Medicine Simplified for Personal Injury Attorneys

 - Prajval Albuquerque

   [Founder: http://www.lextweak.com/paralegal-services] 

 

Medications: General Comments:

1.      Past medication history is critical: Including knowledge of Rx (Prescription Drugs), OTC (Over the Counter) & Herbal previously taken

2.      Watch out for prescribing drug cascade: Identify if any drug is being unnecessarily prescribed, as drugs have side effects, then to counter these side effects even more drugs are prescribed.

3.      In certain cases, Doctors are allowed to prescribe non FDI approved drugs. It is an accepted Medical Practice.

 Lifecare Plan:

1.      The Lifecare Planner in this case will offset the milligrams per dose. Compare the pre-incident dosage with the post-incident dosage and then offset that price.

2.      The medication doses for preexisting diseases may also be increased as a consequence of the incident: Example: A diabetic person may not be able to exercise due to injuries suffered in the INCIDENT, so his blood sugar levels will go up, and the patient will require higher dose of medication to control it.

3.      The Lifecare planner must prescribe the drugs wisely in the lifecare plan: if the Defense cross-questions, as to why the name, brand drugs were chosen over the Generic Drug there should be a valid justification.

  CBD v. Opioids:

1.      The topic is controversial and individual doctors have their own opinion on it.

2.      Opioid: Synthetic. Opiates: Naturally occurring

3.      Opioids are classified into Agonists, antagonists, and Agonist-Antagonist.

4.      Agonist-Antagonist have lower side effects.

5.      If any of your client is on Opioids, he should also have a prescription for Antagonist.

6.      Agonists are pain medications, but to avoid the overdose of Agonists, the Antagonists are prescribed.

7.      EXAMPLES: Pure Agonist: Morphine, fentanyl, propoxyphene, oxycodone, etc. Agonist-Antagonist: Nalbuphine, butorphanol, buprenorphine, etc. Pure Antagonists: Naloxone, Naltrexone.

8.      Opioids have many side effects on body, and then there are problems of: increasing physical and psychological dependence on Opioids, withdrawal symptoms, addiction issues, and overdose  

9. Long-duration opioid medication does not work.

10.  Over a duration of time dependence on Opioids need to be decreased and the patient should be prescribed physical therapy, chiropractic treatment, surgical implant, etc.

11.  Make sure your Client has not been prescribed Opioids for a long duration of time; they will come under strict scrutiny by the Defense Attorney. 

 12.  Opioids prove beneficial in cases of:

a)      Major trauma

b)      Surgery & Post-operative care

c)      Cases where non-opioids have not been effective

 

13.   Opioids ideally prescribed for:

a)      Pain relief/reduction.

b)      Increase body functions.

c)      After major surgery.

d)     The side-effects of these opioids are manageable.

 

14. Patients who are at risk of  Opioids abuse:

a)      Who have a history of substance abuse including alcohol abuse.

b)      Whose family has a history of substance abuse including alcohol abuse.

c)      Who have had Adverse Childhood Experiences (ACE).

d)     Who have Comorbid psychiatric disorder, like personality disorder.

 

15.  Care to be taken by Doctors before/while prescribing Opioids:

a)      Ask patient to fill the free questionnaire.

b)      There should be a Opioid Treatment agreement.

c)      Do random urine drug testing.

d)     Check the Prescription Drug Monitoring Program (PDMP) and California’s Controlled Substance Utilization Review and Evaluation System (CURES).

e)      Avoid concomitant use of CNS depressants.

f)       All the information from a) to e) should be included in life care plan too.

16.  NOTE: Some people benefit from opioids most don’t, not a great idea for long term use.

17.  Some people can never be weaned off their Opioid addiction.

18.  Opioid dependence is fine if it helps patients perform their daily function, but it’s the quantum of dose that matters.

 

19. Non-Opioid Analgesic (Analgesic means acting to relieve pain):

a)      Acetaminophen/Tylenol: It is effective in mild-moderate pain, Side Effects: may lead to liver toxicity. Avoid prescribing it to people with Liver problems. Use the lowest dose discontinue when not needed. Look for its alternatives.

b)      NSAIDs like Ibuprofen aka Advil aka Motrin, Naproxen Sodium aka Aleve aka Naprosyn, Meloxicam aka Mobic, Celecoxib aka Celebrex: Its effective in mild-moderate pain especially in case of inflammation. Side Effects: may cause Gastrointestinal symptoms, Kidney failure, Hypertension, and Heart-related issues. Use the lowest effective dose. Before prescribing check for gastrointestinal issues and get the patient laboratory screened for renal function. Look for its alternatives.

c)      Anticonsulvants (Antiseizure) drugs like Carbamazepine aka Tegretol, Gabapentin (Neurontin), Pregabalin aka Lyrica. Topiramate aka Topamax: Commonly used to treat pain syndromes including migraine and neuropathic pain i.e. Nerve pain, also used for perioperative pain. Side Effects: Cognitive Dysfunction and Respiratory depression. Abruptly stopping these drugs may cause seizures.

d)      

A.    Antidepressants:

·         TCAs i.e. amitriptyline: Most effective for pain but have side effect

·         SNRIs i.e. duloxetine: Effective for pain relief, fewer side effects but should be stopped slowly because of withdrawal symptoms.

·         SSRIs i.e. fluoxetine, sertraline, citalopram, and paroxetine: Good for depression but less effective for pain.

 B.     Side effects:

Drowsiness constipation, Urinary retention, Weight gain, Blurred vision, Nightmares, Increased heart rate.

 

e)      Musculokeletal Agents (Muscle Relaxants) like baclofen aka Lioresal, tizanidine aka Zanaflex, cyclobenzaprine aka Flexiril, carisoprodol aka Soma,: Risks: Confusion, Loss of balance, Constipation. Avoid long term use. Balcofen shouldn’t be withdrawn abruptly.

f)       Anti-Anxiety medications like Benzodizepines, SSRIs and SNRIs help to treat; Anxiety related to acute or fluctuating pain, and Comorbid anxiety disorders. They may be useful in the short term, but their regular or long-term use should be avoided.

g)      Compounded Medications:

A.    Topical agents with compounded mixtures prepared by pharmacists. They are expensive and insurance companies don’t like to pay for them. They are very helpful in selective patients.

             B.     Why use compounded medication?

·         Dosage can be adjusted as compared to the individual pills.

·         There are some medications that cannot be taken separately.

·         Sometimes they are cheaper than Brand Medicines

 

h)      Topical agents like creams, sprays, gels etc.: Work directly over the applied area

i)        Transdermal drugs like patches.: Have effect throughout the body and work when applied away from area of pain.

j)        Herbal Medicines: Come from Plants, suffer from quality issues.

k)      Nutraceuticals:  Nutrient products like fish oils and mega vitamins, suffer from quality issues.

l)        Medical Foods: Dietary supplements marketed for specific disease, suffer from quality issues.

m)    Benzodiazepines:  Sleep Agent but not recommended for chronic pain or with concurrent opioid use. Not to be taken for long term

n)      Z-Drugs:  Sleep Agent. Not to be taken for long term

o)      Ketamine: Is an antagonist. Relieves pain, reduces opioid tolerance, enhances opioid analgesia. Use is controversial with experts having divided opinion on its use.

p)      Low-Dose Naltrexone:  Is an opioid antagonist, effective for chronic pain in low doses Not to be taken within 4 to 5 hours of an opioid.

q)      Clonidine aka Catapres, aka Catapres-TTS patch:  Acts as an Adrenergic Antagonist, but also helps relieve pain.

r)       Surgery: This is not always a good way to manage pain.

s)       Counselling:  Also helps to manage pain.

t)       Simulators:  May also help to manage pain.

Further Reading:

American Chronic Pain Association Stanford Resource Guide. 

 

*This article is a summary of the TBI Med legal seminar titled Pharmacology for PI Lawyers*

 

Use of Botox and TMS in treating TBI

  

Use of Botox and TMS in treating Traumatic Brain Injuries

- Prajval Albuquerque

Post Traumatic Headache:

1. Most patients after Traumatic Brain Injuries (TBI) have a headache.
2. To attribute a headache to Traumatic Brain Injury it should begin within a week from the date of injury.
3. Depending upon the extent of injury to the brain, the headache can be classified into Mild, Moderate or Severe.
4. Post Traumatic Headaches can lead to Migraine.
5. Preexisting Migraines become worse after a Traumatic Brain Injury; an occasional Migraine becomes a daily headache and then a Chronic Migraine.

Post Traumatic Headache and Botox treatment:

1. If the headache persists for more than 3 months, and the patient develops sensitivity to light then the patient is an ideal candidate for Botox treatment.
2. Insurance companies take time to approve Botox treatment for Headaches
3. Botox treatment will reduce the number of headaches a person has. 
4. Botox treatment is administered on a 12 weeks cycle. If the Botox treatment is abused then a person may develop antibodies against Botox
5. Though side effects are rare they include:  Skin rash, neck pain, drooping eyebrow, develop antibodies against Botox.
6. Botox treatment is a continuous treatment and should be included in the healthcare plan. The Botox treatment controls the Migraine from getting worse but there is no cure for it.

Post Concussive Syndrome (PCS): 

1. History of Traumatic Brain Injury (TBI) is obtained from witnesses and family members.
2. TBI can be temporary or permanent.
3. Even mild TBI can develop into Post Concussive Syndrome (PCS).
4. Not every TBI results in loss of consciousness. Symptoms of TBI include dizziness, depression, headache, sleeplessness etc.
5. A client suffering from Post Concussive Syndrome (PCS) can suffer from mood swings, depression etc and make the life of an Attorney difficult. If a client displays these symptoms suggest him/her to undergo PCS evaluation and treatment   
6. Post Concussive Syndrome Symptoms:

Normal Symptoms[1] 

1. Headaches and Migraines
2. Dizziness and Vertigo
3. Fatigue
4. Sensitivity to Light
5. Blurred Vision
6. Noise Sensitivity
7. Difficulty Concentrating
8. Memory Loss
9. Slow / Delayed Thinking
10. Anxiety
11. Depression
12. Sleep Disturbances

Long term Symptoms[2]

1. Migraine and Headache
2. Light Sensitivity and Photophobia
3. Dizziness and Vertigo
4. Depression and Other Emotional Symptoms
5. Alzheimer’s Disease
6. Parkinson’s Disease
7. Chronic Traumatic Encephalopathy (CTE):
8. Cognitive impairments including memory loss, changes in thinking
9. Psychological changes including impulsive behavior, depression, aggression, suicidal thoughts
10. Substance abuse
11. Speech and language changes or difficulties
12. Difficulty walking, weakness and tremor
13. Changes in vision and smell
14. Dementia

Transcranial Magnetic Stimulation (TMS): 

1. Transcranial Magnetic Stimulation TMS is used after anti-depressants fail. It is not based on guesswork. Initially, a PET scan is performed before administering the TMS Treatment
2. TMS is moderately effective but it has very less side effects as compared to anti-depressants and other treatments.
3. TMS is non-invasive, USFDA-approved, and the treatment lasts between 20 minutes to 1 hour. 
4. If within 2 weeks of administering TMS treatment there is no improvement, then a PET scan needs to be performed to check whether the treatment is being administered in the wrong area or verify whether the patient is an ideal candidate for TMS or not.
5. If a patient has had heavy or moderate dental treatment then the patient is not an ideal candidate for TMS 
6. The average number of sessions required for treating depression with TMS is 35 to 40 sessions.
7. Headache may be a side effect of TMS, but it has not been conclusively proven.

Effectiveness of Transcranial Magnetic Stimulation (TMS):

1. Enhances brain function recovery by inducing structural and functional changes in the area affected by trauma.
2. Reduces Post Concussive Syndrome and Depressive Symptoms by 50% post-TBI.  
3. Significant reduction in tinnitus complaint after 5 sessions.
4. TMS reduces migraine attacks by 50%.
5. Patients with CRPS experience at least 30% relief after TMS treatment

The contents of this article are based on a session in TBI Med Legal and my experience of reading multiple medical records.