By Robert Goldberg, MD, FACOEM; Chief Medical Officer and Senior Vice President, Healthesystems
A good friend recently visited his primary care physician for treatment of back pain. He walked out with prescriptions for an opioid pain reliever, a muscle relaxant and an anti-inflammatory. While his problem was not claimed as a workplace injury, his prescribed treatment mirrors what has become the standard of care for injured workers having similar complaints on their initial visits — even though evidence-based medicine dictates otherwise. There are several reasons for this divergence.
The pendulum has swung in the last two decades from reserving opioids to treat the pain associated with surgery and cancer, to widespread use for acute and chronic pain, regardless of the source. The prevailing thoughts were that patients would rarely become dependent on or addicted to opioids, and long-term use was safe and effective. Unfortunately, the evidence for such conclusions was relatively weak and has since been refuted. As a result, society is faced with the fallout in terms of abuse, addiction and misuse that can lead to death.
More experience with opioids. More evidence. The reality is that injured workers frequently consult a primary care physician first – a practitioner who likely treats far fewer musculoskeletal injuries than an occupational medicine specialist does.
As an occupational medicine specialist who treated injured workers in private practice and academic settings, I saw firsthand the impacts of long-term opioid use when primary care physicians and other specialists treated patients who had not made significant functional improvements. It was common for those patients to be taking 8-10 prescriptions — some prescribed to treat the side effects of their opioid therapy. Evidence-based pain management guidelines had not been applied in their treatment.
Occupational medicine specialists have an advantage in that regard. I have had the rewarding experience of working with colleagues to create the original evidence-based guidelines adopted by the American College of Occupational and Environmental Medicine. Even more rewarding has been the opportunity to see the improved outcomes for injured workers, employers and workers’ compensation payers when the guidelines are followed.
I see great opportunities to better integrate evidence-based principles into injured workers’ treatment. We can start by sharing the pain management protocols that have emerged at the state and national levels with primary care physicians as part of the outreach efforts of pharmacy benefit managers.
What would the result look like? If evidence-based principles were routinely incorporated, physicians would prescribe only when appropriate and only the indicated medications. There would be consideration of whether adequate pain relief means no pain or a sufficient reduction to allow improvement in function or resumption of activities of daily living. Doctors would establish realistic expectations for pain management at the outset of treatment. Injured workers coping with chronic pain would have physical medicine, cognitive behavior therapy and/or holistic alternative therapies integrated into their treatment plans.
A better ending. The initial care would be quite different for my friend or any injured worker visiting a primary care physician for back pain. Instead of an opioid, he would receive a prescription for an anti-inflammatory. If there was no improvement or if pain worsened, five to seven days later his physician would screen for risks when considering opioid therapy.
A short trial of opioid therapy at the lowest dose necessary would be initiated only if indicated. The patient would be monitored for compliance, efficacy, adverse effects and functional improvement that enable him to resume a normal routine and return to work. Opioid therapy would be discontinued and alternative therapy started if no functional improvements were achieved.
The benefits of implementing an evidence-based approach to pain management are well worth the effort. Task your PBM with bringing together all stakeholders to collaborate on new strategies. The resulting enhancements to care will mean a better outcome for injured workers, employers and ultimately payers.
About Dr. Robert Goldberg
Robert Goldberg, MD, FACOEM, is board certified specialist in occupational medicine, and the Chief Medical Officer at Healthesystems. As a past president of the American College of Occupational and Environmental Medicine, Dr. Goldberg is recognized nationally as an authority on occupational medicine and musculoskeletal injuries. He has an extensive multidisciplinary background that incorporates 25 years of experience in a variety of roles. Dr. Goldberg has treated injured workers in private practice and academic settings and directed the University of California at San Francisco residency training program. He has also served as a researcher, consultant and corporate executive providing clinical direction to the development of evidence-based medical guidelines and workers’ compensation public policy initiatives.
Healthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while increasing the quality of care for injured workers. To learn more about Healthesystems or to sign up for newsletters, visit www.healthesystems.com or email firstname.lastname@example.org.
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