Medical treatment guidelines can improve worker health by helping doctors and nurses deliver proper care. Multiple pain guidelines exist and, as their use grows, there is a greater need for claims managers to learn how they are best applied. This session at the 2016 National Workers’ Compensation & Disability Conference illustrated the purpose of chronic pain management guidelines and showed how they are used.
- Joseph Paduda, Principal, Health Strategy Associates & author of the Managed Care Matters Blog
- Steven D. Feinberg, M.D., Pain Management Physician, Feinberg Medical Group
About 100,000 people die a year due to medical errors, there is huge variation in practice patterns and one-third of the medical spend is wasted on unnecessary procedures. Guidelines are available to try to combat these problems.
Guidelines in workers’ compensation provide better patient care due to consistency in care provisions, the confidence that employers are paying for good care and the reduction in friction due to misunderstanding or disputes. Guidelines also provide a necessary set of rules for all stakeholders in the workers’ compensation system: regulators, claims adjusters, attorneys, claimants and providers – although each stakeholder has a different perspective on them.
When designing guidelines, there are certain requirements. They must be:
- Clinically sound
- Nationally recognized
- Implemented in phases (so that we do not have to change treatment to large groups of patients at once)
- Consistent with state laws and regulations
- Disease state/condition specific (for chronic pain situations)
- Transparent (on methodology, who reviewed the process, etc.)
Guidelines are only half of a medical management program. The other half is the utilization review process to implement them. Non-standard care must be approved via a standardized utilization review prior to delivery. When properly done, guidelines do not restrict access to appropriate care. They prevent access to the wrong care.
Evidenced-Based Medical (EBM) Guidelines for Chronic Pain
Pain is one of the most-common reasons that patients seek medical attention and one of the most prevalent medical complaints in the U.S. Chronic pain (pain that lasts more than three months) is a large cost driver to the system and opioids are leading to costly, lagging developmental claims. We are seeing situations where the injured worker is the “innocent” in the medical situation, getting lost in a never-ending pattern of surgeries and medication that, ultimately, leads to biological, psychological and social factors that affect recovery. In turn, the workers’ compensation system is not working for some injured workers, however, EBM guidelines can help.
When it comes to pain and opioid treatment guidelines, every state is different. Not every state has them, but most do. They are all similar, however, the methodology can be different. The CDC has also created guidelines for prescribing opioids for chronic pain.
Why do we have them? Chronic pain guidelines are there to:
- Protect the consumer, but also to educate prescribers.
- Recognize importance of psychosocial factors that may delay recovery.
- Identify problematic treaters.
- Identify appropriate medication management.
There are chronic-pain guideline similarities. They all aim to:
- Reduce/eliminate the use of opioids.
- Avoid concomitant use of central nervous system depressants like antihistamines, alcohol and benzodiazepines.
- Encourage use of opioid agreements and urine drug testing.
- Encourage use of state physicians drug monitoring programs.
- Focus on injured worker education and increased function.
What do the pain and opioid treatment guidelines tell us? There are certain principles to follow:
- Opioids should not be the first-line treatment for pain.
- Avoid opioid with concurrent substance use disorder.
- Limit prescriptions for short-term use only.
- Medication must be individualized (because everyone have a unique response to them).
- Repeated weaning trials are recommended.
Overall, chronic pain guidelines recommend focusing on functional restoration, including biopsychosocial whole-person approach. In this approach, there is a coordinated team effort to therapy. The injured worker is an active team member in the process, so the team educates them and puts the focus on healing in their hands.