Integrated approach conquers chronic pain
Integrated approach conquers chronic pain
How to slash 80% of workers’ comp costs
If case managers and physicians gain a better understanding of what chronic pain is and how to prevent it, they could save thousands in workers’ comp costs, Stuart B. Krost, MD, FAAPMR, FAAPM, CIME, medical director of Heartland Pain and Rehabilitation Center in West Palm Beach, FL, told case managers at the 10th annual meeting of the Case Management Society of America held recently in Tampa.
"There are many nonmedicinal alternatives for pain management which are safe and often more effective long-term solutions to chronic pain," he says. "Some workers’ comp agencies and insurance companies spend up to 80% of their budget on chronic pain patients. When patients are appropriately evaluated and directed to the optimum treatment environment, the amount of doctor shopping and redundancy in care decreases and results in control of chronic pain syndrome and reduced costs."
A patient with pain symptoms that last for three months or more after injury is considered to have "chronic" pain, says Krost. He adds that the complex combination of signs and symptoms make chronic pain a syndrome.
Acute pain is a sensory reaction to an injury, he notes. "We all have different psychological capabilities for suppressing or magnifying pain. One person smashes a finger in a door and is able to suppress that pain. Another person smashes a finger in a door and thinks it’s the end of his life. When you notice that a patient has poor pain coping skills, that they are moving from a sensory component of pain to an affective component of pain, you have a problem ready to erupt."
Krost says that chronic pain syndrome consists of what he refers to as the "seven D’s." Those are:
• Duration of pain. Pain must be of at least three months’ duration.
• Dramatization of pain. "Patients in chronic pain will have as their goal to show you with their expression, their actions, or tell you with their words that they are in pain," he notes.
• Drug overuse. "I want to distinguish this from drug-seeking behavior. These [overuse] patients are looking for a magic bullet. If one medication doesn’t work, they want to immediately try another," explains Krost.
• Dysfunction in society. "These patients, especially workers’ comp patients with chronic pain, have trouble functioning in society. If you ask them what they do all day, they will tell you that they stay home, lie on the couch, and watch television."
• Deprivation of sleep. "This is key. A sleep history should always be included in a pain assessment," says Krost. "Chronic pain patients often fail to get restorative sleep which is important to the healing process. Sleep should always be addressed and treated with sleeping aids or antidepressants."
• Depression-reactive to pain. "This is not an organic depression, but rather a feeling of helplessness or hopelessness reactive to pain symptoms," explains Krost.
• Destructive suffering. "This is the cognitive aspect of pain. It’s a feeling of helplessness, as if there is nothing left for the patient but to end his life. The patient will tell you his wife has left him and he lost his job. This is the destructive aspect of the pain in the patient’s life."
Case managers should evaluate patients very carefully for pain and move quickly if they see signs that a patient is moving from sensory components of pain to affective or cognitive components of pain, says Krost. "If you have a patient who is not recovered or making adequate progress three weeks after an injury, I recommend that you look for a physician with strong pain experience.
"There is a time warp. If you identify patients who are heading for trouble and get them appropriate treatment before they hit this affective period, you can save a significant problem," Krost cautions. "If you miss that time warp between sensory pain and affective and cognitive pain, the patient becomes a different person. They have cognitive changes. It becomes harder to bring them back, and now you are really dealing with a long-term care chronic pain patient," he says.
An ounce of prevention
The most important thing for case managers to remember about chronic pain management is that if a chronic pain patient is treated the same as an acute pain patient, treatment will fail, notes Krost. "The goal of appropriate acute pain management is to adequately relieve pain symptoms. It’s also the key to preventing chronic pain," he adds. "Too many physicians are afraid of giving pain medications. Case managers can really help their patients by advocating for adequate pain medications."
However, if your patient does progress from acute pain to chronic pain, Krost says it takes an interdisciplinary approach that addresses the sensory, affective, and cognitive aspects of chronic pain to help your patient conquer their chronic pain and regain control of their life.
Case managers with chronic pain patients should look for a comprehensive four- to six-week pain program that combines both medicinal and nonmedicinal methods of pain management, says Krost. The program should begin with a comprehensive evaluation by each team member. After each discipline completes a full evaluation, team members should work together to develop an interdisciplinary treatment plan. He recommends that the following team members and treatments be part of a comprehensive pain program:
• Physical therapy. "The physical therapist should focus on functional restoration. The goal should be to prevent deconditioning and joint stiffness, facilitate mobilization, and improve strength and endurance," says Krost. "At the very least, the physical therapist should strive to prevent losses. It’s always easier to rehabilitate someone who has maintained than someone who has lost muscle tone and bulk."
• Vocational therapy. "These patients are cognitively affected," he notes. "Unless they see a light at the end of the tunnel, they are going nowhere fast. As a treatment team, the goal should be not only to relive pain, but also to provide that light at the end of the tunnel."
A chronic pain patient won’t go through the morning paper to read the want ads, says Krost. "The goal of vocational rehabilitation is to give the patient something to look forward to tomorrow other than thinking about his pain. The therapist puts opportunities in front of the patient and helps them set a goal and work towards it. It’s wonderful to see the light that turns on in these people when they start thinking about something they could do."
• Psychological counseling. The goal of the psychologist is to address issues that are essential for the patient to get well, says Krost. "I don’t think psychiatric care is necessary in most cases, but psychological counseling helps identify the barriers that might prevent functional restoration and helps each team member work on eliminating these barriers."
• Biofeedback. The psychologist also works with biofeedback specialists, notes Krost. "The most common question I get asked when seeking authorization for pain management plans is, Why do I need biofeedback?’ The answer is that unless the patient receives feedback, they don’t understand how they are reacting to their pain."
He notes that the simplest form of biofeedback is the visual feedback we receive when we look in the mirror each morning. "When you wake up in the morning, you don’t know how bad you look until you look in the mirror. Without that mirror, you don’t know that your hair needs combing."
From a medical standpoint, biofeedback specialists teach pain patients methods of relaxing, of causing changes in their body temperature, blood pressure, and heart rate. Patients are connected to electrodes and can see the positive results, says Krost. "They know if they are doing their exercises correctly. They can go home and do the same exercises and achieve the same positive results."
Krost notes that 12 to 14 sessions should be enough for a patient to have a good grasp of biofeedback techniques.
• Pain medication. The most common medications used in comprehensive pain programs are opioids, says Krost. The ultimate goal of any drug is to prevent progression or complications of disease, says Krost. "Chronic pain patients should be on long-acting, not short-acting narcotics. Short-acting narcotics create a roller coaster effect — the patient experiences a quick rise and a quick fall. Long-acting narcotics slowly rise and reach a steady state. There is a lesser chance of addiction with long-acting narcotics."
Many patients who have been taking short-acting narcotics don’t like the switch to long-acting medications, adds Krost. "They miss their highs. They may tell you they’ve had an allergic reaction to their new drug. I just ask them to come in and show it to me."
Although the risk of addiction to narcotics is very slight in chronic pain patients, Krost recommends that patients be closely monitored. "Patients should be required to sign a contract that says they will use the drugs only as prescribed and will not seek drugs from another physician or use unauthorized drugs with their pain medications," he says. In addition, Krost monitors patients on a monthly basis and conducts random urine screens.
Urine screens are a strong tool in the management of chronic pain patients, he notes. "I trust nobody. Not only do you want to make sure that your patient hasn’t taken any other drugs, but you want to make sure he’s taking his medications and not selling them."
Beware of block shops’
Krost cautions case managers to approach anesthetic approaches to pain management with skepticism. "Everyone is calling themselves a pain clinic these days," says Krost. "I call these anesthesia centers block shops.’ Getting an anesthetic block is not going to solve the problem in itself. The anesthesia is not curative. I do see some benefit from including an anesthesiologist in a comprehensive pain program. The anesthesia gives you a window of relief that provides a window for rehabilitation. You move the patient right into therapy — that’s the only good reason for anesthetic injections."
Case managers who are considering the benefits of an epidural injection for a chronic pain patient should ask whether the epidural adequately addresses the pain generator. "If your patient gets several epidural injections and each one only lasts one day, or [if he] receives no relief from the first or second injection, why consider a third? After two injections, if your patient has not been helped, it’s time to try another treatment."
Krost notes that chronic pain patients require coordinated medicinal and nonmedicinal treatments. "You have to treat all chronic pain patients psychologically because you have to motivate them. You have to encourage them and give them confidence that they are not going to die form their pain," he says.
Chronic pain patients play mind games with themselves, he notes. "The patient feels pain. Patients are concerned that there is a problem that there is an ongoing injury. As case managers, you have to get through to these patients. If you don’t click with a chronic pain patient, they won’t trust you and you will not be able to help them. They complain that nobody gave them enough time to tell their story, nobody listened, nobody touched them — you have to give these patients more."
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