By Dr. Michael Lacroix, Director of Behavioral Health Services, Coventry Workers’ Comp Services
Chronic pain torments those afflicted and those who cover the expense. An estimated 70 to 120 million Americans suffer with chronic pain. The Institute of Medicine reports associated costs up to $635 billion a year in medical treatment and lost productivity…more than coronary heart disease, stroke, and diabetes and cancer combined1.
Is Chronic Pain Really Intractable?
There are varying definitions for chronic pain, and each is associated with time; pain that has continued for 6+ months or beyond medical expectation. Once that line is crossed the assumption is that chronic = intractable = permanent disability. While it is true that multiple expensive medical interventions to eradicate the pain have failed to improve the patient’s sense of health or functional ability, however is it also true that nothing else can be done?
To deal with pain, one must first face reality and look for solutions beyond the standard medical model: pain that exceeds the normal healing time is typically associated with some psychological factors. These factors play an important role in the onset, severity, exacerbation, or maintenance of the pain. This suggests that a major component of treatment for ongoing pain should incorporate a cognitive behavioral approach to treat the real barriers to recovery.
How Does Pain Treatment Typically Start?
Unfortunately, when a patient presents with a condition that includes pain as a symptom, the first line of treatment is usually medication, specifically opioids which we have learned create meaningful risk of addiction for all patients. In evidence is the fact that the last 10 years have shown significant escalations in prescription opioid abuse with devastating consequences. According to the CDC, deaths due to opioid overdose quadrupled between 1999 and 2010, from 4,000 per year to over 16,000.
Moreover, studies suggest that opioid treatment may retard functional recovery2 and in some patients can actually increase the patient’s pain experience, a condition known as ‘hyperalgesia’. According to NCCI studies, the yearly cost of narcotic painkillers and opioids to WC insurers has climbed to about $1.4 billion3. This medical expense is compounded by the incurred indemnity expenses, as research documents that workers treated with high doses of opioids stay out of work three times longer than those with similar injuries given lower dosages, and the associated cost of workplace injuries is nine times higher when a strong opioid is used.4
Medical Research Suggests Dramatic Treatment Changes are Needed
Recently published guidelines instruct providers to use opioid medications for acute or chronic pain only after determining that alternative therapies do not deliver adequate pain relief5. The Washington based Agency Medical Directors Group (AMDG) further recommends behavioral screening, use of patient agreements, random, periodic, and targeted urine testing for opioids and other drugs for any patient less than 65 years old with noncancer pain who has been treated with opioids for more than six weeks.
We now know that early intervention with vigilant oversight to ensure appropriate treatment is key to promote recovery and preempt addiction and delayed functional return that leads to a diagnosis of chronic pain.
Many Have Tried…but…
As far back as the 1980’s we saw a significant growth of ‘multi-disciplinary’ pain management clinics. These clinics included physicians, psychologists, nurses, physical therapists, occupational therapists, and often others working as a team. The focus was on cognitive-behavioral therapy, exercise, and medication weaning. The multi-disciplinary approach did produce results, as a recent Cochrane review argued for a combination of cognitive interventions and exercise as the treatment of choice for chronic back pain6. Yet this approach is in retreat today, with almost a 50% drop in accredited programs from 1998 to 2004. Multi-disciplinary pain clinics are very expensive to maintain, staff, operate and those costs must be borne by someone. The scrutiny of some clinics relative to prescribing behavior and the expense of inpatient stays is causing many payors to rethink the advantages of this facility-based model.
Key Learnings Define a New Model
While the facility-based team model yielded benefit, the return in patient outcome and claim resolution on this high cost investment has been suspect. Today we have a serious need for an innovative approach that incorporates the values of the multi-disciplinary model but can be delivered through telephonic and community-based case managers and clinicians forming a ‘virtual pain management clinic’.
- A program that can identify early indicators for emerging chronic pain claims by mining pharmacy data and medical treatment patterns will have greater success than one that takes action after the risk is evident. There have been tremendous advances in data mining technology recently, with the ability to identify claims with the greatest potential for becoming chronic. Identification of ongoing or inappropriate opioid utilization can be concurrent to treatment enabling immediate pharmacy and case management interventions to occur.
- Since an essential element of a successful program is behavior change, selection criteria should include cognitive – behavioral assessment. Moreover, the knowledge base for cognitive behavioral therapy has now reached well beyond clinical psychologists. Most MA-level counselors and nurses with psychiatric background are taught basic principles and techniques of cognitive behavior therapy as part of their formal education, and can be trained to teach these to patients. Using MA-level counselors and nurses to combine clinical management with cognitive behavioral therapy, cuts down dramatically on the cost of service delivery.
- Not everyone benefits from the same intervention. Hence, there is a need for a strong evaluation component, and for tailoring the program to each patient’s clinical presentation. Appropriate selection criteria must be employed to identify those that will benefit from cognitive behavioral therapy (CBT) and those who would benefit from, for example, a targeted pharmacy approach.
- Successful programs must also include increased physical activity. Is it necessary to have all the ancillary personnel found in the typical multidisciplinary pain program to increase physical activity? Activity coaching can surely be done more cost-effectively, particularly if it is integrated into a CBT coaching approach.
- As patients develop better control of their pain, improvements need to be meaningfully integrated into their lives, such that that they can derive tangible benefits from increased functionality. As functional status improves, return to work efforts should redouble to take advantage of those improvements.
Providers and pharmacy benefit managers must incorporate the latest guidelines for opioid dispensing into their standard practices with all patients entrusted to their care to ward off long term dependence and chronic pain. Payers and employers should align with suppliers who understand the complexity of managing pain for an early to mature claim and can offer the proven clinical components (cognitive-behavioral therapy, exercise, and medication weaning) delivered through a multi-disciplinary virtual pain clinic.
The stakes are high measured in human suffering as well as in societal funding. Far too high to surrender.
About Dr. Michael Lacroix
Dr. Michael Lacroix is the Director of Behavioral Health Services for Coventry Workers’ Comp Services. He is a licensed psychologist in Florida and has attained Diplomate status in Rehabilitation Psychology from the American Board of Psychological Specialties and as a forensic examiner from the American Board of Forensic Examiners. Dr. Lacroix has has authored and/or presented over 100 scientific publications and papers throughout his career. His major areas of interest and specialization include trauma (short-term intervention as well as long-term consequences); rehabilitation psychology, with emphasis on issues of clinical and vocational assessment, behavioral medicine, with emphasis on psychosomatic disorders; and psychotherapy, with emphasis on cognitive-behavioral therapy and hypnosis.
About Coventry Workers’ Comp Services
Coventry Workers’ Comp Services, a division of Coventry Health Care, Inc. (NYSE: CVH), is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers and insureds as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.
Coventry WCS is a WorkCompWire Advertising Partner.
This is not a paid placement.
1 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011; American Diabetes Association: http://www.diabetes.org/diabetes-basics/diabetes-statistics/ ; Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association. Circulation 2011, 123:e18-e209, page 20. http://circ.ahajournals.org/content/123/4/e18.full.pdf ; American Cancer Society, Prevalence of Cancer: http://www.cancer.org/docroot/CRI/content/CRI_2_6x_Cancer_Prevalence_How_Many_People_Have_Cancer.asp
2 Turner JA, Franklin G, Fulton-Kehoe D, et al.ISSLS prize winner: early predictors of chronic work disability: a prospective, population-based study of workers with back injuries. Spine (Phila Pa 1976). 2008;33(25):2809-2818.
3 NCCI, Workers Compensation 2012 Issues Report: https://www.ncci.com/Documents/IssuesRpt-2012-Paduda.pdf
4 Accident Fund Holdings 2010 Study
5 Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain:An educational aid to improve care and safety with opioid therapy (AMDG)
6 Eur Spine J. 2006 January; 15(Suppl 1): S82–S92. Published online 2005 December 1.