Clinical Treatment Pearls in the Everyday Pain Management of Workers’ Compensation Claims

1. Clinical Treatment Pearls in the Everyday Pain Management of Workers’ Compensation ClaimsDr. Jeff Hazlewood, PresenterKelly Burns, Moderator

2. Clinical Treatment Pearls in the Everyday Pain Management of Workers’ Compensation Claims Jeffrey E. Hazlewood MD June 18, 2014

3. Jeffrey E. Hazlewood, MD • Board Certification (ABPMR) in Physical Medicine and Rehabilitation • Sub-specialty Board Certification (ABMS) in Pain Medicine • Private Practice in Lebanon and Murfreesboro, TN with emphasis on: • Workers’ compensation injuries (acute and chronic) • Electrodiagnostic Testing • IME’s, Record Reviews in Pain Management • Assistant Medical Director (part time), Tennessee Division of Workers’ Compensation

4. OVERVIEW • Appropriate Pain Management Referrals • Psycho-social Aspects of Chronic Pain • Physical Therapy and Cases • Opioids and Cases • Causation and Cases • Clinical Pearls • Summary

5. What is Appropriate for Referral to Pain Management? • Need to consider primarily objective findings • Understand false-positive rates of MRI’s • Correlate anatomically with symptoms and signs • Understand appropriateness of chronic opioid usage (take into account new pain guidelines in making that decision) • Understand appropriate candidates for injections

6. What is Appropriate for Referral to Pain Management? • Don’t be afraid to say: “This makes no sense anatomically—you have to become active in your self treatment and not passively reliant on pills and shots!!!”

7. Inappropriate Referrals for Pain Management • “Narcotic seekers” – check state data bases! • Chronic lumbar strain with no objective findings • Axial spine pain for ESI’s and SCS placements • Malingering patients • Somatoform disorders

8. Goals of Pain Management • Assimilate all the data and : • Be fair • Be consistent • Be objective • Be Unbiased • Be cost effective • Use evidence based medicine

9. “MUSTS” in Pain Management • Recognize poor prognostic signs • Document thoroughly • Learn and understand causation analysis • Understand physiology of the injury and appropriate MMI date • Have excellent exam skills, knowledge of anatomy, and take the time to listen and examine the patient

10. “MUSTS” in Pain Management • Separate the legitimate “slow-healer” from the “malingerer” • Develop a “gut feel” • Develop a caring and dedicated office staff • Understand appropriate use of UDS’s • Don’t over-inject or “narcotic” • Communicate, educate, and continually re-evaluate current treatment program

11. “MUSTS” in Pain Management • SO… As you can see, correctly practicing pain management in W/C patients takes a lot of time, effort, patience, and the appropriate “team of players”

12. Psycho-social Aspects of Chronic Pain • Source: AMA Guides Newsletter Jan/Feb 2013 • Scientific studies have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentations • There often is not a causative relationship between structural changes in the spine and serious low back pain

13. Psycho-social Aspects of Chronic Pain • The most important risk factor for chronic pain in these patients appears to be personality disorders (especially, borderline personality disorder) • There often is not a legitimate anatomical target as a pain generator in these patients; therefore, surgery and interventional injections often become a major gamble

14. Psycho-social Aspects of Chronic Pain • SO……….. • Does it make more sense, then, to move away from the concept of chronic pain as a “thing” we can surgically remove, inject away, ablate, spinal cord stimulate, or narcotic, and instead: Pay closer attention to the individual presenting with these chronic pain syndromes

15. PHYSICAL THERAPY • Differences in basic and manual based PT (Not all PT’s are equal!!) • Manual needs: • Soft tissue restrictions • Facet problems • True SIJ problems • Mixed Etiologies; especially difficult spine cases • More important than opioids and injections • PT (not PTA) needed in complicated case

16. PHYSICAL THERAPY • Continuity of care is essential • Encourage Active approach not Passive • Understand where the best PT’s are in each location • Know when to stop PT and convert to HEP (ODG Guidelines??) • Don’t just order “Eval and Treat” !!

17. Case #1 • 55 yo F employee of a restaurant 20+ years who presented with axial LBP after slip and fall injury 12 weeks before presentation • Completed 8 visits of basic PT with no change • MRI negative for “structural injury”; + DDD • Husband recently been very ill; alot of “stress” • 10/10 pain; on narcotics; non-functional • Getting worse, not better

18. Case #1 • Exam: no neuro deficit; tearful; significant Waddell’s signs; very slow gait; took several seconds to rise from the chair • Diagnosis– ?Aggravation of DDD, ?Malingering, ?Pyschosomatic • Gut Feel: terrible prognosis, will have indefinite pain; “I can’t take another one of these patients!!! Why did I go into medicine as a career???”

19. Case #1 • BUT, she had some good prognostic signs: • Worked for same employer over 20 years • No previous claims per adjuster • Had not had hands on therapy • Was under a lot of stress with husband’s illness—was this a big contributor to her “worsening pain”? • She was articulate and had a look in her eyes of “help me please” • MRI was negative and physical exam showed no objective “damage” • Did she not deserve one more chance or should I just call it MMI (by the book) and rate her???

20. Case #1 • Plan: • Discussion about opioids • Counseling about good prognostic signs • Explained CBT concepts: “don’t give into pain” • Local TPI to “facilitate” a manual therapy approach

21. Case #1 • KEYS: • Refer to the right type of PT: a patient, hands on, soft tissue based therapist who could psychologically “work her through the pain” – 6 visit trial • Minimal emphasis on passive medications (I did prescribe a temporary anti-depressant)

22. Case #1 • Outcome: • Excellent • Completed 20 visits of PT to include aggressive strengthening • MMI 3 months after I saw her (6 months after injury) • Released with 0% WP IR • She was very happy (we hugged and teared up on the last visit!!) • I learned a lot from that patient (and I have been practicing almost 20 years!)

23. Case #1 • Take Home Points: • Don’t “cookbook and stereotype” patients • Understand there is a difference in therapy approaches (UR is sometimes wrong!!!!!!!!) • Localized TPI’s can help in the right circumstance (UR is sometimes wrong!!!!!!!!)

24. Case #1 • Take Home Points: • MMI status needs to be “fluid” • Be careful in interpreting positive Waddell’s signs • Don’t just assume the only treatment is pain pills!! • Communicate and develop a rapport with the adjuster

25. Case #2 • 55 yo M s/p MVA on job with neck pain referring to mid arm 8 months out from injury, no better • Had multiple meds, basic non-manual PT, MRI showing multiple disc bulges and HNP at C7-8 • PE: normal neurologically, no abnormal illness pain behavior, significantly decreased ROM; + facet load test

26. Case #2 • Dx: ???? Is that HNP symptomatic? • Referred for “pain management”; deferred permanent restrictions to me • 7% WP IR given (HNP with NVR symptoms)

27. Case #2 • Treatment: • Manual PT with facet joint mobilization, minimal non-opioid medications, no injections/rhizotomies • Outcome: • Pain free after 10 visits, MMI, regular duty, 0% IR, happy patient and no need for chronic “pain management”!! • BUT, he was a good patient who wanted to improve!

28. Case #2 • Take Home Points: • Again, not all PT is the same • Just because a patient is no better months after the injury doesn’t mean: • He’s “faking” • He’ll never get better • He needs chronic pain management; he needed and wanted just to be “fixed” • UR certainly would have denied further treatment with “PT” stating patient should be well versed with a HEP at this stage; one has to take it “case by case”

29. Case #3 • 45 yo F working as cashier at grocery store with “repetitive overuse injury” 10 years ago • W/U negative but underwent TOS release and no improvement  “pain management” • Failed good manual therapy with emphasis on facet mobilization, deep soft tissue work, stretching, and strengthening as well as TPI’s • Treated with chronic Ultram with so/so success

30. Case #3 • Had a data base profile problem (honest mistake) • BUT: I had had a rough encounter on the patient before her; I went into the room in a terrible mood and overly “chastized” her for her inadvertent mistake; my head nurse scolded me after she left and I felt terrible!!!

31. Case #3 • Next visit: • Patient told me had it not been for my “sweet nurse”, she would not have come back • Refused more Ultram • Asked for massage therapy approval • I explained nicely my concerns, UR mentality, etcbut said I would try to order 6 visits (out of guilt!)

32. Case #3 • Outcome: • After 15 visits of massage therapy and Yoga (which she went to on her own), she was 80% better and off drugs, working, and felt the best she had felt in 10 years! • On f/u 6 months later, still doing well using Yoga

33. Case #3 • Take Home Points: • UR would have never approved the massage therapy nor would have private insurance paid for it • Insurance adjuster fortunately approved it • The research studies are not always applicable to every patient! • I WAS WRONG!! (and I admitted it to the patient)

34. Case #3 • BUT: she was a good patient and wanted to get better without drugs • Maybe there is something to this “alternative medicine”!! • I’m blessed with good nurses who set me straight if I stray off course!

35. OPIOIDS • In 2011, TN had the second highest per capita RX rate for opioids in the US • Unintentional overdose deaths increased more than 250% from 2001 to 2011, exceeding deaths due to motor vehicle accidents, homicide, or suicide in 2010 • The number of babies born dependent to drugs who suffered from Neonatal Abstinence Syndrome grew 10 fold from 2001 to 2011(over 900 cases in TN last yr) • Worker’s compensation programs have seen the number of people treated for substance abuse increase five-fold in 10 yrs

36. OPIOIDS • Chronic pain is a significant health problem: 116 million US adults (> than heart disease, DM, and cancer combined) • Acute/chronic pain one of most common reasons for physician visits • 16% of W/C medical costs in TN are related to drugs (in US: 11%); 20-30% are opioids (#1: Hydrocodone) • Risk of overdose/death increases with higher dosages, especially if taking benzodiazepines • 75% of drug overdose deaths are unintentional!!

37. OPIOIDS • Goal of Pain Intensity Decrease: • 30% decrease in pain scores • 4/10 on VAS • Why the Love for Hydrocodone? • Can reduce anxiety, boredom, emotional pain, and increase self esteem • There is an “on and off” reward system that can backfire • Maybe this is why patient doesn’t want to stop the drug even when reported pain level is 8/10!!

38. OPIOIDS • Use of opioids for chronic cancer pain is clear cut • Use of opioids for non-malignant pain is not • No studies have shown long term use has reliably decreased the magnitude of pain or improved overall health and function • Studies have shown the many potential adverse effects and risks

39. OPIOIDS • On >100 mg MEDD • Adverse effects risk increases 9X • 80% of overdose deaths • On >200 mg MEDD • Mortality rates increase 5X • Overall addiction rates vary from 3% to 30% • My biggest battle is not with addiction, but tolerance

40. OPIOIDS • Positives: • “I feel better” • Some patients have improvement in quality of life and function • Negatives: • No research support for long term use • Addiction, tolerance, dependency • Opioid Hyperalgesia • Side effects: respiratory, sexual/endocrine, GI, urinary, itching, cognitive, emotional, legal, oral • Costs to the system and “society”

41. OPIOIDS • Facts: • As the number of prescriptions increase yearly, so do the numbers of adverse events (including unintentional overdose deaths), addiction/abuse, disability rates, and costs in healthcare • There is no data to support overall improvement in the long run of quality of life or function

42. OPIOIDS • Legitimate Questions: • Are these patients really better off with these drugs? • Is their function truly better? • Are the risks really outweighed by the benefits? • What are the costs to the “system”? • Are these patients really happy and content people????????? Do they “look” like they are happy?

43. OPIOIDS • Why do DRs not want to wean patients off opioids? • Patients are reluctant because of fear of pain and may not get them back if they agree to stop • DRs feel patient okay on these “if they help” • DRs don’t know how to taper and are afraid of potential withdrawal • DRs too busy to go thru “hassle”—a lot easier to “just write the prescription” and go to next patient

44. OPIOIDS • Keys in Treatment: • Must have objective basis for pain • Must see improvement in pain levels • Must see improvement in function • Must continually reassess benefit vs risk ratio • Must assess aberrant behavior, monitor for abuse

45. OPIOIDS • Keys in Treatment: • “Hold back the reins”!!! • “Don’t let the horse get out of the barn”!!! • “Treat for the marathon, not the sprint”!!! • “Rotate, not escalate”!!!

46. Case #4 • 50 yo F referred for IME with “CRPS” diagnosis • General body pain with “traveling RSD” X 10 yrs • Failed extensive treatment—multiple blocks (still undergoing these), PT, medications, spinal cord stimulator and peripheral nerve stimulator, CBT in-patient program • On 720 mg MEDD without misuse/abuse • Pain levels 7-8/10 and minimal function • 15 surgeries on one foot, 2 on other

47. Case #4 • Exam: • No objective signs of CRPS (no more than 1 or 2 documented in all the records to support dx) • Very pleasant and no signs of symptom magnification • Was not oversedated or ill-appearing

48. Case #4 • Legitimate Questions: • Did she really ever have true CRPS? • Does she need continued sympathetic blocks? • What does one do with this patient? • Is it appropriate to continue to use opioids and potentially escalate? • Do the benefits outweigh the risks?

49. Case #4 • Legitimate Questions: • Is she even opioid sensitive? Does she have hyperalgesia? • Is she addicted to opioids? • Should we worry about her being found dead some morning from unintentional overdose? (also on Soma, Valium, Prozac, and Ambien) • Are the concerns over the cost of the case important to consider? • My Opinion …

50. Case #5 • 40 yo F with chronic neck pain, hx of 1 level fusion 10 years ago; not working but functional • Never had problems with profiles, UDS’s, pill counts • Low opioid risk assessment scores • Always stable on Oxycontin 10 mg BID • She never felt she could do without it • Exam negative except myofacial tenderness