A Healthesystems publication

Fall 2015

Escaping the Catch-22 of Chronic Pain Management

Prescription medications can be an important part of managing an injured worker’s pain; however, focusing too heavily on pharmacological pain management can hinder rather than help recovery and return to work. 

 TREATING PAIN VS INJURY

Pain management is an all-too-familiar phrase within workers’ compensation. While it is a critical component of overall treatment, too often pain management takes center stage while other components of recovery – such as physical, occupational, or other forms of therapy – are less emphasized. And judging from the 9 million people in the United States who report long-term medical use of opioids,1 there is a disproportionate emphasis on pharmacological pain management, and not enough progress being made on the other piece of the equation, functional recovery efforts.

When considering the injured worker, it is important to remember that pain itself is not the primary affliction being treated; rather, it is a roadblock to healing that affliction. But it would be unreasonable here to “separate the symptom from the disease.” Injury and its symptom – pain – have a frustratingly symbiotic relationship. Pain exists where there is injury. But where there is unmanaged pain, significant efforts to improve the injury cannot be made.

Conservative, evidence-based pharmacological treatment of pain can serve to relieve patient discomfort as they work towards functional recovery. But too often opioid medications are prescribed that ultimately hinder rather than help recovery, sending the patient into an endless cycle as they rely on powerful opioids to mask the pain without gaining any functional improvements. More likely, their injury, overall health, and quality of life will actually deteriorate.

Not only does opioid overuse contribute to poorer claims outcomes, it also has a price tag associated with it. Claims for long-term opioid users cost an average of approximately $28 thousand more than those not using opioids long term.2 And claims containing opioids are up to 8 times as likely to cost more than $100 thousand compared with claimants who were never prescribed opioids.5

 That being said, shifting treatment emphasis to functional outcomes goes beyond encouraging physicians to write prescriptions for physical therapy. For example, how is the right patient identified? Has that patient adhered to the exercise regimen? Is the service being provided of high quality? And most importantly, is the therapy working?

This requires not only an understanding of what true treatment success looks like, but also the ability to objectively measure whether these goals are being met.

 PAIN IS AN UNRELIABLE OUTCOME

It’s not “new news” that no two patients are alike and that the course of injury and its treatment are highly individualized. This is due to a number of known or suggested variables that include attitudes toward pain, existing comorbidities, adherence to treatment, and psychosocial factors such as depression, anxiety, and catastrophizing. (See in this issue The Psychology of Injury: Applications for Cognitive Behavioral Therapy) And research continues to uncover factors that may explain why certain people are more susceptible to chronic pain than others.

A recently published 6-year study of more than 2000 patients shows that adverse life events are direct indicators of chronic pain onset risk, with occurrence of a single event increasing risk of chronic pain onset by 13%. When multiple life events were added, risk increased even more. And individuals who had experienced financial hardship (an event that could very well be applicable to an injured worker) were 54% more likely to develop chronic pain.6

Variability in pain susceptibility underscores that pain control in and of itself is not a reliable outcome, and therefore pain management is not a true measure of successful treatment. Rather, controlling pain enables the application of active modalities that can achieve more objective, functional outcomes.

ACTIVE TREATMENT MODALITIES AND FUNCTIONAL RECOVERY

Active treatment modalities such as physical therapy or an exercise program can have a profound effect on functional recovery and are a necessary component of an overall treatment plan in patients at risk of developing chronic pain. Risk-appropriate prescribing of physical therapy reduces time off from work and costs,7 and it can also lower the odds of other, often higher-risk and/or higher-cost interventions such as surgery, injections, and specialist or emergency department visits.8 An exercise program not only has the potential to increase strength and range of motion, it can also address the potential comorbidity of obesity, which can have a significant impact on claims in its own right, as lost workdays and cost per claim also increase with increasing BMI.9 The direct and indirect benefits of exercise were recently demonstrated in a 6-week indoor hand-bike exercise program in people with spinal cord injury lowered body mass index (BMI) and insulin levels, and also increased strength and extension in the shoulder and elbow.10

THE IMPORTANCE OF OBJECTIVE OUTCOME MEASURES

The goals of treatment within workers’ compensation are tangible and objective: restore function to the injured worker and reduce time away from work. Therefore it follows that the measures to determine whether this is being achieved should also be tangible and objective. If measures such as range of motion and strength are not being assessed, how can it be determined whether therapy is in fact working? The ability to apply these objective outcome measures enables payers to determine the effectiveness of treatment and ensure that they are making the most judicious use of their funds while providing patients with the best possible opportunity for functional improvement and return to work. Conversely, if therapy is not working, the payer should have a means to identify negative impacts treatment effectiveness, such as patient nonadherence or psychosocial factors such as fear avoidance. Yet these measures have often been missing from traditional physical medicine management programs within workers’ compensation.

A greater emphasis on active therapy that addresses functional improvement versus passive, pharmacologic therapy that only addresses symptomatic pain is necessary to break this “catch-22” of pain management that so many injured workers are stuck in. But payers need the right tools to manage utilization of physical medicine services in a way that departs from tradition, and instead supports a more outcomes-driven model that can maximize the effectiveness of care to help speed recovery and return to work, shorten claim durations, and reduce overall costs.

Healthesystems has developed a new physical medicine program that provides payers with unprecedented outcomes data to more effectively manage the quality and utilization of physical medicine services. More information can be found online and in our white paper Physical Therapy in the Injured Worker at www.healthesystems.com/physicalmedicine.

 

 

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SOURCES

1 -CDC Grand Rounds: Prescription drug overdoses – a U.S. Epidemic. MMWR Morbid Mortal Wkly Rep. 2012;61:10-3
2 -Anderson JT, Haas AR, Percy R, et al. Chronic opioid therapy after lumbar fusion surgery for degenerative disc disease in a workers’ compensation setting. Spine (Phila Pa 1976). July 2015. [Epublished ahead of print].
3 -Workers’ Compensation Insurance Rating Bureau of California. California Medical Payment Development Up to 30 Years Post-Injury. July 8, 2015.
4 -Hooten WM, St Sauver JL, McGree ME, et al. Incidence and risk factors for progression from short-term to episodic or long-term opioid prescribing: a population-based study. Mayo Clin Proc. 2015;90:850-6.
5 -Tao XG, Lavin RA, Yuspeh L, et al. The association of the use of opioid and psychotropic medications with workers’ compensation claim costs and lost work time. J Occup Environ Med. 2015;57:196-201.
6 -Generaal E, Vogelzangs N, Macfarlane GJ, et al. Biological stress systems, adverse life events and the onset of chronic multisite musculoskeletal pain: a 6-year cohort study. Ann Rheum Dis. April 2015. [Epublished ahead of print].
7 -Foster NE, Mullis R, Hill JC, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;13:102-11.
8 -Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: association with future health care utilization and charges. Health Serv Res. 2015 Mar 16. [Epublished ahead of print].
9 -Ostbye T, Dement JM, Krause KM. Obesity and workers’ compensation: results from the Duke Health and Safety Surveillance System. Arch Intern Med. 2007;167:766-773.
10 -Kim DI, Lee H, Lee BS, et al. Effects of a six-week indoor hand-bike exercise program on health and fitness levels in people with spinal cord injury: a randomized controlled trial study. Arch Phys Med Rehabil. 2015 Aug 5. [Epublished ahead of print].
11 -da Silva Ribeiro NM, Ferraz DD, Pedreira E, et al. Virtual rehabilitation via Nintendo Wii® and conventional physical therapy effectively treat post-stroke hemiparetic patients. Top Stroke Rehabil. 2015;22:299-305.
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