Treating Pre-Pain and Acute Pain

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:

• Anita Breedlove – One Call (moderator)
• Maja Jurisic, MD – Concentra
• Frank Lovecchio, DO – Banner Health
• Chrysten Shea – AkosMD
• Dawn Watkins – LAUSD

Pain by definition is an emotional and sensory experience. It is not always correlated with actual tissue or structural damage. All pain is created by the brain as a response to some stimuli and everyone’s response to the stimuli is different. People who “think” they are seriously injured can experience severe pain even if their injury is relatively minor.

After three days, opioids are no longer effective to treat pain so the only way they continue to work is to increase the dosage or add another medication. The reason we have an opioid epidemic is inappropriate prescribing patterns. The CDC, FDA and many state agencies have developed prescribing guidelines to try and eliminate inappropriate prescriptions. Studies have shown that a combination of Tylenol and an NSAD (ibuprofen or naprosyn) are more effective for pain control than an opioid.

The concept of “pre-pain” is an important one to understand. Setting expectations around pain helps people be prepared for pain before it happens and allows the patients to cope better with the pain. For years, pregnant women have taken classes where the concept of coping with the pain of childbirth is a significant element. This same concept is very useful for patients who are pending surgery. Setting expectations can reduce patient anxiety which is important as increased anxiety typically leads to increased pain.

Patients can “pre-hab” before a surgery to be better prepared for the recovery process. There are apps to support this and the activities include getting your your house in order, stocking the refrigerator with healthy food, and clearing your schedule as much as possible. Reducing unnecessary stressors is an important part of pain management. Also, patients need to understand that pain is a normal part of the healing process.

It is important for clinicians to focus less on asking patients about pain and more about their function. Every time you ask a patient about their pain you make them focus on the pain and think about it which makes it worse. Focus on functional goals and increasing function. Sleep is an important body function that can be disrupted with pain so taking steps to ensure adequate sleep is important. You do not give pain medications to help people sleep as there are medications designed to assist you in sleeping that are more appropriate for that problem.

Sometimes issues in the workplace and home can exacerbate a patient’s pain complaints. Pain is subjective and fear or anxiety over workplace issues can inhibit a patient’s recovery. Are there issues around job performance that predated the work injury? Is the injured worker in a troubled environment at home? These “psycho-social” factors are known to delay recovery and they need to be recognized and addresses as much as possible.

There are many risk assessment tools to help identify patients who are prone to a poor medical outcome. The first question is when do you deploy such tools? Most patients recover as expected so it makes no sense to use a risk assessment tool on every workers’ compensation claims. However when you start seeing signs of delayed recovery it is time to take a deeper look into what may be driving the problem. One big area that studies show lead to bad medical outcomes are early child events. If a person had a traumatic childhood, they were abused or assaulted, etc, they are more likely to experience a delayed recovery from other adverse events in their lives including workplace injuries.