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
Arizona voters passed the Arizona Medical
Marijuana Act (“AMMA”) in November 2010,
and since then, the Arizona Department of
Health Services (“ADHS”) has developed a
medical marijuana program to administer
the certification of qualifying patients and
license the dispensaries. The first dispensary
was opened in December 2012, after
Maricopa County Attorney Bill Montgomery
unsuccessfully challenged ADHS’s authority
to license marijuana dispensaries. Mr.
Montgomery has appealed the court’s ruling
and continues to argue that the AMMA is in
violation of the federal Controlled Substances
Act.
In the meantime, however, the AMMA is
in effect and patients who hold a valid
medical marijuana card are protected from
state prosecution for using marijuana. This
presents concerns for employers, carriers,
and third-party administrators in the workers’
compensation industry, so my intent with this
article is to inform you about how the AMMA
works and what it allows and disallows.
The Construct of the Statute
The purpose of AMMA is to protect seriously
ill patients from state prosecution for using
medical marijuana under their doctor’s
recommendation. It allows a “qualifying
patient” to possess up to 2.5 ounces of
usable marijuana or 12 marijuana plants.
ADHS only issues medical marijuana cards
to “qualifying patients,” and in order to be
deemed a qualifying patient, the individual
must suffer from a “debilitating medical
condition.”
The statute defines a “debilitating medical
condition” as follows:
A. Cancer, glaucoma, HIV+, AIDS,
hepatitis C, ALS, Chrohn’s disease,
Alzheimer’s, or the treatment of these
conditions;
B. A chronic or debilitating disease,
medical condition, or its treatment
that produces:
a. Cachexia or wasting syndrome
b. Severe and chronic pain
c. Severe nausea
d. Seizures
e. Severe and persistent muscle
spasms
The physician that prescribes marijuana
must make or confirm the diagnosis of
a debilitating medical condition, and
must examine the patient regarding the
debilitating medical condition within 90 days
Medical Marijuana and Arizona Workers’ Compensation
Continued on page 2…
Medical Marijuana and
Arizona Workers’
Compensation ...................... Page 1
Let the AWCCA Job Referral
Line Work for YOU!… ........... Page 4
State Legislators Across U.S.
Reform in Dispensing
of Opioids… ........................ Page 5
ICA to Hold Fee Schedule
Hearing ................................ Page 5
NCCI Study Analysis: Effects
of an Aging Workforce .......... Page 6
Red flags in back pain
When to worry and
what to do ..........................Page 10
Winter/Spring 2013
By Rachel Brozina, Esq., Lester & Norton
Page 2
www.AWCCA.org: Your L ink to the Ar izona Work Comp Indust r y!
If you’re looking for information on AWCCA membership, upcoming events, past issues of The Examiner, links to AWCCA sponsor websites or contact information for
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For quick access to the most current AWCCA news, remember to bookmark www.awcca.org in your internet browser.
… Medical Marijuana continued from page 1
of prescribing marijuana. The physician
must also review the patient’s medical
records for the past 12 months to evaluate
the patient’s responses to other forms of
treatment. Finally, the physician must fill
out a document to attest that the patient
is likely to receive a therapeutic benefit
to alleviate the effects of the debilitating
condition.
ADHS will permit one dispensary for every
10 pharmacies permitted each year. The
dispensaries must be operated as not-for-
profit entities, and must contract with an
Arizona-licensed physician to act as its
medical director. ADHS does not provide
a list of dispensaries to the public; rather,
it will provide a list to a qualifying patient
when it assigns the person a medical
marijuana card.
Impact on Employers
The AMMA precludes Arizona employers
from discriminating against marijuana
cardholders in hiring, termination, or
imposing employment conditions.
However, if an employer is at risk for
losing benefits under federal law, it is not
precluded from discriminatory practices.
Furthermore, employers cannot penalize
a cardholding employee for a positive
drug test, unless the employee used,
possessed, or was impaired by marijuana
on the employer’s premises or during
the employee’s working hours. In other
words, the mere fact that a cardholding
employee’s drug test is positive for
marijuana metabolite is not sufficient for
the employer to penalize the employee.
In the absence of evidence that the
employee used or possessed the
marijuana on the premises or during
working hours, there must be evidence
that the employee was impaired by
marijuana. Because our statute is relatively
new, we have not had any cases that
lend us guidance as to what constitutes
“impairment.”
ADHS has an online verification system
that employers may access to verify
whether an employee’s marijuana card
is valid. However, employers’ access to
the system is limited to verifying a card
that the employee produces; employers
cannot access the system to check
whether it is employing any cardholders.
Impact on Workers’ Compensation
Benefits
It has already been established that a
workers’ compensation claim cannot
be denied solely on the basis that an
injured worker has marijuana (or alcohol
or other drugs) in his/her system. As long
as the necessary risks and dangers of the
employment cause or contribute to the
injury, the claim is compensable even
in the face of a positive drug test. (See
Grammatico v. Industrial Comm’n, 117
P.3d 786 (2005)).
If an injured worker is prescribed
marijuana for an industrial injury, does the
carrier have to pay for or reimburse the
injured worker for the marijuana? Because
our statute is relatively new, we have not
had an opportunity to see how this plays
out in our workers’ compensation arena.
However, our neighbor to the west recently
took this issue up.
Continued on page 3…
Page 3
In Cockrell v. Farmers Insurance and
Liberty Mutual Insurance Company,
an injured worker sought to have the
California Workers’ Compensation Judge
order the carrier to reimburse him for
the costs associated with purchasing
marijuana that had been prescribed by
a physician. The evidence showed that
the injured worker had complications with
using Oxycontin, so the marijuana was
intended to replace that medication.
The judge awarded the injured worker
reimbursement for the purchase of
marijuana, and the carrier was ordered
to pay the value of the medication that
the marijuana was intended to replace
(Oxycontin). The carrier appealed the
judge’s decision, citing to a provision in
California’s medical marijuana statute
that provided that the statute does “not
require a governmental, private, or any
other health insurance provider or heath
care service plan to be liable for any
claim for reimbursement for the medical
use of marijuana.” (See Health and Safety
Code Section 11362.785(d)). The Appeals
Board remanded the matter back to
the lower level for the judge to make a
determination as to how that provision
applies to the case. Thus far, a decision
on this point has not been published.
The AMMA includes a specific provision
that is very similar to the California
provision cited above. Our statute
indicates that it does not require private
or public health insurers to reimburse a
patient for the costs associated with the
use of marijuana. Although our statute
does not require the carrier to pay for or
reimburse for the cost of marijuana, it does
not necessarily preclude an injured worker
from seeking reimbursement in a workers’
compensation matter because the use of
marijuana could be deemed a medical
benefit under our workers’ compensation
statute. It is worth noting that federal law
(the Controlled Substances Act) does not
recognize the medical use of marijuana
and it prohibits the cultivation, sale,
distribution, and possession of marijuana
under any circumstance. A pertinent
question is whether our Administrative Law
Judges interpret the interplay among the
Controlled Substances Act, the Arizona
Medical Marijuana Act, and the Arizona
Workers’ Compensation Law to permit
our judges to order a carrier to pay for
… Medical Marijuana continued from page 2
medical marijuana. In the meantime,
SCF Arizona has publicly announced its
position on this issue and it will not cover
the cost or reimburse injured workers for
the use of medical marijuana.
The impact of AMMA on our workers’
compensation system is yet to be
determined, but with over 35,000 medical
marijuana cards issued and a handful
of dispensaries open for business, it will
serve us all well to be aware of potential
complications.
The Arizona Department of Health
Services has an excellent website for
the Arizona Medical Marijuana Program.
You can access it at www.azdhs.gov/
medicalmarijuana/
For further information, please contact
Rachel Brozina at 602-357-1162, or via
e-mail at: [email protected]
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 AWCCA, Inc., 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 AWCCA, Inc., its
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encourages the submission of
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are welcome. AWCCA, Inc. seeks
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exchange of ideas and opinions.
Neither Snow, Nor Rain…
Yes--you can still contact AWCCA the “old school” way, via the U.S. Postal Service!
All U.S. mail correspondence including checks, membership applications, hard copies of Letters to the Editor of The Examiner and other items addressed to the organization or its officers should be sent to:
AWCCA, Inc.P.O. Box 44941 • Phoenix, AZ 85064-4941
Page 4
You’re a claim manager whose senior
examiner just quit to compete in the
new reality TV show “The Voice…of
Workers’ Compensation”. Or, you’re
a doctor whose office manager just
resigned to put together an exploratory
committee for her 2016 presidential
campaign.
How are you going to fill those
positions?
Simple: contact AWCCA’s new Job
Referral Coordinator Linda Barton
to post your open positions on the
AWCCA’s Job Referral Line.
Whether you’re an employer looking
for the perfect new hire, or an
adjuster, private investigator or voc
rehab consultant looking for a new
employment opportunity in the work
comp industry, AWCCA may be able
to help.
As a no-cost service to employers in
the Arizona workers’ compensation
community, companies looking to hire
claims adjusters, supervisors, managers
or support staff can post job openings
on the AWCCA website. Additionally,
individuals seeking positions as
adjusters, supervisors, managers or
support staff employees can post
short professional bios on the AWCCA
website. Further, the Job Referral
Line can also be used by medical
professionals, vocational rehabilitation
companies, private investigators, IME
or DME companies or any other
insurance-related organization that
has a job opening. And, industry
professionals looking for employment
in any insurance-related field can post
their bios using the AWCCA’s website*.
The AWCCA offers an excellent,
cost-free way to match up qualified
employees with ANY job opportunities
in the Arizona workers’ compensation
industry.
To post an job opening or an
employment bio, or to learn more
about the AWCCA’s Job Referral
Program, contact AWCCA Job Referral
Coordinator Linda Barton via e-mail
*Note: The AWCCA Job Referral Line is a service provided for individuals seeking employment with an organization in the Arizona workers’ compensation industry. It is not a forum for vendors to advertise their qualifications, goods or services. AWCCA reserves the right to screen, edit or reject all Job Referral Line submissions based on this criteria.
Let the AWCCA Job Referral Line Work for YOU!
Page 5
State Legislators Across U.S. Reform in Dispensing of Opioids
The National Conference of Insurance
Legislators (NCOIL) agreed at its Spring
Meeting to develop best practice
strategies for states debating possible
reforms to curb opiod abuse. NCOIL’s
move to develop guidelines instead of
model legislation came after discussion
at a special session in Washington D.C.
NCOIL is a national organization of state
legislators whose main public policy
interests are insurance legislation and
regulation. Most NCOIL legislators either
chair or are members of committees
responsible for insurance legislation
within their respective state legislatures.
Arizona is a general member, but not a
contributing member of NCOIL.
Accord ing to NCOIL Workers ’
Compensation Committee Chairman
Representative Bill Botzow of Vermont,
“opioid abuse is a growing epidemic
that reaches across state lines and may
be impossible to address with any single
approach. Because states are in different
places in their efforts to address opioid
abuse, the appropriate role for NCOIL is to
lay out guidelines for states to consider as
they develop their state-specific reforms.”
In light of legislative discussions at the
special meeting, the proposed best
practices will likely address a number of
issues including prescribing practices,
funding, drug monitoring program
reforms, and data sharing. Draft
guidelines will be considered at NCOIL’s
July 11 Summer Meeting in Philadelphia,
Pennsylvania.
The Industrial Commission of
Arizona (ICA) will hold its 2013
Fee Schedule hearing on April
17, 2013 at 10:00 a.m. in the first
floor auditorium of the ICA offices,
located at 800 W. Washington Street
in Phoenix. The Commissioners
will listen to public comments in
addition to considering a report
prepared by Commission staff as a
preliminary document created as a
foundation for discussions during
the hearing process. The document
can be viewed online at: http://www.
ica.state.az.us/Director/DIR_2013_
FS_preliminaries.aspx.
ICA to Hold Fee Schedule
Hearing
Page 6
NCCI Study Analysis: Effects of an Aging Workforce
The National Council on Compensation
Insurance (NCCI), a U.S. insurance rating
and data collection bureau specializing
in workers’ compensation, recently
conducted a study to address widespread
industry concern over the impact of the
“baby boomer” generation postponing
retirement, thus aging the workforce and
creating the potential for adverse impact
on workers’ compensation loss costs.
The study, which indeed confirms the labor
force’s share of older workers is increasing,
analyzes frequency and severity across
multiple age groups, identifies factors
accounting for the differences in severity
between each age group, and compares
the combined effects of frequency and
severity for each age group to determine
costs per worker.
Share of Older Workers Increasing
Study data shows workers over 45 years
old account for an increasing share of
the U.S. workforce. This group, commonly
referred to as “baby boomers”, was
divided into two separate groups for data
collection purposes. Cumulatively, the
45-and-older share increased from 34
percent of the workforce in 2000 to 42
percent in 2010. Separately, the share
of workers 65 and older is growing but
remains small, increasing from about 3
percent of the total workforce in 2000 to
just fewer than 5 percent in 2010, while the
45- to 54-year-old group has continued to
increase modestly. Notably, researchers
conclude “if the shares of older workers
are increasing, the shares of younger
workers must be decreasing. This is most
evident for workers 35 to 44.”
Continued on page 7…
By Shala Morley, Special for The Examiner
Page 7
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Frequency Across Different Age Groups
NCCI researchers note two key findings
from their frequency analysis. First, upon
analyzing occurrence of injury of full-time
(40 hours per week) workers from 1994 to
2009, a decline in frequency has occurred
for all age groups; second, the marked
differences among age groups in the
early 1990s had largely disappeared by
2009. In 1994, the incidence rate for 20- to
24-year- olds was 300 per 10,000 full-time
equivalent workers, while the rate for the
55- to 64-year-old group was 200 injuries
per 10,000. In 2009, although reduced,
those numbers were comparable at 97
and 93 injuries per 10,000, respectively.
In terms of frequency relative to older
workers, the injury rate for workers aged
55 to 64 was 16 percent lower than
frequency for all workers in 1994, but 1
percent higher in 2009. These findings
prompted researchers to conclude “the
differences in injury frequency among
age groups clearly have narrowed.”
Researchers offer that one likely question
is whether the narrowing in frequency of
injury is due to a change in the types of
jobs held by younger workers throughout
the study period. That question was
addressed by analyzing the days away
from work across all age groups and
occupations; all showed very similar
results. Researchers concluded while the
occupational mix may have changed
among age groups, all jobs are much
safer and do not affect frequency of
injury.
… NCCI Study Analysis: continued from page 6
Continued on page 8…
Page 8
… NCCI Study Analysis: continued from page 7
Severity Across Age Groups
The study analyzed both indemnity and
medical severity. Key findings are as
follows:
• Severity has been increasing over
time for all age groups and typically
is higher for the older age bracket.
• Relativedifferencesinmedicalseverity
by age have continued, but have
somewhat narrowed. Medical severity
for the 55- to 64-year-old group was
25 percent above average in 1995
and 17 percent above average in
2008; meanwhile, medical severity for
the 20- to 24-year-old group was 31
percent below average in 1995 and
23 percent below average in 2008.
• Overall, data shows that both
indemnity and medical severity
have exhibited steady increases over
time, with severity for older claimants
costing more.
• Medical costs were more than 50
percent higher for older workers. From
1996 to 2007, the average medical
cost for claims severe enough to
warrant temporary indemnity for 20-
to 34-year-olds was $5,073; 45- to
64-year-olds averaged $7,649, a 51
percent difference.
• Differencesinleadingtypesofinjuries
are a major factor in differences in
severity by age. Older workers tend
to have more rotator cuff and knee
injuries, while younger workers are
most often treated for back and ankle
sprains.
• Ontheindemnityside,higherwages
are a key factor leading to higher
claim costs for older workers; in terms
of medical costs, more treatments
per claim are a factor.
Continued on page 9…
Page 9
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Combined Effects (Costs per Worker)
When researchers took into account both
frequency and severity data to determine
costs per worker, the data showed
that when differences in wages were
accounted for, total cost differences by
age shrink across the board.
The overall conclusion of the study was
that the “baby boomer” generation
does not necessarily pose an adverse
impact on the work comp industry, as all
groups of workers aged 35 to 64 showed
similar costs per worker. From a workers’
compensation perspective, the higher
costs are offset by the higher premium
due to higher wages of older workers.
… NCCI Study Analysis: continued from page 8
NCCI concludes, “Overall, the findings
can be viewed as reassuring, in that an
aging workforce may have less negative
impact on loss costs than originally
thought.”
The complete report can be accessed at
www.ncci.com.
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Page 10
Red Flags in Back PainWhen to Worry and What to Do
By Issada Thongtrangan, M.D. Spine Specialist, Valley Orthopedics
Most back pain is benign but some
isn’t. Five or six times a year, I treat
a patient who’s progressed from
backache to paraplegia over a few
months, via discitis or cancer or
cord/cauda equina compression. My
experience is not unique; these issues
are recognized around the world and
we will review some “red flags” which
will help protect the patients from
delayed treatment.
INCIDENCE
According to the U.S. Bureau of
Labor Statistics, there were 4.2
million nonfatal occupational injuries
and illnesses reported by private
industries in 2005. Sprains and
strains accounted for approximately
42 percent of injuries and illnesses
requiring time away from work.
The body part most often involved
in these injuries was the trunk, and
63 percent of injuries to the trunk
involved the spine. As many as 90
percent of persons with occupational
nonspecific low back pain are able to
return to work in a relatively short
period of time; however some aren’t
and need more attention especially
those who have “red flags”. As long
as no “red flags” exist, the patient
should be encouraged to remain
as active as possible, minimize bed
rest, use ice or heat compresses,
take anti-inflammatory or analgesic
medications if desired, participate in
Continued on page 11…
Page 11
Anthony S. Rhorer, MDBoard Certified ABOS
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• Complex fracture work
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• Surgical orthopaedic care
• Prompt second opinions
• Same-day reports (includes physical therapy and work restrictions)
• Bilingual staff
• Extended visit times (each patient receives up to 40 minutes of scheduled appointment time)
… Red flags in back pain continued from page 10
Continued on page 13…
home exercises, and return to work as
soon as possible.
PATHOLOGY AND NATURAL
HISTORY
Imaging pathology is very common
and usually false (positive), meaning
that it’s not indicative of a source
of symptoms. Odds are 50/50
that a claimant who was lumbar-
asymptomatic before an on-the-job
injury will have major degenerative
abnormalities in any imaging study
from x-rays to MRI, that don’t hurt
one bit. That’s why we’ve all been
taught that acute spine imaging is
useless and generally it is. That
bone spur or degenerated disc or
spondylolisthesis seen in an injured
worker’s x-ray was almost certainly
there last week too, when the
claimant felt fine!
Even acute structural spine disease
gets better in most cases by ‘hand of
God,’ and time. Acute sciatica from
disc hernia resolves within weeks
in 60-75 percent of cases. Seventy
percent of acute symptoms from
spinal stenosis or spondylolisthesis
resolve within a few months, and
even insufficiency fractures heal
70 percent of the time to become
asymptomatic within three to four
months.
COST
Spine care is costly, but we know
that a small minority (10 percent) of
patients who have recurrent or chronic
pain generate 90 percent of the cost.
Most of these have nonspecific pain,
usually major secondary gain motives,
and a big behavioral component
to their pain; and honestly most of
the treatment applied here has been
shown to be ineffective. The elite,
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Page 13
… Red flags in back pain continued from page 11
Continued on page 14…
evidence-based healthcare flagship
Cochrane Collaboration’s meta-
analysis website (www.cochrane.
org) uniformly reports little long-
term benefit from virtually all back
care treatments with the probable
exception of well-done cognitive
behavioral therapy (CBT) — which
doesn’t mean that every chronic back
pain patient is a hypochondriac;
it just means that many patients
benefit from therapeutic assistance
with understanding and coping
mechanisms.
So, most cases get better without
intervention, but some don’t. There
are several very real structural spine
pathologies that can benefit greatly
from acute diagnosis and care.
Things like discitis and metastatic
lesions and chronic cauda equina
syndrome are population-rare,
but all too common in a referral
spine practice like mine, and the
history is almost always one of
tragically delayed diagnosis and
compromised outcomes — including
paraplegia and death — from missed
opportunities for early care. There
are relatively few spine surgeons out
there but many primary caregivers, so
the burden of screening naturally falls
on general and family practitioners,
or in the case of the injured worker, it
can fall on the urgent care physician.
A lot can be achieved by remembering
the usual profile of benign back pain,
and also by knowing and recognizing
some red flags for low back pain,
which can be identified by asking just
a few simple questions.
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Page 14
… Red flags in back pain continued from page 13
Continued on page 15…
THE PROFILE OF BENIGN
BACK PAIN
Benign chronic or recurrent back pain
generally presents around the 40s,
most often in the lumbar region of
males who do heavy physical work and
who have a history of work injuries
or other trauma. The pain episodes
are generally of stable or consistent
intensity; it gets better with rest/lying
down (it’s “mechanical”); there are
no neurological or constitutional
symptoms; and while there may be
work and activities disability, there is
almost never a locomotor disability.
THE RED FLAGS
So, one red flag is a history of onset
at age either > 50 or < 20 years. A
second is the absence of a trauma/
injuries history (i.e. the spontaneous
onset of pain). The third red flag is
pain located outside the low back
region where cancers and fractures
and infections are actually quite rare.
A history of significant trauma should
be a fourth red flag for fracture, but
too often isn’t.
Any patient with a history of
cancer (there’s red flag number five)
who presents with new-onset low
back pain should be considered as
metastatic until proven otherwise.
And anybody with a history or
high risk of immunosuppression —
identified AIDS or HIV, recreational
needle drug users, taking steroids or
immunosuppressants — has a discitis
until proven otherwise (that’s red flag
number six).
Another red flag frequently
missed (number seven) is history
of neurological symptoms, like
numbness/tingling or claudication
(i.e. “I can only walk a short distance
or time before my back pain forces me
to stop”). Physicians shouldn’t depend
on concrete neurological findings on
physical exam — such symptoms are
often delayed and by then, it’s often
too late. The history is enough to alert
an examining physician, but he or she
must ask for it. Incredibly, just about
every year I see a patient who gets
to the point where they’re crawling
around the house on hands and knees
from pain, but because they don’t
have a weak ankle or numb toe, they
don’t get referred.
Constitutionality is red flag number
eight — the backache patient who is
losing weight or having fevers should
be taken very seriously indeed. Night
pain is less of a concern. We used to
think that pain at night was a red flag
but it’s been conclusively shown that’s
not so. Pain that isn’t mechanical,
that persists even when lying down,
can be red flag number nine.
The final red flag, number ten, is a
history of rapidly escalating pain.
These patients with chronic benign
Page 15
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… Red flags in back pain continued from page 14
Continued on page 16…
back pain often have a slowly
escalating analgesic requirement
as their livers respond to the stress
challenge of metabolizing their
prescribed drugs and they become
habituated. But that evolves over
months and years. When injured
workers need more and more
drugs daily or weekly, there’s often
something very bad going on.
WHAT TREATING DOCTORS
SHOULD ASK:
A screening can be done in just a few
seconds.
How old are you? (1st red flag)
Where’s the pain? (3rd)
How did it start, with no injury (2nd)
or serious trauma? (4th)
Any history of cancer (5th), immune
suppression or recreational drug
use? (6th)
Neurological symptoms? (7th)
Fever or weight loss? (8th)
Does it get better when you lie down,
or not? (9th)
Is it pretty stable in intensity or is it
worse than it was last week? (10th)
WHAT IF SCREENING IS
POSITIVE?
As long as no “red flags” exist, an
injured worker should be encouraged
to remain as active as possible,
Page 16
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… Red flags in back pain continued from page 15
minimize bed rest, use ice or heat
compresses, take anti-inflammatory
or analgesic medications if desired,
participate in home exercises, and
return to work as soon as possible.
Patients whose answers raise red
flags should be referred immediately
to a qualified spine surgeon and/or
appropriate subspecialties. However,
some of the “red flags” might indicate
a pre-existing condition and not a
work-related injury. By understanding
this we can channel the patients to
the right doctor very quickly with less
confusion in regard to “work-related
injury” vs. “pre-existing injury”
CONCLUSION
Keep all these “red flags” in mind
because all injured workers with back
pain are not the same. We should
identify these “red flags” and refer
as indicated to prevent a disastrous
consequence. Some of the “red flags”
indicate work-related injury but
some don’t. This is very important
to differentiate industrial-injury-
related conditions from pre-existing
conditions. Be sure the physicians
you’re relying upon pay attention to
detail.
For information on how to contact
Dr. Thongtrangan, go to: www.
arizonaspinedoctor.com or www.
valleyorthoaz.com