| January 31, 2012
Last week, I participated as a medical expert in eight social security disability hearings. Within these hearings, my role was to review the medical evidence consisting of physician notes and opinions, then to render a neutral opinion regarding medical condition and impairment levels of the claimant. Within each of the hearings, substance use was a relevant aspect of the case.
In the first hearing, the claimant had been seeing a psychiatrist for over one decade. The psychiatrist prescribed a combination of three different sedative-hypnotics to his patient, who was now, unsurprisingly, complaining of worsening anxiety and depression. The claimant was now impaired, though she had not been impaired at the start of treatment. I noted to the court that the claimant was impaired as a result of the treatment she had been receiving, and that while she was physiologically dependent upon her prescribed sedative-hypnotics, she did not have any evidence of addictive illness. The result: her case was paid, largely due to her having been impaired secondary to poor medical treatment.
In the second hearing, the claimant was complaining of pain of such severity as to impair his ability to focus and concentrate. The medical notes revealed that he was receiving increasing doses of narcotic agents, that these agents were prescribed despite his subjective perception of pain worsening in response to the medication, and that no efforts had been made to prescribe non-narcotic alternatives. The claimant had never seen a psychiatrist or addiction specialist, and had no reason to suspect such an evaluation would be useful. Ultimately, this case was also paid, again largely due to his being impaired secondary to poor medical treatment.
In the third hearing, the claimant had a long history of heavy substance use alongside symptoms consistent with addictive disease. The claimant had been evaluated by a physician board certified in psychiatry. That physician opined that the claimant had major depression and an anxiety disorder (no mention of a substance use disorder), and further opined that the claimant was impaired as a result of these disorders. The case would have been paid were it not for a well-informed judge asking for medical expertise and opinion at trial. I indicated that the psychiatrist's opinion was in error, noting DSM-IV's criteria requiring that symptoms of depression and anxiety not be secondary to psychoactive substance use before permitting a diagnosis of major depression and generalized anxiety disorder. This case was ultimately not paid, as impairments secondary to addictive disease are not covered by social security.
The remaining five cases each had similar stories in which poor assessment or care led to significant impairment and potential or actual societal cost. The first two claimants will now be receiving taxpayer dollars as a result of their poor treatment. They will not be productive members of society. The third claimant's misdiagnosis leaves him untreated for an easily treated illness. He too will remain unproductive, though not at taxpayer expense, unless he paid attention to my testimony and takes action accordingly.
These stories are repeated on a daily basis across the nation, bearing witness to the issues raised in our press release last week and the new ASAM Prescription Drug Policy. ASAM is now asking for a requirement that DEA certification be tied to mandated prescriber education. Although this request will make us no friends within the medical community, which has by and large opposed such a requirement, it is clear that definitive action must be taken to stem the tide of overprescribing of addictive medications. It is also clear that such action must take place not only within the prescriber community but within medical schools and residency programs. As those students and trainees become practicing physicians, it is my hope that the DEA certification/education tie-in could be phased out, though I recognize that adding restrictions is easy but taking them away is difficult. Close study of the entire process will be necessary to determine when and whether the educational requirements are both successful, and ultimately, no longer needed on a recurring basis.
As always, I welcome your comments and concerns here at the President's Blog.