New Centers for Disease Control Guidelines on Opioid Prescriptions

Posted on Thursday, August 3rd, 2017 at 10:04 am    

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

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

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

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

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

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

The purpose of the guidelines

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

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

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

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

What’s included in the guideline?

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

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

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

There are several key differences:

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

Additional Centers for Disease Control activities to address the opioid crisis

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

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

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

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

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

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

Categories of opioids

The CDC examines these four types of opioids:

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

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

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

Why the opioid epidemic is growing

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

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

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

Between 1999 and 2014:

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

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

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

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

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

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

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

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

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New Virginia Laws and Rules on Prescribing Opioid and Buprenorphine Pain Medications

Posted on Wednesday, July 19th, 2017 at 9:00 am    

In response to the growing nationwide and statewide opioid epidemic, the Virginia Board of Medicine recently adopted new rules to respond to the health danger of opioids and buprenorphine, two medications given for acute and chronic pain. These new regulations are largely based on the CDC Guidelines which came out in 2016. On March 15, 2017, the new regulations were signed by Governor McAuliffe and became active as the law in the Commonwealth of Virginia on July 1, 2017. Additional regulations have been proposed.

The Crisis in Virginia

At least 1400 people died in Virginia in 2016 from Drug Overdoses, with the biggest increases from 2015—175 percent—coming from powerful opioids such as Fentanyl or Carfentanil being laced into street heroin, according to The Virginia Department of Health and law enforcement. While Fentanyl is 10 times more potent than heroin, Carfentanil can be 10,000 times stronger. The drug is generally only prescribed for large animals, such as elephants.

In 2015, opioid overdose deaths accounted for 79% of all overdose deaths in Virginia.

Our Concern as a Workers Comp Law Firm

While this is certainly a horrific crisis that must be dealt with, as a law firm trying to help severely injured workers, we are concerned that the new regulations merely make our clients unwitting victims of regulations designed to combat illegal behavior mostly by young drug addicts and drug dealers. We agree something must be done, but at what cost? When we start hearing our clients— who have just had hardware literally screwed into their bones— complain of excruciating pain, what are we to do when the doctor says, after only 2 weeks, that he can no longer prescribe our client any more pain medication due to these new regulations?

The current approved regulations apply to medical doctors, osteopathic practitioners, podiatrists, and physician assistants. Nurses have adopted similar regulations for nurse practitioners who have the authority to prescribe medications. There are some exceptions. The regulations don’t apply if a person is being treated for pain (chronic or acute) related to cancer and patients who are getting palliative or hospice care for their pain. The regulations also don’t apply if the patient is being treated for pain as a hospital patient, while in a nursing home or in assisted living facility – if that facility uses just one pharmacy source. Medical providers may also be exempt if the patient is part of a federal or state clinical trial.

Summary of the Regulations

Acute pain is defined as pain that happens during the normal course of a disease or condition (such as a workplace injury) or because of surgery where controlled medicines are prescribed for three months or less.

Chronic pain is defined as pain that happens outside of any disease or any condition where controlled medicines can be ordered for more than three months.

Opioids and treatment of acute pain under the new regulations
The regulations provide that prescribers of opioids must:

·       First duly consider non-pharmacologic and treatments that don’t involve opioids before prescribing opioids.

·       Prescribers must conduct a history and a physical exam, assess the risk of the patient for abuse and conduct a Prescription Monitoring Program query pursuant to the Virginia Code

Various bills and proposals had different conditions for pain medicine prescriptions. The regulations that were passed will became law on July 1, 2017 and will sunset on January 1, 2022 unless further legal moves are made.

Prescribing opioids for acute pain treatment under the regulations
When doctors and others with authority to prescribe opioids do fill out the prescription for opioids, they must start the patient with short-acting opioids and not long-acting drugs because of the concern by the Virginia Board of Medicine that the likelihood of addiction increases with long-acting opioids. The amount given should not be more than a 7-day supply unless there are “extenuating circumstances.” If opioids are given pursuant to surgery, they shouldn’t be prescribed for more than 14 days in a row unless there are “extenuating circumstances.”

The regulations suggest that prescribers review the Centers for Disease Control information on morphine milligram equivalent (“MME”). The regulations provide additional requirements on prescribers on how to handle pain management medicines for acute pain.

If other medications such as benzodiazepines are prescribed along with the opioids, the prescribers must document a “tapering plan” so that the lowest effective does is prescribed. Doctors need to document all the prescriptions for acute pain that they make. The documentation requirements are very strict. Doctors, nurses, and others who are allowed to prescribe opioids can be subject to disciplinary action for noncompliance.

Prescribing Opioids for Chronic Pain
The second part of the new Virginia regulations covers opioid prescription for chronic pain. Prescribers must conduct a physical exam of the patient and take an oral history. The doctor or other prescriber must also evaluate the patient’s mental health. Mental health can be a key factor in determining the probability the patient who uses opioid will become addicted.

There are nine evaluation items that must be recorded:

1.     Current treatment for pain and past treatments

2.     How intense the pain is and the scope of the pain

3.     The diseases and conditions (such as injury) that are causing the patient’s pain

4.     How the pain is affecting the patient’s physical and emotional health – including his/her quality of life and daily activities such as sleeping, eating, and walking

5.     The patient’s history of addition, substance abuse, and psychiatric problems – and those of any family members

6.     The results of a urine test to determine what drugs are in the patient’s system or a serum medication test

7.     A Prescription Monitoring Program query – as defined in the Virginia Code

8.     The risk of substance abuse based on the patient’s prior history

9.     A request to see and examine prior medical reports and records

Prescribers of opioids are also required to review the safe and best way to store controlled medications that contain opioids and the proper way to dispose of them. Prescribers must also discuss with patients, where the opioid prescriptions are not effective, a methodology for terminating the use of the opioids.

As with acute pain prescriptions, prescribers of opioids for chronic pain management should consider other less risky alternative and properly document use of MME medications.

The new Virginia regulations require that prescribers document the reasons for opioid prescriptions that last more than three months and if benzodiazepine and other medications are used with opioid medications, the prescriber must document how the lowest doses can be achieved.

Prescribers must routinely monitor the patient for signs of an opioid use disorder. If such a disorder is present, the physician or other prescriber should begin a treatment plan, refer the patient for evaluation and treatment, and review the case with a qualified healthcare professional.

Patient treatment plan, according to the Virginia Board of Medicine, must include detailed requirements including detailed documentation of the patient’s progress, including diagnostic evaluations and risks of abuse, misuse, or diversion – and other steps that can be taken.

Informed consent
Patients who are being prescribed opioids for chronic pain should be told of the risks, alternative remedies, and benefits of opioid medications before any treatment plan begins. The informed consent must be in writing before the prescriptions can be started. The informed consent should be properly documented. The informed consent must have the patient’s signature and must also disclose the treatment conditions, when treatment will cease, and any behaviors that require a referral.

There should also be a signed treatment agreement. The Medical Society of Virginia has a template of an informed consent form. The treatment plan should include the patient’s consent to obtain serum medication levels or urine drug screening, the Prescription Monitoring Program query and identify any other prescribers or pharmacies that are dispensing the opioids.

Prescribers must periodically review how the treatments are working – at least once every three months. Precise documentation is a must. If the patient is not responding well to the opioid medications, the prescriber has to document the reason for continuing the opioid prescription and what other treatment options are being considered.

The Prescription Monitoring Program query must also be conducted every three months. Urine tests or serum tests must be given every three months to see how well the patient is doing and what other medications he/she may be using. After the first year of opioid treatments, the tests can be done once every six months. As with acute pain, doctors and other health care providers who write opioid prescriptions should evaluate any opioid use disorders.

Prescribers, according to the Virginia Medical Board’s regulations, must also refer patients for new evaluations and treatments when needed or if the chronic patient has an opioid use disorder.

Documentation should be detailed and ready for review. Prescribers must include in their documentation of chronic pain:

1.     An oral history and physical exam

2.     The patient’s past medical history

3.     The records of prior treatment doctors and healthcare providers

4.     Laboratory test results, diagnostic statements, and therapeutic results

5.     Any evaluations and consultations with other doctors

6.     The goals of treatment

7.     A review of the risks and benefits that were disclosed

8.     An informed consent and a treatment agreement plan

9.     Descriptions of any treatments

10.  All medications the patient is taking including type, dosage, quantity, any refills, and the dates of the prescriptions

11.  The patient instructions

12.  What reviews have been given, when, and the summaries of the reviews

The third part of the Regulations – Buprenorphine Prescriptions-Used to Battle Addiction

Buprenorphine is one of the most common types of medications used in attempting to battle heroin or other opioid addiction. It actually reverses the effects of opioids and is fast-acting. Commonly prescribed names are Naloxone, and Narcan (nasal spray). Some of the regulations promulgated by the Virginia Medical Board are:

1.     Acute pain – buprenorphine is not indicated for acute pain if the setting is an outpatient setting unless there is a primary diagnosis of addiction.

2.     There are specific regulations indicating how doctors, physician assistants, and nurse practitioners are able to obtain waivers to allow them to prescribe Buprenorphine/Naloxone in an outpatient setting. There are certain waivers that must be obtained through the DEA.

3.     Important especially for folks suffering from anxiety in addition to the pain: Anti-anxiety Medications containing Benzodiazepine, such as Lorazapam (Valium) or Xanax, can cause an adverse reaction when used with opioids. So the regulations require that if the physician is prescribing both the anxiety medication and the opioid, Naloxone MUST also be prescribed.

4.     The Virginia Board of Medicine also requires that health care providers refer patients who are being prescribed buprenorphine to treat addiction to a mental health care provider for counseling or give the patient their own counseling – provided everything is documented. Mental health care providers include “a person who provides professional services as a certified substance abuse counselor, clinical psychologist, clinical social worker, licensed substance abuse treatment practitioner, licensed practical nurse, marriage and family therapist, mental health professional, physician, professional counselor, psychologist, registered nurse, school psychologist, or social workers. . .”

There are many additional requirements for health providers who prescribe Buprenorphine such as:

·       Urine drug tests

·       Pregnancy tests for women who might be pregnant

·       Prescription Monitoring Program tests for HIV, Tuberculosis, and Hepatitis B and C) if indicated

·       A tapering plan when buprenorphine is combined with other medications

Patients who take buprenorphine should start with 8mg/day or less. The health care prescriber should see the patient once a week and document any occasions for subscribing more than 8mg/day. Dosages over 16 mg/day require detailed medical documentation and dosages over 24 mg/day are specifically forbidden.

If buprenorphine is being prescribed for addiction treatment, then, as with chronic pain prescriptions, health care prescribers need to conduct urine drug tests or serum drug level tests at least once every three months during the first year and, at least, once every six months for the second year and beyond

Patients who are 15 years or younger should not be prescribed buprenorphine as part of a treatment plan for addition until the FDA gives its approval. Patients who are getting buprenorphine for addiction treatment should be monitored to see if their chronic pain is improving. Patients who have unstable psychiatric problems should get psychiatric help and treatment before buprenorphine is considered.

Summary and Our Take on these Regulations
The new laws were enacted in response to the rising dangers of Opioid Addiction and Abuse and the growing crisis in response to the rise in deaths due to overdose from opioids.

Unfortunately, for many of the severely injured workers’ compensation clients who we represent, which clients frequently require ongoing, severe pain management, these regulations simply mean more “hoops” to jump through in order to obtain relief from their unrelenting pain.  This is in addition to the already burdensome issues which often accompany obtaining prescriptions in workers compensation cases, such as miscommunications or lack of approval from the comp adjusters or disconnects between the pharmacies and comp adjusters.

Our take on this is that while opioid addiction and overdose deaths from drugs like heroin and fentanyl are horrific problems which much be addressed, severely injured workers should not have to pay the price or be lumped in with criminals, and common drug addicts who abuse themselves and routinely break the law in order to feed their addiction.
We do applaud the efforts to make sure doctors are monitoring patients to make sure that opioids are being used for actual, real pain and are not the first drug of choice, particularly in cases where there is a history of addiction for the patient. We certainly do not want our clients to have the added problem of opioid addiction added to their work injuries.

That being said, we do have many clients who undergo spinal fusion surgeries and other highly invasive surgeries that often entail implantation of hardware and severe pain that may last for many weeks or even months; but now, under these new regulations, the surgeon must provide proof of “extenuating circumstances” to provide opioids beyond two weeks after performing surgery. This will cause needless suffering of our clients—mostly due to the reckless actions of a small minority of criminals and drug dealers.

The truth is most pain practices are already heavily regulated and follow certain protective protocols already in existence. Our office has already has a “warning letter” that goes out to every client we represent who enters a pain management program which basically states: beware of running afoul of the protocols of your pain management physician’s practice. Most of these doctors require you to sign a pain management “contract” which states that you will religiously take all of your medications as prescribed, be subjected to urine screens at each appointment, obtain no outside prescriptions even remotely considered pain medication or anxiety medication, stay off of illicit drugs such as marijuana, and bring all prescribed pills to each and every appointment to undergo a “pill count.” If anything seems out of place, these physicians will routinely eject you from the practice, which could result in damage to your workers compensation claim, and of course, difficultly and interruption in your course of pain management, which can be devastating in the most severe cases.

Now, these restrictions and limitations on physicians will only become more onerous for our clients and their doctors. Many physicians may simply refuse to prescribe pain medications for fear of running afoul of these regulations.

Contact a skilled Virginia work injury to learn more about the medical requirements for prescribing opioids
The new Virginia regulations on opioid prescriptions have just started. Many Virginia workers’ compensation employees do see pain management doctors and other physicians to try to manage their pain. Attorney Joe Miller Esq. can help you understand how these new regulations apply to you, your doctors, and your workers’ compensation case. To learn more and to speak with an experienced legal advocate, please call (888) 694-1671 or fill out our contact form.

Can I Sue My Employer?

Posted on Monday, July 17th, 2017 at 4:51 pm    

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A Glossary of Pain Management Terms and an Explanation of Neck Pain

Posted on Friday, July 14th, 2017 at 8:34 am    

What is pain management?
Pain management is that area of medicine that deals with the attempt to manage pain.  Physicians who practice pain management are most often found within the practices of Orthopedic Surgery, Neurosurgery, Osteopathy, or Anesthesiology. The treatments often involve a variety of modalities, but typically involve utilization of various prescribed pain medications, and sometimes injections and in the most severe cases, the implantation of nerve devices to attempt to control a patient’s pain, short of having to undergo some kind of anatomical revision such as a spine fusion.

Glossary of Pain Management Terms
Acute: Pain that can be intense but usually lasts for a short period of time, usually shorter than six months. It usually relates to a bodily injury (such as injury at work) and ends when the injury heals. (more…)

A Few Exceptions to Standard North Carolina Workers’ Compensation Issues

Posted on Wednesday, June 28th, 2017 at 11:39 am    

Many workers work a 40-hour shift at just one location. Most get a paycheck based on their hours of work. There are many exceptions though that an experienced work injury lawyer can help you with. Attorney Joe Miller, Esq. has been helping North Carolina employees for over 25 years. He’s handled almost every type of unusual situation that can arise. Here are a few unique work situations:

Commuting to work or traveling for work

As a general rule, employees are not eligible for worker’s compensation if they are hurt on the way to work or on the way home. This is often referred to as the “Coming and Going” rule. Employees are normally only eligible for worker’s compensation while they at the job site. Employees who leave the job site during the day will be judged by whether they were running company errands or were doing personal chores.

There are a few exceptions though:

  • Workers who are expected to be on the road should be able to recover work injury benefits. This includes salespeople, nurses, and others who travel to see customers and clients at their homes and businesses.
  • Employees who are on-call are expected to be ready to come to work on a moment’s notice. They may be eligible for worker’s compensation from the moment they get the call.
  • Employees who are at a trade show or conducting business away from the standard work are helping their employer. It only seems fair they should be protected if they are hurt while helping their employer. They may be eligible even if they aren’t doing work activities such as shopping or enjoying a social activity.
  • If the employee is running a work-related errand on the way to work or on the way home, they may be eligible for work benefits.
  • If the worker has to drive through a construction site or dangerous site to get to work, getting work injury benefits may be possible.
  • If the employee is using the company car and the company is paying for the gas and mileage, then if the employee is hurt coming or going, he/she may be entitled to work injury benefits.

Some of the questions and answers that we will review for our clients are:

  • Was the accident during a typical commute or did the employee go off-course for some reason?
  • Did the accident happen while the employee was running personal errands, business errands, or a combination of both?
  • Who paid for the commute?
  • Was the employee travelling from one work site to another work site?
  • Did the accident happen in a company parking lot or a private parking lot?
  • Did the employer benefit from the trip in any way?

Part-time, Temporary, and Seasonal employees

Many employers hire workers only when they need them. For example, retailers often hire employees during the winter holidays and construction companies hire crews when the weather is warmer. Non-full time workers are classified as follows:

  • Part time employees. As a general rule, full-time employees work 40 hours while part-time employees work 35 hours or less. Employees who work 35-40 hours are in a grey hour. Another rule of thumb is that full-time employees are more likely to paid a weekly salary while part-time employees work on an hourly rate. Part-time workers usually receive no or little benefits especially health benefits – which makes getting work injury benefits all the more important because worker’s compensation pays for necessary medical bills.
  • Temporary employees. Temporary workers are normally hired for just a few days or a few weeks to fill in for someone who is on maternity leave or vacation or to fill a short-term need in the company. Temps may work for a temp agency or for the company where they are doing the work. Temporary employees may work full-time meaning they are paid a salary.
  • Seasonal Employees. Most seasonal workers are hired during Christmas seasons or during the summer months. Some industries like the hotel industry may add workers during the summer when there is a lot more travel. Seasonal workers may also be full-time employees for the time they work.

Whether these workers qualify for workers’ compensation depends on whether the worker is classified as an employee or an independent contractor. That distinction, in turn, is based on a variety of factors. Injured workers shouldn’t automatically assume that just because they don’t get a weekly paycheck and health benefits that they are an independent contractor. The main criteria that North Carolina will use in deciding if you are an employee or not is how much control over the worker’s duties the company had. If the employer decided what hours you worked, where your worked, what job tasks you did at work, who provided the tools that used; then you may be eligible for worker’s compensation because you’re an employee, even if the company claims that you are not.

Working for Tips

Workers such as waitresses who work for tips need to make sure they are getting the correct weekly income. Employees who are injured on the job get 2/3rds of their lost wages until they can return to work or for up to 500 weeks for more serious injuries. For waitresses, the starting point is their weekly pay which for many isn’t much more than the state minimum wage. The amount of the employees tips should also be determined. Most workers who have a work history know (and their employers know) how much extra they are getting in tips. Tips should be reported as income on the waitresses’ tax returns. If returns are reported then it should be straightforward that the waitress is entitled to 2/3rds of the tips and the wages added together. If tips were not reported, then getting 2/3rds of the tips paid for a work injury can be more difficult.

Make the call to an experienced work injury lawyer today.

Attorney Joe Miller Esq. has helped thousands of injured workers get the full workers’ compensation benefits they’ve earned. In many cases, he had to argue the exceptional or unique case. To see if you’re eligible and to get the best recovery the law allows, please call us at (888) 694-1671 or complete the contact form.


Must Your Virginia Accident be Work- Related in order to Collect Worker’s Compensation Payments?

In any work injury case, it is necessary to prove the following in order to be paid your benefits:

  • The injury or illness must be work-related
  • You must be an employee
  • The injury must be what is preventing you from working

Each of these elements can be complicated. The good news is that injured and ill workers do not need to prove the employer was negligent or reckless. Fault is not an issue in work injury cases. Your doctors or independent physicians can usually confirm that your injuries are what is preventing you from doing your job.

It is the work-related issue that can often lead to litigation. An experienced Virginia work injury lawyer like Joe Miller can help you convince an insurance company or the worker’s compensation hearing officer that your accident was indeed work-related. Some common work-related issues that often arise in Virginia are:

  • Lunch breaks. Whether an employee who is injured while they are on a lunch break is entitled to benefits depends on several factors. If you had lunch in the company cafeteria, that’s a stronger argument for collecting Virginia work injury benefits than if you were hurt away from the office. Likewise, if you were getting lunch for your employer or even other workers, that’s a better case than if you had lunch on your own. If you were meeting a customer or client, that’s good for business and you should be covered. Lunch while at a trade show on company time is similarly a better case than if you were just having lunch with personal friends or your family.


  • Employer events. Many businesses hold events to foster better social relations among office workers. If you hurt playing softball while you were representing the company team against other community businesses, you may be entitled to work injury benefits because that’s good marketing for the business. If the event was a class or some training activity, that also is helping your employer and you’d have a strong argument that you should be compensated.


  • Company travel. This topic is covered in the companion blog about the ‘going and coming’ rule.  The more you can show that the employer was directly benefited by your commute or travel activities, the stronger case for benefits you will have if you get into a car accident while traveling.


  • Your own negligence or misconduct. Just as you do not have to show an employer was negligent in order to collect Virginia worker’s compensation rule, the employer generally can’t argue that you were negligent to deprive you of you worker’s compensation benefits. If you were careless, failed to watch where you were going, used the wrong tool, or made an error in judgment; you still should be able to collect worker’s compensation.


The case gets tougher if you deliberately violated a safety rule or safety law. If you committed a crime at work, and were injured while doing so; then you probably won’t get Virginia worker’s compensation.


North Carolina and Virginia law differ significantly as to these concepts. In Virginia, a showing by the employer of a deliberate rule or safety statute violation could completely bar your claim, whereas in North Carolina, such a violation would only decrease your weekly comp checks by 10%.


  • Preexisting conditions. If you have a prior injury, then the employer or the employer’s insurance company will likely claim that the prior injury defeats your claim. An experienced Virginia work injury attorney will know what counterarguments to apply. For example, so long as your treating physician (who must be an M.D.) is able to give an opinion that the accident caused a sudden mechanical change in the body part in question, even of the slightest amount, and that this change is at least partially responsible for the current treatment and disability, then it makes no difference whether you had a pre-existing condition or not. The good news is also that there is no reduction in your benefits for the pre-existing condition. The entire claim is compensable if your doctor can support it in Virginia, despite whatever pre-existing conditions you may have had in the same injured body part.  


  • Hearing loss. Just because you work in a noisy environment, doesn’t mean you should be denied benefits. As long as it can be shown the hearing loss was work-related, you should be entitled to worker’s compensation, although the benefits for the hearing loss alone are very limited. Unless the hearing loss is so severe that it prevents you from working, the maximum you can recover for hearing loss is 50 weeks of compensation for each ear.  How much of the 50 weeks you will get is determined by the severity of your hearing loss and there is a hearing loss table that sets forth the decibel reduction with the corresponding percentage of hearing loss.


  • Occupational illnesses. You also are entitled to benefits if you suffer a disease or illness from work. Examples can include black lung disease or asbestosis. In order to qualify, the worker must be able to prove that the illness was not an ordinary disease that the community at large would suffer – and that the disease was characteristic of conditions found in a specific type of profession. The job must increase the odds of getting the illness.


Other example diseases include hepatitis suffered by a lab technician or a contagious disease suffered by a healthcare worker at a hospital. The employee does need to also show that the work conditions were what directly caused the disease.


There is one key difference between an occupational illness and a work injury caused by a fall or a specific workplace accident. An occupational illness can accumulate over time – that is the worker doesn’t have to prove any specific incident triggered the illness or disease.


  • Emotional/Psychiatric injuries. You don’t have to suffer a physical injury in order to qualify for benefits. In many cases though, emotional distress, or a psychiatric illness such as PTSD is something that occurs through either experiencing or witnessing an extremely traumatic event. The key in these cases is that the traumatic triggering event must be outside the realm of what the worker would normally encounter in his or her occupation. For instance, a police officer who tries to claim that witnessing a shooting caused him PTSD is going to have a difficult time proving that was outside the normal realm of his occupation. On the other hand, a nurse’s aide who witnesses a patient kill themselves through a self-inflicted gunshot wound to the brain is likely going to recover for her psychiatric injuries, as this is not something that she would normally encounter in her duties as a nurse’s aide.


Speak with an experienced Virginia lawyer as soon as possible

Attorney Joe Miller Esq. has helped thousands of injured workers during the past 25 years. He has the skills and experience to handle the tough cases and the exceptions to the rule. He understands what arguments to make to challenge arguments that injuries weren’t work related. For strong advocacy, please call (888) 694-1671 or fill out the contact form.

Burn Injuries and Worker’s Compensation

Posted on Monday, June 26th, 2017 at 11:34 am    

Many North Carolina and Virginia workers suffer serious burn injuries at work. While employers are required to follow a variety of federal, state, and industry standard guidelines – employees in both states are entitled to workers compensation benefits regardless of employer fault. In serious burn injury cases, the employer’s insurance company or self-insurance is required to pay for all the reasonable surgeries, doctor visits, and medications the employee needs to be able to manage the pain and be able to maximize the chances of recovery. If multiple skin grafts are needed and the burns are deep and extensive, the cost for the medical care can become quite expensive.

There are three basic types of workplace burns:

  • Thermal burns. These can be from a stove, steam, hot liquids, industrial equipment, or other causes
  • Electrical burns. These usually occur from some sort of electrical current or spark
  • Chemical burns. These can be caused by an product the worker uses that has caustic or toxic components such as cleansers.

Whenever a worker suffers any type of burn injury, it is crucial to get medical help as soon as possible. The burn victim should immediately contact the supervisor and then get emergency help.

Thermal burn injuries

If a person’s clothing catches fire, the first priority is to be able to put out the flames. The person should be helped to stop, drop, and roll. All burned clothing should be removed from the worker. The worker should then be given something to wrap their body in such as a jacket or blanket. All burn victims who catch fire will need emotional help as well as physical help.

According to the Centers for Disease Control (CDC), any jewelry, belts, and rings should be removed immediately because burned areas often swell.

There are three types of burns – first, second, and third degree

  • First-degree burns. These burns involve the skin’s top layer. Sunburn is a classic example. Signs include redness, sensitivity to touch, and mild swelling. Treatments include wet cool compresses or immersing the skin in fresh, cool water until the pain ebbs. The burn should be covered with a sterile non-adhesive bandage or sterile gauze. Ointments should be avoided because they can cause infection which can lead to serious complications. Some over-the counter medications may be used to help reduce the swelling and ease the pain. Most first-degree burns heal with time though if the first-degree burn covers a large portion of the body or the employee is elderly, emergency treatment should be sought.
  • Second-degree burns. These burns penetrate into the second layer of the skin. Deep skin reddening, blisters, leaking fluid, pain, and possible skin loss are likely symptoms. The skin should be immersed in fresh water for 10-15 minutes. The blisters should not be broken and ointments should be avoided because, again, they can cause infections. Burned arms and legs should be elevated. Steps should be taken to help avoid shock. This includes laying the burn victim flat and elevating the feet and covering the victim with a blanket. If a head, neck, back, or leg injury is suspected – then the shock position should be avoided. The best course of action for second-degree burns is to get immediate emergency medical assistance.
  • Third-degree burns. These burns penetrate the skin completely and can damage underlying tissue also. The skin can appear leathery and dry, charred, or have discolored patches. Breathing issues can be a real problem. Emergency help is mandatory.

Electrical burn victims

Electrical jolts, shocks, or burns often aren’t visible like thermal burns – though the damage is often deep underneath the skin. The electrical burn can cause heart problems and even cardiac arrest. Many electrical burn victims suffer breathing problems and loss of consciousness in addition to heart problems.

The best treatment is to seek immediate medical help. In addition, care should be taken to remove the burn victim from any electrical source by using an object that doesn’t’ conduct electricity. The source of the electricity that caused the burn should be cut off. Cardiopulmonary resuscitation (CPR) may be required.

Chemical burns

Mining and other industries are especially prone to cause serious chemical burns

According to the Mayo Clinic,, strong acids, lyes, paint thinners, and gasoline are among some of the causes of chemical burns. If an employee has a chemical burn:

  • The chemical that is causing the burn should be removed.
  • Dry chemicals can be brushed.
  • Wet chemicals need to be treated more carefully. The person removing the chemical should wear gloves and take other precautionary steps so they don’t get burned as well.
  • Any contaminated clothing or jewelry should be removed.
  • A stream of cool tap water should be run over the burn.
  • Loose fitting bandages or gauze should be applied.
  • Some over-the-counter pain relievers may help.
  • Your doctor may give you a tetanus shot.

If the employee is in shock (is pale, fainted, or has difficulty breathing), the chemical burn is deep (penetrating the first layer of the skin), or the burn involves the eyes, hands, feet, face, buttocks, groins, or a major joint – then emergency medical help should be called for.

Recovery for Scarring and Disfigurement from Burns

Often, there are terrible scars or disfigurement left on the skin as a result of severe burns. Unfortunately, under the laws in North Carolina and Virginia, separate recovery for scarring or disfigurement is extremely limited, unless the scarring is so severe that it interferes with one’s ability to work, such as restriction in the range of motion or limited use of the disfigured area that prevents you from returning to work. In that regard, such cases are treated just like a regular comp case.  

In Virginia, if you are able to return to work, you are only entitled to a maximum of 60 weeks of temporary total disability payments for scarring and disfigurement.

In North Carolina, if the disfigurement is on the head or face, the maximum payment is $20,000.00. Elsewhere on the body, it’s only $10,000.00.

Also, as with all workers compensation cases, there are no payments for pain and suffering. All payments are determined by statute.  

Speak with an experienced North Carolina and Virginia Worker’s Compensation Lawyer Today

Burn injuries can require long-term medical care. Employees may not be able to return to work for months, years, or, in severe cases, never. North Carolina and Virginia attorney Joe Miller Esq. has been helping injured workers get their benefits and legal recoveries for over 26 years. He has helped thousands of employees get their full workers’ compensation benefits. For help now, please phone us at (888) 694-1671 or complete our contact form.

Head Injuries, Concussions, and Workers’ Compensation

Head trauma of all types is a very common workplace injury. An employee can suffer a head injury due to a slip and fall, an automobile or truck accident, a piece of equipment that doesn’t work, or an object that falls from above. Head injuries can happen to:

  • Construction workers
  • Manufacturer employees
  • Police officers
  • Firefighters
  • Truck drivers
  • Anyone who uses a car for their job
  • And any worker anywhere

Common head trauma tests

The brain is made of soft tissue which can be easily damaged. Inside the skull is a cerebrospinal fluid layer that helps protect the brain from the skull. A concussion happens when a blow to the head causes the brain to pass through the fluid and strike the skull.

If a head injury, concussion, or brain trauma is suspected; your physician will conduct several types of tests:

  • The doctor will take an oral history to determine what caused the blow to the head
  • The doctor will conduct a variety of physical tests to determine the loss of any physical or cognitive function
  • The physician will likely order several imaging tests including:


      • A CT scan. This test will help determine if you have any hemorrhaging or a skull fracture
      • An MRI (Magnetic Resolution Imaging). This test is use to evaluate the function of the brain.


  • An EEG test (Electroencephalography)-electrodes are placed on the head and measure electrical activity in the brain over time.


    • Brain PET Scan- (positron emission tomography)-this can give the physician real-time visuals of metabolic processes taking place in the brain.

Head trauma victims will often be seen by several doctors such as a neurosurgeon, a neurologist, and a psychiatrist , psychologist, or a neuropsychologist. Other professional help can include social workers, speech and language pathologists, recreational therapists, and a traumatic brain injury nurse specialist.

Some milder head injuries can heal within days, weeks, or months. In serious cases, the first thing an emergency team will examine is that the employee/patient has an adequate supply of oxygen and blood. They will also work to make sure the patient’s blood pressure is monitored.

Some serious traumatic brain injuries which can last a lifetime. Symptoms can include:

  • Pain
  • Confusion
  • Nausea
  • Blurred vision
  • Loss of bodily functions
  • Loss of memory
  • Poor concentration
  • An inability to make decisions
  • Impulsiveness
  • Inability to communicate or speak
  • Inability to understand what is being said when you are spoken to

According to the Mayo Clinic, medications can include:

  • Diuretics which reduce the amount of fluid in tissues and, if given intravenously, can help reduce pressure inside the brain
  • Anti-seizure medications to he help avoid any additional brain damage
  • In some severe cases, drugs that actually induce a coma may be used to reduce swelling and pressure on the brain case.

Surgeries can include:

  • Removing blood clots (subdural hematomas)
  • Repairing a fracture to the skull
  • Draining cerebral brain fluid
  • Creating a window in the skull

Head trauma victims may need the following types of treatments:

  • Physical therapy. This will address the ability of the patient to perform physical tasks such as walking, feeding oneself, sleeping, personal grooming, bowel and bladder functions, and other daily functions. The physical therapist will also help with any pain issues, strength, posture, and balance.
  • Occupational therapy. This therapy will address the ability of the worker to do his former job. It can include the ability to lift and carry objects, perform repetitive tasks, bend, stretch, and manual dexterity. The occupational therapist will also help with the ability to bank and handle budgets.
  • Psychological therapy. Many head trauma patients need help coping with their physical difficulties, depressions, and anxiety. Their family situations are often put under tremendous strain as they often say they no longer recognize the behavior of the brain injury victim.

What to do after a head injury

Head injury symptoms often don’t show themselves right away. If an employee suffers any blow to the head for any reason, the best course of action is to see a physician right away. The sooner the condition is treated, the better the chances for a recovery will be. Also, delay in treatment can be taken as a sign or proof that the injury happened outside of work. Employers and insurance companies will look for any excuse to say your injuries are not work-related.

Your work status and benefits

You should be paid for all of your medical bills until you reach a state of Maximum Medical Improvement. This means that your hospital, therapy, and other bills will be paid until it is clear than additional medical treatment will not help you get any better.

The amount of income you receive will depend on the extent of your recover

  • If you are able to return to your normal job, you will receive 2/3rds of your lost wages up to the time that you are able to return to work
  • If you can return to a different type of work that is less strenuous, because you have a permanent partial disability, you will receive
    • 2/3rds of your lost wages until you can return to work
    • An additional allocation to reflect that you cannot earn the same income as before the blow to your head because you need to work at a less strenuous job (Temporary Partial Disability)
  • If you cannot return to work at all, you will receive 2/3rds of the average weekly wages up to the maximum amount of weeks that North Carolina or Virginia law allows, which, in the most severe cases of brain injury, could mean permanent and total disability , or lifetime compensation.

You may also be entitled to vocational rehabilitation. Many serious brain injury victims need occupational therapy or behavioral therapy to be able to return to their original job. In some cases, the worker can be retrained to do another job. For example, a construction worker who suffers a brain injury when a piece of equipment falls on his head from several stories up, may never be able to do physical labor again. A lot will depend on what the testing reveals are the extent of any permanent cognitive impairments you may have as a result of your brain injury.

Contact a trusted Virginia and North Carolina work injury lawyer now

Lawyer Joe Miller Esq. has helped thousands of employees get the workers’ compensation benefits they deserve. In some cases, he helps workers obtain a long-term settlement of your claim. He works with your medical providers to understand each and every treatment, test, and surgery that will be required and each type of therapy that help you improve your life. He cares about your recovery and your ability to pay for your medical bills and getting paid a regular income. For experienced help, please call (888) 694-1671 or fill out the contact form.

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