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How Can Pinnacol’s Utilization Review Department Help Your Business?

March 2016

Billing/Administration

Pinnacol Assurance recently launched a new Utilization Review department to support clinical outcomes, ensure the appropriate utilization of medical resources and provide timely service to providers. 

What you need to know:

1. Our process has not changed. Prior authorization is still necessary when:

  • Required by the Division of Workers’ Compensation (DOWC) Medical Treatment Guidelines; 
  • The treatment exceeds established number of visits; or
  • The guidelines do not address the service being requested.

2. Prior authorization questions should be directed to the assigned claims representative handling the claim. Any requests for medical services should go to the assigned medical reviewer, viewable on the Pinnacol Provider Portal at Pinnacol.com. Requests for transportation and interpretation should be directed to the claims reviewer.

For more information on prior authorization requirements for payment, please refer to Rule 16 – Utilization Standards (7 CCR 1101-3, Section 16-9) on the DOWC website. Please share this information with your colleagues.

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Cognitive Training for Traumatic Brain Injuries

March 2016

Featured Story

Contributed by Torsten Jess, M.S., CCC-SLP

How many times have you heard “Oh, he or she is fine because they have a hard head” when someone suffers a blow to the head? Truth be told, even if a person should have an unusually thick or tough skull, the inside of their brain is still moving. This is called a “coup” or “countercoup” injury and is described as the brain rocking back and forth forcibly against the inside of the skull. The result can leave the brain bruised and can injure the tissues by way of forcing them together or pulling them apart. This occurrence can cause physical, cognitive/thinking, communicative/language and emotional deficits that may very well impact an individual's ability to function as he or she once had. The extent of damage is often described as mild, moderate or severe, and is determined by the length of time of unconsciousness and/or by the force of impact. Such deficits can be temporary or permanent depending on the extent of damage. The causes of such are more often than not from motor vehicle accidents, assault, falls and sports-related injuries. 

As a cognitive (memory/problem solving) specialist and therapist for over 18 years, I can attest to the fact that each individual who walks through my door is unique. The initial focus is to determine where the individual sees his or her own deficits by way of a series of carefully delineated questions as well as their goals for treatment. Once obtained, a standardized test is pursued to assess the severity of deficits. From then on, a systematic approach is implemented that involves paper and pencil exercises, the manipulation of objects, computerized training as well as other various applications. In addition, specialty techniques are implemented so as to literally teach the individual to develop a photographic memory. Such techniques are considered to be invaluable and can be utilized in nearly every facet of an individual’s day-to-day routine. The potential to remember long lists of concrete items, abstract thoughts, numbers and names as well as many different lists of worthwhile information at the same time is often met with skepticism at first. Yet, there is rarely an individual that I come across who cannot benefit from this technique and/or master it within a mere five sessions, although 10 sessions are recommended. In fact, I relish the third session which is often when I ask the patient to devise their own list consisting of a combination of 30 or so objects, names, numbers, colors, etc., for me to remember. I then verbally repeat their list back to them in any order imaginable with the greatest of ease and can still do so when called upon throughout the entirety of our time together. By the end of that very session, the patient is also able to emulate exactly what it is I do … and that is only the beginning. 

If the case for cognitive training and the potential it offers wasn’t strong enough, studies also point to the fact that the more trauma a person’s brain undergoes throughout life, the greater the likelihood of developing dementia. Therefore, the need to undergo cognitive training is essential and the sooner the better. For more information, please refer to BrainFunctionOptimization.com or call Torsten Jess, M.S., CCC-SLP, at 303.658.9868. 

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Causation of Upper Extremity Injuries

March 2016

Clinical Corner

Contributed by Jonathan L. Sollender, M.D., FACS

Causation of upper extremity injuries can sometimes be easily accomplished, or at times can be quite challenging for both treating providers and injured workers. When a singular injury occurs at the workplace, claims typically require a modest investigation before they're approved for coverage. However, in the case of a cumulative trauma condition, a more thorough investigation is frequently required, where the assistance of the employer and treating providers make the system work at its best. Fortunately, we have the assistance of the Medical Treatment Guideline known as Rule 17, Exhibit 5 (aka Cumulative Trauma Conditions) to lean against when making causation statements. This guideline only addresses issues from the elbow to fingertips and is not useful for shoulder conditions.

The first step is somewhat obvious and requires a diagnosis. Remember that pain is not a proper diagnosis but a symptom of some pathology, be it tendonitis, strain, fracture, laceration, etc. The second step is to clearly define the job duties of the worker. Here, one is asked to “not rely solely on the employer’s description of job duties. The worker’s description of how they actually perform the duties is extremely important. Jobsite evaluations are always appropriate, but are sometimes unnecessary when the physician can identify the job duty which appears to be causing the symptoms and provide a method for ergonomically correcting the activity.” This means the physician must ask, in detail, what the worker does, for how long per day, and the exact details of weight of objects lifted, the frequency per hour, and the postures assumed of the wrist and elbows. If the provider can’t quite image in their mind how the worker conducts his or her work, then lean on a vocational expert to go on-site for a Job Demands Analysis (JDA). Remember that the objective observations and record of a vocational expert is invaluable to confirm (or refute) the accuracy of what the injured worker tells you. They might think there work is repetitive for them, but without some numbers, to attach the allegation of repetitiveness or forcefulness or awkwardness, sometimes the determination of work relatedness can be challenging.

If a JDA is needed, ensure you understand the quality of information a JDA will give you rather than an ergonomic evaluation. An ergonomic evaluation will tell you if improper postures are present, but might not tell you how long the injured worker maintains such posture. A JDA will likely provide both awkward postures as well as the length of time such postures are present through a typical workday.

The third and fourth step requires comparing the worker’s duties with Primary and Secondary Risk Factor definitions on pages 21 and 22 of Rule 17, Exhibit 5. If, and only if, no Primary Risk Factor is present and a single Secondary Risk Factor is present, then one should look at the Diagnosis Based Risk Factor Table, not as a substitute for the steps 3 and 4. Looking at this table one sees various combinations of potential risk factors that must be present to confirm a work-related condition. There is also an easy-to-understand algorithm on page 19 of the guideline.

Remember, the goal of causation is to verify that a cumulative trauma condition could have arisen from the workplace. One also has to use logic to confirm a physiologic exposure to the factor that could cause certain conditions. Thus, if someone is seen for trigger finger on the left long finger, and a JDA shows a risk factor for mousing over four hours per workday, and they mouse with the right hand, it is not physiologically related to have a trigger finger of the left hand as an occupational condition if the only risk factor is right-handed mousing.

Causation analysis is time-consuming and challenging, especially in cases where the subjective information of an injured worker conveyed to the treating provider is vastly different from the information supplied by a vocational expert. Pinnacol has a multitude of consulting Physician Advisors who would be happy to assist you with these difficult issues. Feel free to reach out to your claims representative for assistance if you get into one of these situations. 

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Pinnacol’s Physician Advisor Program

March 2016

From Pinnacol's Medical Director

Don’t you hate having someone looking over your shoulder and questioning your decisions?

So do I.

I don’t know of any physician who relishes the idea of having another doc reviewing your treatment choices and deciding what they feel is best for your patient. It’s just not something that most of us are ever going to enjoy.

But there are some bright spots on the horizon.

You already know that you don’t need our approval to provide treatments that are recommended by the DOWC’s Medical Treatment Guidelines, although we recognize that sometimes you ask us to give you a written authorization so that you can get other entities (like surgery centers) to book your cases, etc. To that end, we’re working to make it quicker and easier for you and your staff to get something in writing from us if you need it.

Then there’s the issue of getting approval for treatments not in the guidelines.

The Colorado statutes mandate that we have to have a process for this, but they don’t require that we make the process painful or slow.

We have a great group of your very dedicated colleagues that serve on our Physician Advisor panel. They’re doing all they can to provide timely, accurate and fair evaluations of your patient treatment requests. We hear that our system works pretty well (a lot better than any of our competitors), but we know it’s not perfect.

So we’re evaluating how to improve our Physician Advisor process, and we’re looking for ways to enhance our service to you. 

Here are some of the ideas we’re talking about:

1. Adding more physicians in several specialties so they can respond more quickly to your requests for approvals.

2. Assessing video conferencing solutions that:

  • Allow our Physician Advisors to do more work from their offices or homes as opposed to having to come to Pinnacol; and
  • Encourage more physicians who aren’t in Denver to become part of our Physician Advisor team.

3. Using our Physician Advisor team to help evaluate new treatments that hold promise for improving patient care.

4. Track the decisions the Physician Advisors are making and correlating how these decisions impact patient outcomes.

5. Providing options for high-performing providers to skip the Physician Advisor process completely (and get automatic approvals).

I’m sure you may have other ideas on how we can improve the service our Physician Advisors are providing to you, our most important partners. 

Finally, you may have heard that there is a proposal being discussed (likely at the March or April DOWC stakeholders meeting) asking the Division to consider bringing all authorization reviews for all Colorado providers into the Division. In other words, if you want to request a treatment that is not in the Colorado Guidelines, then you would not ask Pinnacol (or any other payer) for authorization. Instead, you would send your request to the DOWC and their panel of physicians who would review it and decide.

Please feel free to contact me and let me know your thoughts and ideas on how we’re doing and how we can improve our processes.

Sincerely,

Rick May, MD

Orthopedic Surgeon

Senior Medical Director

Pinnacol Assurance

Cell: 303.618.4366

rick.may@pinnacol.com

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Announcing Apple Watch Winners

March 2016

Corporate News

Recently a research firm conducted a provider clinic survey on Pinnacol Assurance’s behalf. Thank you for your time and thoughtful participation in this effort. You have provided valuable insights that will help us better serve your needs and support the best care and outcomes for injured workers in Colorado. 

Survey participants were entered into a drawing to win one of three Apple Watches. We are pleased to share that the winners are David C. Jackson, DC, owner/Doctor of Chiropractic, Jackson Chiropractic; Tiffanie Hoover, occupational medicine program manager/nurse case manager, SLV Health Occupational Medicine Department; and Katelyn Bach, supervisor of clinical practice, CCOM (Durango). 

Again, you have our most sincere thanks for your time and effort. 

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Interdisciplinary Treatment for Chronic Pain

December 2015

Featured Story

Contributed by Daniel Bruns, PsyD

Studies by the National Center for Health Statistics1 and the Centers for Disease Control2 confirm that pain is by far the most common reason why patients see a physician: something hurts. Although no data is available, given that the workers’ compensation system revolves primarily around the treatment of injury, the prevalence of pain in the workers’ compensation system is probably even higher than that observed in the primary care system.

In the United States population at large, at least 116 million US adults are burdened by chronic pain,3 and in a study of a random sample of community members, 27% reported having chronic low back pain.4 Pain is not only common, it is also an extraordinarily costly condition, with an estimated annual national economic cost of $560–$635 billion.3 Because of the challenges that pain presents to our society, the U.S. Institute of Medicine concluded, “Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions” (p. S-3).3

Despite the prevalence of pain, training for professionals in the treatment of pain has been lacking. Remarkably, a study by the Institute of Medicine also discovered that no American medical school required a class in pain, and only 3.4% of schools offered an elective class in pain. As a result, medical schools do not expose the physician to the full scope of options for pain treatment, and until recently, have not informed medical students of the risks of opioids.3 Recently, however, efforts have been made to correct this, and peer-reviewed online CME coursework is now becoming available.5,6

In the U.S., the treatment of pain has relied heavily on the use of opioid pain medications. Opioids (a.k.a. narcotics) are powerful pain-relieving medications and are very widely used in the U.S.. For example, even though the US accounts for only 4.6% of the global population, the U.S. accounts for 99% of the global consumption of hydrocodone.7 While the humane treatment of pain is a professional responsibility, in the US the number of deaths from prescription pain medications each year exceeds the number of deaths from cocaine and heroin combined,8 and also exceeds the number of deaths from motor vehicle accidents.9 This rapidly growing rate of iatrogenic addiction10 and opioid-related deaths has been referred to alternately as a “crisis”11 or an “epidemic.”10

A common mistake in pain treatment is to think of pain as solely a symptom of tissue damage. In fact, pain is an extraordinarily complex sensory experience, with biological, psychological, and social components. Imaging studies of the brain show that while acute pain is primarily associated with activation of sensory areas of the brain, chronic pain is more closely associated with the brain’s emotion center.12,13 Because of that, effective treatments for pain must address both its psychological and biological aspects.3

A review of the evidence determined that psychological tests are the scientific equal of medical tests,14 and can sometimes exceed the ability of medical tests to predict the outcome of medical treatments for pain.15,16 Similarly, psychological interventions have been shown to be effective treatments for pain.17 Psychological treatments to improve pain-coping skills can produce improvements in functioning that equal those of surgery.18,19 However, one study found that surgery was 168 times more expensive than psychological treatments, and involved significant risks.20 In contrast, psychological interventions are safe, effective, and economical treatments for pain. Despite that, studies show that psychological treatments are generally underutilized.21

Unlike many states, Colorado’s system of medical treatment guidelines integrates medical and psychological treatments. This approach not only offered more comprehensive care, but produced an estimated $859 million savings in one year.20 Overall, the interdisciplinary approach to pain treatment has been shown to produce better outcomes while reducing expenditures, and that is why it has become the standard of care. 

References

1. National Center for Health Statistics. Vital health statistics: Reporting chronic pain episodes on health surveys. Vol Series 6: Cognition and survey measurement. Washington DC: Centers for Disease Control: US Department of Health and Human Services; 1992.

2. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009. 2010; http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf. Accessed July 22, 2013.

3. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington D.C.: National Academies of Science; 2011.

4. Smith BH, Elliott AM, Hannaford PC, Chambers WA, Smith WC. Factors related to the onset and persistence of chronic back pain in the community: results from a general population follow-up study. Spine. 2004;29(9):1032-1040.

5. Goldman BL. Interdisciplinary Rehabilitation of the Injured Worker With Chronic Pain. [1.00 AMA PRA Category 1 Credit ™ Continuing Medical Education Webinar]. 2015; http://me.aapmr.org/diweb/catalog/item/id/680436/q/q=injured*20worker*20chronic*20pain&c=141.

6. Bruns D, Disorbio JM. The Assessment of Factors Associated with Delayed Recovery. A Biopsychosocial Paradigm. [1.00 AMA PRA Category 1 Credit ™ Continuing Medical Education Webinar]. 2015; http://me.aapmr.org/diweb/catalog?dp=0&c=141&q=biopsychosocial+paradigm&f1=1.

7. International Narcotics Control Board. Narcotic drugs: estimated world requirements for 2011­—statistics for 2009. 2010; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659213/ - ref6. Accessed October 1, 2015.

8. Centers for Disease Control and Prevention. CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. Morbidity and Mortality Weekly Report (MMWR) 2012; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm?s_cid=mm6101a3_w. Accessed August 9, 2012.

9. Centers for Disease Control and Prevention. Prescription drug abuse and overdose: Public Health Perspective. 2012; http://www.cdc.gov/primarycare/materials/opoidabuse/docs/pda-phperspective-508.pdf. Accessed October 1, 2015.

10. Beauchamp GA, Winstanley EL, Ryan SA, Lyons MS. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic. Am J Public Health. 2014;104(11):2023-2029.

11. Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.

12. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(Pt 9):2751-2768.

13. Mansour AR, Farmer MA, Baliki MN, Apkarian AV. Chronic pain: the role of learning and brain plasticity. Restorative neurology and neuroscience. 2014;32(1):129-139.

14. Meyer GJ, Finn SE, Eyde LD, et al. Psychological testing and psychological assessment. A review of evidence and issues. Am Psychol. 2001;56(2):128-165.

15. Carragee EJ, Barcohana B, Alamin T, van den Haak E. Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography. Spine. 2004;29(10):1112-1117.

16. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005;5(1):24-35.

17. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1-9.

18. Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122(1-2):145-155.

19. Brox JI, Nygaard OP, Holm I, Keller A, Ingebrigtsen T, Reikeras O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648.

20. Bruns D, Mueller K, Warren PA. Biopsychosocial law, health care reform, and the control of medical inflation in Colorado. Rehabilitation psychology. 2012;57(2):81-97.

21. Robbins H, Gatchel RJ, Noe C, et al. A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies. Anesth Analg. 2003;97(1):156-162.

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Pointing Fingers: Are Passive Prosthetics After Digital Amputation Really Valuable?

December 2015

Clinical Corner

Contributed by Carlton Clinkscales, MD, and Kelli Brazier, BA

In the Colorado Workers’ Compensation environment, finger amputations, by a variety of mechanisms, are commonly seen. They are most often treated by hand surgeons and hand therapists. While replantation is an option for a few select patients, not all are candidates. Many cases of isolated digital amputation “successfully” replanted are in fact “failures” due to stiffness, pain, numbness, and cold sensitivity. However, some patients with lost digits may experience emotional pain and difficulty. In some of these instances, passive (non-moving) digital prostheses may afford some credible benefit. 

It should be noted, however, that a discussion of passive cosmetic digital prostheses for partial hand or finger loss is vastly different from that of functional prostheses following loss of the entire hand or a portion of the upper extremity. This is a brief introduction to the potential issues involved in decision-making for patients after a partial finger, total finger, or partial hand amputation.

Prosthetic replacements currently available for these types of amputations are usually made of silicone, molded to the individual and, to some degree, artistically matched to the host part. Usually they rely on suction, but other techniques such as a wire coil base have been used. As passive devices, these do not bend or flex. Importantly, no degree of sensation is offered by any of the current prosthetic options. 

The benefits of cosmetic digital prostheses are primarily aesthetic, but emotional improvement during the rehabilitation program and potential long-term psychological value can be gained. In certain circumstances, there may also be social value in visually presenting a “whole” hand. 

Digital cosmetic prostheses are available in a variety of forms, ranging from a shaped, hard plastic mold to a highly individualized and realistic silicone proxy. John Claude Pillet is an established innovator and advocate of these particular prostheses. Many other programs have followed his lead. Hanger Inc. prostheses are currently the most readily available provider in Denver, Colorado.

Not all patients tolerate their digital prostheses well, however. As passive devices with weak attachments that make them somewhat insecure, they often get in the way of more normal hand activities. Lack of function and absent sensation often limit long-term use. In addition, over time the materials wear and discolor. As such, the high recurring costs for these devices are difficult to justify. 

Generally speaking, cosmetic prostheses for injured workers are not indicated. There may be special circumstances where a certain individual might benefit from a trial use. These should be limited to cases where there is a demonstrated emotional need or an isolated, documented, cosmetic requirement for specific social circumstances such as public speaking. This is best addressed by the designated provider.

Dr.  Clinkscales is a board-certified hand and orthopaedic surgeon with Hand Surgery Associates (303.744.7078). He spends most of his time at Littleton and Swedish hospitals where he treats a variety of hand and upper extremity trauma and reconstruction. 

References

1. White W. Why I hate the index finger. HAND. 2010;5(4):461-465.

2. Healio.com. The Psychology of Losing a Limb.  2002. Available at: http://www.healio.com/orthotics-prosthetics/prosthetics/news/online/%7B20bb0ac6-5ae1-4c65-b8e7-281ca1821228%7D/the-psychology-of-losing-a-limb. Accessed July 15, 2015.

3. Goyal A, Goel H. Prosthetic rehabilitation of a patient with finger amputation using silicone material. Prosthetics and Orthotics International. 2014;39(4):333-337.

4. Reddy R. Acrylic Finger Prosthesis: A Case Report. Journal of Clinical and Diagnostic Research. 2014.

5. Leow M, Pereira B, Kour A, Pho R. Aesthetic life-like finger and hand prostheses: prosthetic prescription and factors influencing choices. Annals Of The Academy Of Medicine, Singapore. 1997;26(6):834-9.

6. Aydin C, Nemli S, Yilmaz H. Esthetic, functional, and prosthetic outcomes with implant-retained finger prostheses. Prosthetics and Orthotics International. 2012;37(2):168-174.

7. Pillet J. Esthetic hand prostheses. The Journal of Hand Surgery. 1983;8(5):778-781.

8. Pillet J. And thus, the hand revealed its beauty. Journal of Hand Therapy. 1997;10(4):258-261.

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Pinnacol's New Path

December 2015

From Pinnacol's Medical Director

“We cannot solve our problems with the same thinking we used when we created them.” - Albert Einstein

I’m coming to like this quote more and more. It seems to sum up a lot of what’s happening here at Pinnacol these days.

I just joined Pinnacol a few months ago and I’m still getting my bearings, but every day I find myself more and more impressed with the people here.

Pinnacol has taken on a new challenge, one that is both simple and epic. The idea is simple: Fundamentally change how we care for employees in Colorado. But the reality of that challenge is huge. It will take us years to achieve and take us down roads we’ve never traveled before.

This is Pinnacol’s new path:

  • Better understand the needs of every employee we cover at work.
  • Support all of them in maintaining and improving their health and wellbeing.
  • Do everything we can to prevent illnesses and injuries but,
  • If they should be injured, help enable quality, patient-centered, compassionate care.

We’re very excited about this new road, but we can’t do it alone.

  • Our dialogue will be crucial to our success. Whether you have a complaint, a question or a bold new idea, I want to hear it. My door (and my email inbox) is always open to you.
  • If you want to change the world of workers’ comp, then this is your time.

You’ll be hearing a lot more soon about our new way of caring for employees but in the meantime feel free to reach out to me anytime with your thoughts and ideas. Together, we’re going to build something great.

Sincerely,

Rick May, MD
Orthopedic Surgeon
Senior Medical Director
Pinnacol Assurance
rick.may@pinnacol.com
Cell: 303.618.4366

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Reminder About Prescription Medication Dispensing

December 2015

Workers' Comp Coordination

Pinnacol Assurance allows medical clinics that dispense medications to provide a one-time, 14-day supply of medication to injured workers at the time of the injured worker’s initial visit. It is not appropriate for a clinic to continually dispense medications to an injured worker throughout the life of his or her claim. 

The intention of this policy is to provide the injured worker a convenient way to obtain the necessary medication immediately following an injury, and permit time for Pinnacol’s pharmacy benefit manager, Helios, to receive the patient information necessary to provide for the injured worker’s ongoing medication needs.

It’s important to note that a physician who dispenses a controlled substance from his or her clinic is not required to submit such information to the PDMP. The law requires only Pharmacy Board-registered pharmacies to submit controlled substance dispensing information to the PDMP. When medications are dispensed directly from a clinic, please remember that PDMP safety precautions are not in place to keep our injured workers from harming themselves and possibly others.

For the safety of our injured workers and their families, please adhere to the one-time, 14-day rule when dispensing medication(s) from your clinic.

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