By Mark Pew, Senior VP, Preferred Medical
Last week’s article “What’s Next for Pain – Pharma?” discussed how medications (“pharma”) can potentially be beneficial (even needed) by some patients (including injured workers) to help manage pain. That includes prescription opioids even as U.S. healthcare and workers’ compensation attempts to find the appropriate balance between too much and too little.
On the other hand, since most “painkiller” medications are palliative (per Google, “relieving pain without dealing with the cause of the condition”) they are often at best a stop-gap measure and at worst an instigator of iatrogenic illness (per Dictionary.com, “a medical disorder caused by the diagnosis, manner, or treatment of a physician”). That poor outcome is often evidenced by the introduction over time of additional medications to manage side effects and symptoms (inability to sleep, over sedation, constipation, anxiety, depression, hypogonadism and dry mouth are but a few) that can make matters worse, not better.
So if drugs do not work for everyone, what does?
Nothing, actually. Every individual is unique. The source of their pain is unique. Their body chemistry and how they metabolize chemicals is unique. Their past experience with pain (and life’s difficulties) is unique. Their level of fitness (physically, emotionally, psychologically, financially, relationally) is unique. Their number and severity of health co-morbidities is unique, as are the medications and supplements they may be taking for those conditions. Their social determinants of health in the past, right now and anticipated in the future are unique. In addition, their condition changes over time (usually for the worse), so even those variables become more variable. In other words, an individual is an individual.
That is why it is paramount to have the full spectrum of evidence-based modalities from which to choose to identify what will work for this specific person with this specific condition at this specific time. And why the selection needs to be consistently reviewed for efficacy and adjusted as appropriate. As work comp has begun to understand over the past few years, this means a BioPsychoSocialSpiritual approach that acknowledges and engages the whole-person. Given the industry’s historical reliance on a BioMedical model, some of these treatments are unfamiliar and even slightly uncomfortable within the context of a very explicitly defined work-related injury. This article is meant to continue the expansion of a conversation about a not-pharma approach in the journey towards understanding what’s next.
One example of a not-pharma approach is physical in nature. Some are passive treatments (i.e. somebody does something to/for the patient) like physical therapy, chiropractic, massage therapy, acupuncture or dry needling. This also includes medical devices and non-pharmaceutical treatments of various types. While PT and chiropractic have been part of work comp for decades the other modalities (especially acupuncture) are gaining wider acceptance by treatment guidelines, state regulators and payers. Other treatments rely more on the patient than a practitioner so they are focused on engaged self-management. Some examples are Yoga, Tai Chi, stretching, deep diaphragmatic breathing and RICE (rest, ice, compression, elevation). While the passive treatments have CPT codes for billing purposes, self-management techniques generally do not. The reliance on patient education and self-discipline requires a more creative approach by payers to advocate for and implement their use. More (but, unfortunately, not all) payers are realizing that addressing the body (Bio) in methods that do not require medications is a way to significantly reduce negative side effects and increase positive clinical outcomes. However, that is not the end of the story.
Another example of not-pharma options are psychological modalities like Cognitive Behavioral Therapy (CBT). Only within the past five years has the science proving the value of this kind of psychotherapy been enough to convince some (but, unfortunately, not all) in work comp to not just reimburse but actively advocate for the use of CBT. Other similar approaches, such as Motivational Interviewing and Acceptance and Commitment Therapy (with equal amounts of science to validate their efficacy), are still being explained and understood. Also growing into the conversation is the efficacy of mindfulness, the evolving acceptance of music/pet therapy and virtual reality, the proven success of peer coaching and a variety of other methods by which catastrophizing negative thought patterns can be reversed. This all leads to a greater understanding of neuroplasticity (per Wikipedia, “the ability of the brain to change continuously throughout an individual’s life”) and how the sensation of pain (body) is often less important than the perception of pain (brain) in being able to manage the pain. Work comp does not want “psych as a compensable diagnosis,” but ignoring the impact that thoughts and emotions have on managing pain has actually made it indirectly compensable by leading to an injured worker’s sub-optimal clinical outcomes. Early identification of PsychoSocial issues, and then proactively addressing them, is becoming more accepted by some (but, unfortunately, not all) payers as a strategy to increase positive clinical (and financial) outcomes.
Yet another example of not-pharma options are healthy choices. Why should work comp be responsible for educating an injured worker about making healthier choices? How can things like eating a more nutritious diet, proper hydration, developing a lifestyle of activity, properly managing stress, smoking cessation, or getting restful sleep be considered compensable? Should work comp actually pay for a nutritionist, gym membership, monthly subscription to a wellness app, or a sleep study? For a moment consider an alternative: An overweight, de-conditioned, stressed out, sleep deprived, dehydrated, vitamin D deficient, emotionally drained human being with broken relationships. They are likely not going to be very resilient. When managing chronic pain, resilience that comes from a balanced approach to life is key. Is there a work comp statute in any jurisdiction that requires this type of reimbursement? No. But aren’t statutes the bare minimum for what payers can do to help an injured worker return to work … return to function … return to life?
And, finally, don’t forget the last word in this whole-person treatment approach – spiritual. That is not the same as religion, although for some faith can be a key component. Instead, it is the innate search by all humans for ultimate meaning, purpose and significance that yields a transcendent view of life. Hopelessness is not just the opposite of hope. It is the killer of dreams and ambitions, function and life (sometimes literally). That lack of hope for the present and the future can drive poor outcomes. Almost everyone that is in active, successful recovery from an addiction, especially drugs and alcohol, shares a common need to pay-it-forward. Their recovery is more than just about them, but about helping others. In other words, a restoration of their purpose in life. That is why return-to-work and escaping the work comp system is so important to an injured worker as it gives them back what they thought they had lost.
Ultimately, the goal is to help that injured worker find the resilience, coping skills, discipline and self-management capability to live with their pain. To live their life in spite of their pain. To not just sedate the pain but to truly manage their pain – as opposed to the pain managing them. To be a highly functional human being. To understand that eradication of pain may not be possible. To acknowledge they may have a new “normal” because of the scope of their injuries and move on with their life.
So what is the “next thing” as we pivot away from prescription opioids as the default choice for managing all pain all of the time? Treat every individual as an individual by creating (and paying for) a whole-person strategy so they can manage their pain. Why? Because it is the right thing to do.
About Mark Pew
Mark Pew, Senior Vice President of Product Development and Marketing for Preferred Medical, is a passionate educator and agitator. Known as the RxProfessor, Mark is focused on the intersection of chronic pain and appropriate treatment, particularly as it relates to the clinical and financial implications of prescription painkillers, non-pharma treatment modalities and the evolution of medical marijuana. He is a strong champion for the workers’ compensation industry to #PreventTheMess and #CleanUpTheMess, movements he created to drive attention to the importance of individualized appropriate treatment for injured workers. Mark is a vocal advocate of the BioPsychoSocialSpiritual treatment model.
Mark serves on the IAIABC’s Medical Issues Committee and SIIA’s Workers’ Compensation Committee. In addition, he serves as technical advisor to regulators and legislators in 20+ jurisdictions on subjects such as drug formularies, treatment guidelines, Opioid Task Force initiatives, encouraging support of non-pharma treatment options and the medicinal use of cannabis. Mark received the WorkCompCentral Magna Comp Laude award in 2016 and the IAIABC’s Samuel Gompers Award in 2017.