December 17, 2017

Dr. Steven Feinberg: What is the Best Approach to Preventing and Managing Chronic Pain?

By Dr. Steven Feinberg

Dr Steven FeinbergThe treatment of injured workers with chronic pain conditions throughout the United States is at best problematic and at worse a disaster. We continue to see individuals overtreated by well-meaning physicians with excessive opioids and psychotropic medications while undergoing numerous passive invasive interventions but with at best transient and little, if any, lasting benefit. We see considerable resources being utilized and high dollars spent but we often do not see the injured worker improving function and returning to gainful employment.

Workers’ compensation is very legal and procedural and often misses the mark by not focusing on the health, welfare and return to work of the injured worker. It has been estimated that 10–15 percent of cases consume 75–80 percent of medical/indemnity resources. This subset of injured workers often has underlying medical (obesity, diabetes, obstructive sleep apnea, etc.) and psychological comorbidities (substance abuse history, adverse childhood experiences, poor coping skills, etc.) Payers/employers who focus on the mechanics of the claim and physicians who focus on the injured body part and ignore the patient’s risk factors for delayed recovery, will often be unsuccessful in achieving cost-effective treatment and claims closure and return to function and to work for the injured worker.

There are many potential approaches to preventing a bad outcome after an industrial injury and all concerned parties need to be part of the solution.

This article will focus on one very important aspect to achieve cost-effective care of injured workers; education and empowerment of injured workers using a biopsychosocial functional restoration model. Becoming educated and taking responsibility for their rehabilitation (internal locus of control) is the most effective and only long-lasting tool to achieve meaningful and cost-effective use of resources for optimal gain. Pills and procedures at best provided partial and temporary benefit and at worst, causes increased illness, injury and indemnity.

Evidence-based medicine clearly supports a biopsychosocial functional restoration program (FRP), but it is often hard to get authorization for this approach and even when approved and provided, we see a high degree of recidivism. Payers and employers are understandably skeptical when the injured worker undertakes costly treatments without lasting benefit.

The biopsychosocial FRP approach should start early with recognition of injured workers at risk for delayed recovery. Once identified, specific coordinated psychological and physical restorative services are provided. Select individuals may need a more intense FR Program. There are limited numbers of such programs nationally. On the negative side, for those programs that do exist, there is a wide range of admission criteria (i.e., often too liberal). Additionally, and quality of the existing programs. Lastly, while benefit is often seen during such programs, recidivism after discharge and over time remains a critical issue. Ongoing treatment with the FRP team post program for 6–12 months – also termed aftercare – is just as, if not more, important to assist the injured worker in maintaining gains, dealing with expected flareups and in preventing recidivism.

For long-term success with functional restoration treatment approaches, it is critical that the locus of control shifts to the patient and away from the treatment team. This is an educational model where the individual become self-sufficient and responsible for their care and where the healthcare team become educators and advisors.

While the FRP serves as a primary educational resource to the patient, there are other resources that can help cement long-term success and maintenance of pain management and functional gains. If the injured worker is to be empowered and take responsibility for his or her health and well-being (i.e., the locus of control rests with the injured worker not the healthcare provider), then the individual needs to be educated about his or her diagnosis and treatment and take responsibility for ongoing care.

There are many educational resources available on the Internet. While there are excellent resources available, there is also misleading and erroneous information regarding health issues. Selectivity is important and there are a number of excellent resources available on the Web.

Once such resource is the American Chronic Pain Association. It is one of several organizations that focus on patient empowerment and education. The ACPA website, which I encourage you to visit and share with injured workers, has numerous tools to help chronic pain patients better manage chronic pain while improving their function and productivity. The organization has just published the updated 2017 ACPA Resource Guide to Chronic Pain Management: An Integrated Guide to Medical, Interventional, Behavioral, Pharmacologic and Rehabilitation Therapies. I serve as the lead author. While directed at individuals with chronic pain, it can be useful to employers/payers, attorneys, nurse case managers and healthcare practitioners. It is available at no charge and can be downloaded as a PDF here: 2017 ACPA Resource Guide to Chronic Pain Management (PDF)

About Dr. Steven Feinberg
Dr. Steven Feinberg is a physiatrist and pain medicine specialist practicing in Palo Alto. He is an Adjunct Clinical Professor and teaches at the Stanford University Pain Service.

Dr. Feinberg is a past president (1996) of the American Academy of Pain Medicine (AAPM). He served as a California Society of Medicine & Surgery (CSIMS) Year 2001 President. He serves on the Board of Directors of the American Chronic Pain Association (www.theacpa.org) and is lead author of the 2017 ACPA Resource Guide to Chronic Pain Treatment.

Dr. Feinberg served as Associate Editor on the ACOEM Chronic Pain Guidelines Panel Chapter 2008 Update and is serving currently serving as Panel Chair for the 2017 update (soon to be released). He served as a Medical Reviewer for the ACOEM 2014 Opioid Guidelines.

About Feinberg Medical Group
Feinberg Medical GroupFMG is a private practice medical group in Palo Alto which focuses on the treatment of injured workers using a biopsychosocial functional restoration approach following the CA Medical Treatment Utilization Schedule (MTUS) adhering to evidence based medical guidelines.

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