Chronic Pain Management
At the 2018 Comp Laude Gala, the Alliance of Women in Workers’ Compensation hosted sessions focused on rethinking pain management. The panel for this session was:
- Mark Walls – Safety National (moderator)
- Patricia Cole PhD – Shirley Ryan Ability Lab
- Marcos Iglesias MD – Broadspire
- Alan Pierce – Pierce, Pierce & Napolitano
- Becky Curtis – Take Courage Coaching
How Did We Get Here?
Chronic pain is a secondary diagnosis. It usually means that the primary injury has been resolved in that no further structural issues need to be addressed (such as surgery). That doesn’t mean there is not an objective reason for the pain, it just means it cannot be repaired.
The pain persists for any of an number of reasons. Pain is the brain’s response to stimuli, meaning mental health plays a tremendous role in chronic pain. Patients with psycho-social challenges are more prone to developing chronic pain. These psycho-social issues can include adverse early childhood experiences, financial pressures, issues with personal relationships, or even adverse feelings about the workplace.
The workers’ compensation system itself can be a factor in chronic pain as pain complaints can be tied to secondary gain issues. If a person is concerned about their disability benefits ending or their permanent disability award you can see increased pain complaints.. If secondary gain is the driver, resolving the indemnity issues on the claim tends to resolve the medical issues as well.
First Steps In Addressing Chronic Pain
The first step toward addressing chronic pain is acknowledging the psychological component of pain. Many payers and injured workers are hesitant to do this because of the stigma associated with mental health issues.
Patient education including setting up realistic expectations is also very important. Pain is part of life. Having pain is a normal human condition. It is not realistic to expect to be pain free after a significant injury. Understanding that fact is key in that it shifts the focus from the unrealistic goal of eliminating the pain to learning how to cope with the pain.
Multidisciplinary pain management programs are a great tool to help patients develop the skills needed to cope with chronic pain. These programs include psychological counseling, active physical therapy, occupational therapy, and other specialties. Programs can last up to a month and are often inpatient. But these programs have shown to be very successful. It is important to note that not all pain management programs are created equal. When evaluating these programs it is important to ask them about patient outcomes. Are patients getting increased function including return to work? Unfortunately there are few pain management programs out there that deliver consistent results.
The underlying focus of any good pain management program is function, not pain. Pain will always be there. Patients can learn coping skills such as biofeedback that may lessen the pain. However the ultimate goal is to increase function. Physical activity may be painful at first, but persistence is important as consistent physical activity will help decrease pain and help aid in getting proper sleep. Find out what is important to the patient in terms of functional goals. Do they want to be able to go on vacation, go hunting, plays with their children, etc. Focus on these functional goals as these things that are important to the injured worker will help motivate them and overcome psychological barriers.
Long Term Care
Chronic pain does not go away. The hope is the patient learns self help skills in their functional restoration programs and uses these skills the rest of their life. Pain coaching can be an important tool to help patients maintain their functional gains. Pain coaching programs usually include peer groups as well as individual counseling. Pain coaching can be done over the phone or using things like FaceTime or Skype, so it is easy to use. The goal is to give positive feedback to the injured worker so they stick with what works, even as their pain fluctuates.
Many are questioning whether medical marijuana is a potential solution for chronic pain. The panel felt strongly that there was no science to support that contention. Even recent studies claiming to show the effectiveness of medical marijuana for pain are very narrow in scope. There are also concerns about the impact of long-term marijuana use. Marijuana today is very different from the marijuana of 20 years ago in that the TCH concentration is much higher. The fear is that because of the lack of study we will find out someday that there are significant long term side effects of marijuana use. There is no magic pill to cure chronic pain, and trading opioids for medical marijuana is just trading one drug for another. The goal is to get off the drugs and strengthen your mind and body, not just try to numb your senses.