The Toxic Balloon
Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.
It was 9:30 p.m. on a sweltering Miami night.
The emergency medical response team had just pulled into the parking lot of the Maki Madness pickup sushi restaurant when their scanner went off.
“Attention all northwest emergency medical personnel, we have a one-car accident involving a late model Pontiac Bonneville near the intersection of Opa Locka Boulevard and Northwest 135th Street. Victim is a large Hispanic male with a head injury. The victim is conscious, but believed to be intoxicated, possible drug user, please advise as to proximity and availability …over.”
Patty Broomhilde, the ambulance’s driver, snatched up the radio transmitter before her partner, medical technician Rick Cornell, could grab it.
“Unit 457 responding, we are in that vicinity, we’ll take it, over…”
Patty rolled her eyes at Rick and wheeled the ambulance around. Their much-anticipated Miami Maki rolls with stone crab, yellow tail and avocado would have to wait.
Rick, who wasn’t supposed to smoke on duty, had a cigarette on the way over to help temper his appetite.
That very same evening, Rick’s older brother Petey, a hard drinking blues guitarist, pulled out of the Purple Rose, a Miami waterfront blues club. To most guys, three beers was plenty. Petey had four in him already, plus two shots of 100-proof bourbon. Petey gunned the engine on his Harley, and with a cigarette in his mouth and his guitar strapped to his back, motored out of the parking lot and onto a busy two-lane road.
Petey wore his blond hair long and he didn’t even own a helmet. The draft from a passing truck whipped his ponytail into his eyes for just a second. Petey, buzzed from the booze, took his right hand off of the bike to clear his vision and temporarily lost control just long enough for the Harley to swerve into the path of a landscaper’s pickup that was hauling a trailer. The truck caught Petey and his bike and t-boned him. Petey was killed almost instantly.
The emergency medical team was only two blocks from the scene of the Pontiac accident when they heard sharp scanner chatter about a fatal involving a motorcyclist who wasn’t wearing a helmet.
“Wouldn’t want that one,” Patty said stoically as she slowed down to where the wine-red Pontiac had slammed into a telephone pole.
There was steam coming up from the Pontiac’s engine and the smell of gasoline was strong.
Rick got out of the unit first and ran to get close. The odor of marijuana and brandy in the car almost eclipsed the smell of gas.
“¡Dónde le duele! ¡Dónde le duele! (Where does it hurt?)” Rick shouted at the driver, who had blood streaming from a cut on his forehead.
“Me duele la cabeza,” said the driver.
“¿Le duele otra parte de su cuerpo? (Does anything else hurt?)” Rick said.
“Nah…nah…jus’ my head,” the driver said, switching inexplicably to English and letting a bleary, stoned smile cross his face.
Rick had to move the driver now based on the information he had. There was too much risk that the car could explode with that much gas coming out of it.
He reached in under the driver’s arm pits and started to move him. The man’s t-shirt was soaked with blood and he was hot and sweaty. This was going to be tough!
Rick set his feet and pulled. The man came with him.
Rick grunted. He was strong but this guy weighed a ton.
Rick was still bearing most of the man’s weight when he felt something pop in his lower back and a buzzing, sickening pain shot down his left side and into his leg.
“Ahhh…cripe,” Rick said as the patrolman and Patty came to his aid and they all brought the injured driver fully out of the car. Rick didn’t let go of the driver despite his pain.
Rick was sitting in the waiting room of a general medicine practice waiting for his X-Ray results when he got the phone call from Petey’s friend Buddy.
Petey and Rick weren’t exactly close. They came from a dysfunctional family. But your brother is your brother.
Petey had always done his best to look out for Rick. Now Buddy was saying Petey was gone. His death hit Rick deep inside.
A partially ruptured disc was the word the doctor gave Rick that day. Along with that news he gave Rick prescriptions for hydrocodone, a semi-synthetic opioid, tramadol, a synthetic pain reliever, ibuprofen and metaxalone, a muscle relaxant.
As the weeks rolled by, Rick, off work now, tried to make a go of it in physical therapy and by sticking to his prescribed medications.
But the combination of his injury, not working his job and Petey’s death was wearing on him. He felt like he was down and couldn’t get up.
His back injury was extremely painful, it felt like someone, or something, was driving a knife into his lower back at times. Sometimes the jolts of pain would hit him so bad he would collapse and fall to the floor.
Rick didn’t much like spending time around doctors, but he felt so down he sought out his group health plan doctor for help with the sleeplessness and the depression he was experiencing.
“Are you on any medications?” the doctor said.
“No,” Rick said.
Rick left that doctor with prescriptions for Prozac, an anti-depressant and Ambien, a sleep aid.
“Why did I just lie about that?” he asked himself.
In that moment, he had no answer.
From what Nancy Strolich, a claims professional for the Kankakee, Ill.-based Birchwood Underwriters was seeing, on paper anyway, Rick Cornell’s workers’ compensation case was no different from many others.
Among the 220 cases she reviewed each month, Rick’s was one of those that she flagged because he was on an opioid analgesic. But there wasn’t much else there to worry about, at least not yet.
Still, Rick was in Florida and although she was licensed in Florida and her firm had an office there, she didn’t have face to face contact with him.
What Nancy couldn’t see was the inside of Rick’s body, which was beginning to resemble a chemical lab on tilt.
Five months after his work-related injury, Rick’s back injury was acutely painful and he was struggling to control the pain.
Rather than use the medications that he was given in the prescribed way, Rick was doubling up on his dosages.
Nancy could see that Rick was beginning to use more and more pain killers. But she couldn’t see evidence that he was taking Ambien and Prozac because those prescriptions were filled through his group health plan.
Rick worked in the medical field, but he was no student of pharmacy. So he wasn’t aware that taking all those drugs, the hydrocodone, the tramadol, the ibuprofen, the metaxalone, the Prozac and the Ambien was in some cases limiting the properties of individual drugs and amplifying the impacts of some of the other drugs in concert.
Nor would he acknowledge the fact that because he, his father and brother were all smokers, that meant that he had traits that predisposed him to becoming addicted to opioids.
All Rick knew was that less pills meant more pain. His dependency and use had gotten so strong and voluminous that he was beginning to feel withdrawal effects like sweating and nausea if he went without ingesting an opioid for more than five hours.
He knew he should cool it with the pills, but with his brother Petey gone, Rick just wasn’t in a mind frame to be self-preserving, despite the fact that he was married with two young children. Rick had always told himself that he would never be a heavy drinker like his father or take drugs, like he knew Petey did on occasion.
But the combination of ongoing pain and increased physical dependency on drugs was mastering Rick. So back Rick went to another doctor, recommended by Petey’s friend Buddy. “Dr. Limon’s the man. He gives you the pills right there,” Buddy said.
“Cash and carry, baby,” Buddy said.
“I like it. You got his number?” Rick said.
Rick told Dr. Limon a different story. He told him he was agitated, he couldn’t sleep from the pain and quite frankly, was now suffering from constipation.
More tales, more pills, and Rick was out the door with some Xanax, an anti-anxiety medication, the narcotic pain reliever Oxycontin IR and a laxative.
Rick wasn’t about to ask what the doctor was charging for the dispensing out of his office.
It was several weeks until Nancy got the bill for those prescriptions on paper and her eyes nearly jumped out of her head. Dr. Limon was charging for the Xanax and the Oxycontin IR at a 200 percent premium compared to what is usually charged at the retail pharmacy. He had even billed a 100 percent premium on the laxative.
In addition to using physical therapy, Rick was also seeing a chiropractor. He had been off work now for nine months and indications were that his back was still weak and he was still experiencing significant pain levels.
Just a few days after seeing Dr. Limon, Rick still wasn’t feeling right, so back he went to the doctor he used in his group health plan.
“Don’t you have anything that will help me sleep at night?” he said, using his voice to be a little accusative. After all, it was the doctor’s job to help him feel better.
“The Ambien’s not cutting it for you, eh?” the doctor said.
“No. Not really,” Rick said.
“Okay, try Lunesta.”
Nancy was now starting to see the volume of medications Rick was taking under his workers’ comp claim increase. But she had no indication of whether he was getting any better, or how his combined prescription regimen was affecting him.
Rick was now taking Xanax from one source and Prozac from another. Nancy was able to see that Rick was increasing his prescription frequency of hydrocodone, tramadol and metaxalone. She decided to place a call to the workers’ comp network physician to open up a dialogue.
This is what she got in her first attempt.
“Hello, you have reached Fountainebleu Medical Associates, where your health is our No. 1 priority. Due to high call volume, we are not available to answer your call at this time. Para Espanol, oprima el dos. If you are experiencing a medical emergency, dial 911. To fill a prescription, press one, to get lab results, press two, to speak to a medical associate, press three.”
Nancy dutifully pressed three.
“There is no one available to receive your call at this time. Please leave a message with your name, date of birth, social security number…”
Nancy’s other line buzzed. She had to answer it. She’d have to try that doctor in Florida again sometime. “Social security number? My social security number?”
“Rick!” his wife said from upstairs where she had apparently logged on to their bank account from the family’s desk top computer.
“What?” Rick said from the living room where he was putting on his shoes as fast as he could, given how weak and pain-ridden his back was.
“What’s this charge from Williams Sonoma for a sea salt grinder?”
“Unnnhh…it’s a present for my mom.”
“Your mom uses a sea salt grinder? You think we can afford that? We’re putting diapers and formula on credit cards for God’s sake!”
Rick didn’t say anything.
Too late, Rick was out the door. Somewhere behind him in the Miami night was what used to be his life; what used to be his children and his wife.
He well knew where the sea salt grinder was and who it was for. When he got to the pain clinic in Hialeah, Rick ground up an Oxycontin pill and snorted it, using a plastic spoon he got with some ice cream.
Inside, things went as smoothly. Rick was in drug heaven and feeling no pain..
The pain clinic had two physicians on staff who wrote him prescriptions for what he wanted. The main doctor, the one with the beard, wrote him a prescription for Exalgo, another narcotic pain killer, plus Oxycontin IR, plus hydrocodone, a morphine equivalent dose of 360 much higher than the 120 threshold that is medically suggested.
Rick walked out into the humid night with the prescription folded up in his jeans pocket.
He had his phone turned off. He wasn’t answering anybody’s calls tonight.
The kids were asleep. She had no business nagging him.
He’d heard her on the phone with that guy anyway, whoever he was. Mr. Emotionally Supportive: Whatever. He didn’t care who she babbled to.
Rick was feeling agitated from the pill he had just snorted. That and the heat were making him thirsty.
Nothing like an icey six pack of beer to cool everything off.
The bright lights of a nearby liquor store beckoned. Rick smugly congratulated himself for having the good sense to pick a pain clinic in the same strip mall as a liquor store.
As he walked in, Rick caught just a peripheral glimpse of himself in the mirror that was in the corner of the liquor store ceiling. He looked almost like Petey had looked, with his beard and as thin as he was. Heh, a regular Southern rocker. Just like Petey.
Nancy had made some headway in her battle with the in-network physician practice to stop giving Rick hydrocodone refills. Dealing with Dr. Limon had been next to impossible. Now these billings from the pain clinic were really concerning and frustrating her.
She had now flagged Rick’s case for intervention but he wasn’t returning her calls.
Rick was so far past Nancy’s efforts to get a grip on what he was ingesting and the effect it was having on his mental and physical health that she might as well have closed the file.
Nancy began moving to file the paperwork to deny some of Rick’s medication bills under the grounds that they had become medically unnecessary, but sadly, she was too late.
Rick had three beers in him and was reaching for his fourth when it happened.
He was trying to make a left on West 12th Street when everything just melted out from under him. His car ran right into the side of a parked pickup truck and Rick’s reflexes were so impacted he didn’t even have time to hit the brakes.
Rick’s head hit the rear view mirror, but he was more drunk and numb from narcotics then he was impacted by the crash. He closed his eyes, giving in to the booze and the drugs, the flash from the police lights and the EMT vehicle coming to him through closed eyelids.
“Where are you hurt? Where are you hurt?” he heard the EMT saying to him.
“Nowhere,” Rick answered.
“I don’t know what pain is,” Rick added with an eerie giggle.
He felt strong arms lifting him out of the car.
“I got him, he’s light,” the EMT said.
Nancy Strolich, a workers’ compensation claims professional for a carrier, is doing what she feels is a diligent job in tracking the pharmacy intake and quality of care for an injured emergency medical technician. But the case spins out of control when the injured worker displays a voracious appetite for narcotic pain killers. While this Risk Scenario depicts a case example that could be considered an outlier type of scenario, there are several significant situations and opportunities illustrated that are very common.
Video Insights: Cyril Tuohy sat down with Daryl Corr, President of Healthesystems who is the sponsor of this scenario, for an in-depth discussion of “The Toxic Balloon”. Highlights of their conversation are integrated into the summary below.
1. Establish a comprehensive pharmacy management process: In this scenario, Nancy is blindsided by bills that come to her through different mediums and from different billing sources and she isn’t provided with any alerts or visibility about the escalating prescription activity until it is too late. Nancy needed much greater transparency into the number of prescriptions Rick was getting filled, who was prescribing them and where they were being filled. In addition, she needed more tools that would have enforced prior authorizations of certain retail dispensed scripts while providing her with the capability to deny payments of scripts being received on paper.
2. Screen for addiction predisposition: The fact that Rick was a smoker, combined with his brother Petey and his father both being smokers and excessive drinkers was valuable information that could have helped alert Nancy to about Rick’s potential for becoming addicted to opioids. Had Nancy’s claims best practices included processes such as monitoring whether prescribing physicians were screening injured employees for risks of opioid addiction, it could have provided earlier warning sings to intervene and challenge the appropriateness and safety of certain prescriptions being used in Rick’s therapy much sooner.
3. Aggressive intervention and treatment analysis: The prescribing activity occurring in Rick’s case escalated over a period of time and Nancy was ill-equipped to slow it down or reverse course. Several prescribing physicians were writing scripts, many of which made the combined therapies excessive if not potentially lethal.
4. Monitor jurisdictional trends and new legislation: Cases based in a state like Florida, which has become a hot bed of physician drug dispensation and drug repackaging, should warrant extra attention. States that allow the proliferation of such pill mills are a dangerous environment for an injured worker and for the payer who is paying for their prescriptions. Prescription costs for physician-dispensed drugs can dwarf those of drugs obtained at a pharmacy. Legislation is one of the key areas of focus that can help regain control over challenges such as physician dispensing and repackaged drugs.
5. Consider urine drug monitoring: Had Nancy been able to get a chemical picture of what was going on inside Rick she would have been shocked and perhaps motivated to intervene in his case much sooner. Monitoring bills is one thing, but getting biological evidence of the state of an injured employee can go a long way in determining whether the worker is taking too many drugs, or in some cases, obtaining the lucrative drugs, not taking them and selling them on the black market.
6. Assess the mind set: In many cases, assessing the mind set of an injured employee can be just as important as monitoring the injured employee’s physical recovery process. In Rick’s case, his depression over his brother’s death led him to seek additional physicians and additionally prescriptions, greatly complicating his workers’ compensation case and negatively impacting his recovery.