may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

NSAIDs are contraindicated for the treatment of perioperative pain in setting up coronary artery bypass graft (CABG) surgery.

• Gastrointestinal Risk - NSAIDs cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be

… Pain Consult continued from page 18

Continued on page 20…

Page 20

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fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal events.

Although uncommon, NSAIDs can cause renal insufficiency and kidney damage. A recent warning was issued regarding potential liver problems with diclofenac (Voltaren). Therefore, the above issues warrant monitoring with EKG, blood count and liver and kidney functions studies.

ACETAMINOPHEN - LIVER FUNCTION TESTS

Acetaminophen (Tylenol) is so readily available over-the-counter, on its own, or as a co-ingredient with decongestants and antihistamines, but also as a co-ingredient in prescription products such as Percocet, Vicodin, Darvocet, and Tylenol with codeine. For example, with Percocet 5/325, the 325 refers to 325 mg of acetaminophen.

Acetaminophen can cause liver toxicity, especially in patients with alcoholism, recent fasting, or liver disease. It is not uncommon for chronic pain patients, thinking it’s safe because acetaminophen is over-the-counter, to take over-the-counter acetaminophen in addition to the acetaminophen contained in Percocet or Vicodin, and the daily dose adds up to potentially toxic levels.

Many have considered the maximum daily dose of acetaminophen to be kept at or below 4000 mg per day, and in combination with other medications or with existing liver problem, to keep the daily maximum even lower.

OPIOIDS – testosterone, estrogen testing

Opioids (narcotic pain medications) can interfere with the hormone balance in the body, and cause decreased testosterone in men and menstrual irregularities and infertility in women. Symptoms may include loss of libido, impotence, infertility, depression and anxiety, loss of muscle mass and strength, loss of gender role, fatigue, amenorrhea, irregular menses, galactorrhea osteoporosis, and increased pain.

You cannot assume that just because the patient is taking opioids, that low testosterone is caused by the opioids. Other hormone deficiency factors such as tumors, radiation, pituitary-hypothalamic injury may be issues. Testosterone levels, especially, should be monitored.

CONCOMITANT DIABETES and/or THYROID DISEASE

Since diabetes and thyroid abnormalities can significantly influence pain, it is useful to check for and monitor these disorders. Look for the pain of diabetic neuropathy or circulatory compromise. Low or low-

normal thyroid levels can cause muscle pain. These issues would not be related to a work injury, but their presence can impact on pain complaints. The actual treatment of diabetes and thyroid problems is left to the primary care physician, under non-industrial insurance.

SUMMARY SO FAR

At least yearly, order or obtain the results of primary care physician testing of blood count, liver and kidney function tests, glucose, thyroid, EKG and testosterone (men).

Letters to the Editor

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… Pain Consult continued from page 19