At the 2017 Comp Laude education event, a panel discussed the need to look beyond opioids for the treatment of chronic pain. The panel included:
- Kimberly George – Sedgwick (moderator)
- Beth Darnall, PhD – Stanford University
- Steve Stanos, DO – Swedish Medical Group
- James Atchison, DO – Shirley Ryan Ability Lab
These speakers are some of the most innovative people in the pain management industry who are leading research efforts into non-opioid pain management opportunities.
Patients are often not given tools to assist them in the management of pain. The only “tool” they are given is a pill. It is important to provide patients with the tools to assist them in management of pain so that they do not need the pills.
The CDC guidelines that came out last year was a big first step toward limiting excessive opioid prescribing early on. Many health insurance carriers, including Medicare, and many pharmacies are now limiting the initial prescribing of opioids in response to these guidelines. We need to change the “norm” around the use of opioids. People are used to receiving opioid pain medications as the norm for treatment. It has become expected. But more often than not these drugs are unnecessary and their pain could be managed with over the counter medications. Hopefully the increased publicity around this issue will start to change this perception that a person needs opioids for any pain.
If people are reporting their “pain” is a 10 or higher, it doesn’t mean they necessarily have more pain than others. Instead it is probably more reflective of a psychological component. People with the highest pain scores likely need a bigger focus on psychological issues instead of opioid medications for pain control. Pain is a sensory and an emotional experience. The psychological component is huge. When someone gives you their pain score, that is an index of their distress, not just their pain. It reflects everything that is going on in their lives not just their pain.
Americans do not have more pain than other countries. Yet, we are consuming more than 80% of the world’s supplies of opioid pain medications. There are two elements to controlling this. First is provider education. But patient education is just as important. Not prescribing opioids is not withholding treatment. Instead it is appropriate care to NOT prescribe opioids when they are not warranted.
An increased focus on the psycho social element of claims is needed. This is something that is needed not just in workers’ comp but in society as a whole. We need people to develop better coping skills before something happens to them so they are better equipped psychologically to cope in the event they suffer an injury or illness in the future.
It is important to engage in “pre-habilitation” whereby we teach patients pain control and coping skills BEFORE surgery so they have a better response after surgery. We also need to address the fear patients have about their recovery in the front end. This can be part of some pre-surgery physical therapy. The PT can help strengthen the body and to prepare them for surgery and the cognitive therapy can help prep their mind for the recovery.
One big question. As payers are we willing to consider this pre-habilitation. This requires a change in mindset from how we currently approach pain management.
People are beginning to be more open to the concept of non opioid pain management because of all the publicity around opioids. It is important to emphasize these non opioid methods are the “best practices” and do follow evidence based medicine. It’s not about taking opioids away, it’s about providing BETTER pain management. This is a cultural transformation. We need to help people understand opioids are not best practices and are not appropriate all the time.
Another thing we need to do a better job is assessing the patients to determine the source of the pain instead of just trying to mask the pain. There could be an objective source to the pain which could be medically corrected. We need to make sure we are ruling out objective and correctable sources to the pain.
Another thing to keep in mind is that not all opioids are bad. There are time when opioids are appropriate for pain control. Immediately post surgery is an example. End of life is another.
We also need to change the approach in medical school to pain management. Students in veterinarian school actually receive more instruction on pain management than students in medical school. Medical students are not trained on how to properly assess pain and the best practices in the management of pain. That’s why they tend to just prescribe a pill. It’s all they know how to do.
Injured worker behavior can be different than general healthcare injuries because of other complications and incentives including perceived injustice. Beth said they exclude people with an open claim from research studies because secondary factors from that claim cause different expectations of outcomes by the injured person which in turn leads to different outcomes. Because of this, there are not good studies focused on workers’ compensation patients.
Tapering people off of long term opioid use is something that must be done carefully. The CDC guidelines included suggestions for tapering. The important thing is to couple tapering with training on coping skills and other pain management techniques. The tapering must be done gradually. Trust from the patient is a key component. They must trust that you have their best interests in heart and that you are working with them to assist in helping them with their pain during the tapering process. If the tapering is done gradually, you can usually avoid the need for a detox program. It is very important to pay attention to the psychological state of the patient. The patient’s anxiety may go up as their opioid use goes down so you need to be thinking in terms of ways to help manage that anxiety. The anxiety can also impact their sleep process which again will impact their pain. All these things tie together. If you taper too quickly, you could trigger masked psychological problems.
Inpatient pain management programs may be needed to get a person to the base levels of functional activity. If there are good outpatient pain programs in your area an inpatient program may not be needed. However, if a person does not have availability to a good outpatient program you should consider an inpatient program lasting two weeks to a month. This could have tremendous success. The cost of such programs is significantly less than the long term costs of the opioids and thus well worth the investment. If a person has significant psychological overlay then an inpatient program may be needed to provide the high level of support these people need.
A psychological evaluation is part of any pain management evaluation. This does not mean a full neuropsychology evaluation, but they will need an evaluation to gauge the psycho social elements in their lives than can impact their pain management and coping skills. Keep in mind that pain is individual. Every person is different.
Urine drug screening is recommended under the CDC guidelines and this should be part of a pain management program including when you are weaning someone from medications. You need to make sure people are not turning to alcohol, marijuana, or other substances. People with addictive behaviors tend to shift to other substances.
Some of the key takeaways for claims handlers is to push for the injured worker to have a psycho social evaluation early in any complex claim. It is important to know what you are dealing with as this could completely derail the claim. It is also important to track patient engagement. A more engaged patient has better outcomes. Watch for the claim to progress. Too often people get locked into a treatment program with no progression in their functional outcomes. Finally, whatever the injury is there is a natural progression to recovery. If people are not recovering as expected should lead the claims handler to start asking why. Is the treatment appropriate? Is the diagnosis appropriate? What is inhibiting the recovery?
The 2018 American Academy of Pain Management conference in Vancouver will be focusing on payer engagement with the pain management community. They encouraged carrier /TPA medical directors, nurse case managers, and others to consider attending this event in April 2018. http://www.painmed.org/annualmeeting/