One of the areas of focus on Out Front Ideas with Kimberly and Mark has been addressing chronic pain without opioids. The workers compensation industry's approach to chronic pain has historically been trying drugs and other medical procedures first. Then, if the pain has not subsided or has worsened, we look for psychological factors.
If we truly want to help injured workers in pain and prevent opioid abuse and other unnecessary measures, we need to reverse that protocol. To learn more, we spoke with two of the nation's most highly respected pain management experts who gave us great insights into the experience of pain, how it can be best treated, and nonpharmaceutical ways to treat pain.
Beth Darnell is a clinical associate professor in the Division of Pain Management at Stanford, a clinical pain psychologist at the Stanford Pain Management Center, a National Institutes of Health-funded scientist doing research on psychological treatment for chronic pain, one of the cochairs of the Pain Psychology Task Force at the American Academy of Pain Medicine, one of the coauthors of the 2017 Chronic Pain Guideline updates from the American College of Occupational and Environmental Medicine, and she has written multiple books on the subject: Less Pain, Fewer Pills and The Opioid-Free Pain Relief Kit—both written for patients. Dr. Darnell also recently copublished a research paper for the Journal of the American Medical Association Internal Medicine titled "Patient-Centered Prescription Opioid Tapering in Community Outpatients with Chronic Pain."
Dr. Steve Stanos is the medical director of Pain Management Services for the Swedish Medical System in Seattle and runs the pain services for five hospitals in the system, the director of Occupational Medicine Services at Swedish, the president of the American Academy of Pain Medicine, and the medical director for myMatrixx. He was also a reviewer for the Guidelines for Opioid Management that was released by the Centers for Disease Control and Prevention (CDC) and was involved in the National Pain Strategy.
Myths and Facts
Many of us have preconceived ideas about pain—what it is and how it should be treated. Unfortunately, many of these ideas are misconceptions and have led us to where we are today.
We think of pain as solely a physical experience. But our experts explained that pain is really a negative sensory and emotional experience. Psychology is an integral part of the pain experience, and if we ignore that, we are not adequately addressing an injured worker's pain.
Pain is very helpful in alerting us to situations where our bodies are at risk. If you put your hand on a hot stove, for example, the pain signals your brain to remove your hand. However, that does not work well for chronic pain when the ongoing pain alert does not help us. Instead, it causes us fear and stress, which can actually exacerbate the pain. Those fears and stress are what we need to address in injured workers with chronic pain.
Another misconception is that people in pain are powerless to do anything about it and are at the mercy of drugs or other medical procedures. That simply is not true. There are teachable skills patients can use to assuage their own pain. These are learned skills.
We need to help injured workers understand and deal with the psychology of their pain experience up front instead of waiting until the claim deteriorates. Medical providers, payers, and others involved in a claim need to be aware of that and work with the injured worker to empower him or her to reduce their fears and stress and, in doing so, reduce their pain.
That leads us to another misconception—that dealing with the psychology of pain requires a specialist for extended sessions. Actually, nonbehavioral health individuals can teach valuable skills to help cope with pain. Again, this should be done early in the claim process for the best outcomes. The best predictor of outcomes in a pain program is early intervention with psychosocial factors. We need to have an early emphasis on behavioral health.
Yet another falsehood is that using drugs and medical procedures first is better for the patient because it does not assume he or she has any psychological issues. Instead, we are missing the elephant in the room, and when the injured worker is finally sent for psychological intervention, it can be demoralizing. It sends a message to the injured worker that he or she is a failure and the pain is all in his or her head. It does a terrible disservice to the injured worker.
We asked our experts whether all patients in chronic pain need psychological intervention. The answer was yes, anyone in chronic pain can benefit from some level of behavioral intervention. That does not mean long-term expensive one-on-one treatments with a trained psychologist. Again, there are teachable skills to deal with chronic pain. The focus is on changing behavior.
Nonpharma Pain Treatments
There are a variety of programs to help people deal with pain, many of which are based on cognitive behavioral therapy (CBT). This short-term treatment is goal-oriented and takes a practical approach to problem-solving by changing patterns of thinking and behavior. Doing so helps change the way patients feel.
CBT is considered the gold standard of psychological treatment for chronic pain. It teaches concrete information and skills with action plans to move forward. It helps in creating care pathways that promote organized and efficient patient care based on evidence-based medicine. It helps patients become engaged and active in their own treatment so they rely on themselves more than the medical system.
Patients can learn the skills of behavioral health principles through classes and videos as well as talking with therapists and others. Again, it is something anyone in pain can and should learn—not just those who are profoundly depressed or have other, more serious psychosocial issues. It is active management of pain.
Some newer treatments include mindfulness training, acceptance and commitment therapy, and chronic pain self-management. These are all based somewhat on CBT, although not necessarily on pain management. Acceptance and commitment therapy trains you to stay focused in the moment so that you do not react to pain. Negatively reacting to pain can be more distressing than the pain itself. These programs teach people how to self-soothe. They also help establish meaningful goals and the steps to achieve them so people are not stuck in a passive mindset about their pain.
Functional restoration programs incorporate many of these aspects and can also be great, not only for at-risk patients already struggling with chronic pain but also for early intervention. These programs have been around for years and typically involve physical and occupational therapy, psychology, relaxation training, exercise, and vocational rehabilitation. The cost is fairly inexpensive when you compare them to unnecessary surgeries, so they can be helpful.
There are also certain medical procedures and services that have been overused in the past but can actually have a role as part of an overall pain management plan. Spinal cord stimulators and injections are among them, along with chiropractic care and spinal manipulation. These can help with function for certain patients, such as those with acute pain. But they must be integrated into an overall plan, and they are only appropriate for certain individuals.
Passive treatments, such as acupuncture and massage therapy might be helpful for some pain patients, at least in the short term. But again, it needs to be used in conjunction with an active therapy program in which the patient is helping to manage his own pain through skills learned from CBT and other techniques.
One treatment on which both experts are hesitant to recommend at this point is medical marijuana, mostly because of its classification as a Schedule I drug under federal law. The science on it is just too sparse, there is no safety around it, and no protocols for when to use it, what type, and how much could help.
"Prehab" is a relatively new term that might hold some promise. Think of rehab before the fact. It focuses on things like wellness, how to relax during the day, and stress reduction techniques. The idea is to intervene with patients prior to surgery or other treatments and prevent poor outcomes. Patients who have fear avoidance or catastrophic thinking can be taught skills so they are better able to deal with their pain and stress later on.
Education programs are key in helping pain patients to avoid overutilization of medications and services. Since so many do not understand pain or how to control it, they may seek multiple treatments to eliminate the pain.
The 2017 revisions to the American College of Occupational and Environmental Medicine Chronic Pain Guidelines that were released in May 2017 included an extensive section on behavioral health, the role of psychology, and recommendations to integrate psychological principles in chronic pain.
The CDC's guidelines for managing opioids have been invaluable in the attention they have brought to the opioid issue since they were released last year. However, there has been some confusion and pushback, especially on the recommendations that deal with the morphine equivalent dose (MED). The CDC recommends providers avoid or carefully justify prescriptions of more than 90 MED. Some payers have incorrectly interpreted that to mean physicians cannot prescribe above the 90 MED.
Another controversial recommendation says providers should only prescribe opioids for the duration of expected pain, typically between 3 and 7 days. But some providers have been mistakenly told that they can only prescribe the drugs for a specific number of days.
Both experts say a shift from fee-for-service to outcomes-based care could be a huge benefit because it would allow for a more holistic approach, including the integration of behavioral health. Putting behavioral health efforts on the front end of the claim is one of the biggest changes that they believe would help chronic pain patients. This would be a game changer in the workers compensation system and would cost more up front, but the speakers believe it would pay off in dividends.
Precision medicine is an emerging field that could provide great promise for treating injured workers with chronic pain. It involves deep phenotyping patients on the front end and at each point of care. It includes an array of psychosocial variables and assessments to determine the specific needs of each patient for targeted interventions. It moves beyond the one-size-fits-all approach.
Technological advancements will allow for more and better treatment, such as apps and videos that reinforce behavioral health techniques. Telemedicine is a way to help keep patients engaged. Telehealth can allow for virtual face-to-face meetings between patients and psychologists. Virtual reality also holds promise as a way to help decrease pain levels during treatments.
Clearly, there is much that the industry can do to reap better outcomes for our injured workers and, in turn, their employers. However, it requires new ways of thinking and a change in the way we have been doing things. All stakeholders need to truly understand pain and what we can do to address it better and faster.
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