Presentation on theme: "Clinical Treatment Pearls in the Everyday Pain Management of Workers’ Compensation Claims Dr. Jeff Hazlewood, Presenter Kelly Burns, Moderator."— Presentation transcript:
1 Clinical Treatment Pearls in the Everyday Pain Management of Workers’ Compensation Claims Dr. Jeff Hazlewood, Presenter Kelly Burns, Moderator
2 Jeffrey E. Hazlewood MD June 18, 2014 Clinical Treatment Pearls in the Everyday Pain Management of Workers’ Compensation ClaimsJeffrey E. Hazlewood MDJune 18, 2014
3 Jeffrey E. Hazlewood, MDBoard Certification (ABPMR) in Physical Medicine and RehabilitationSub-specialty Board Certification (ABMS) in Pain MedicinePrivate Practice in Lebanon and Murfreesboro, TN with emphasis on:Workers’ compensation injuries (acute and chronic)Electrodiagnostic TestingIME’s, Record Reviews in Pain ManagementAssistant Medical Director (part time), Tennessee Division of Workers’ Compensation
4 OVERVIEW Appropriate Pain Management Referrals Psycho-social Aspects of Chronic PainPhysical Therapy and CasesOpioids and CasesCausation and CasesClinical PearlsSummary
5 What is Appropriate for Referral to Pain Management? Need to consider primarily objective findingsUnderstand false-positive rates of MRI’sCorrelate anatomically with symptoms and signsUnderstand 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—youhave to become active in your selftreatment and not passively reliant onpills and shots!!!”
7 Inappropriate Referrals for Pain Management “Narcotic seekers” – check state data bases!Chronic lumbar strain with no objective findingsAxial spine pain for ESI’s and SCS placementsMalingering patientsSomatoform disorders
8 Goals of Pain Management Assimilate all the data and :Be fairBe consistentBe objectiveBe UnbiasedBe cost effectiveUse evidence based medicine
9 “MUSTS” in Pain Management Recognize poor prognostic signsDocument thoroughlyLearn and understand causation analysisUnderstand physiology of the injury and appropriate MMI dateHave 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 staffUnderstand appropriate use of UDS’sDon’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 2013Scientific studies have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentationsThere 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 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 presentingwith these chronic pain syndromes
15 PHYSICAL THERAPY Differences in basic and manual based PT (Not all PT’s are equal!!)Manual needs:Soft tissue restrictionsFacet problemsTrue SIJ problemsMixed Etiologies; especially difficult spine casesMore important than opioids and injectionsPT (not PTA) needed in complicated case
16 PHYSICAL THERAPY Continuity of care is essential Encourage Active approach not PassiveUnderstand where the best PT’s are in each locationKnow when to stop PT and convert to HEP (ODG Guidelines??)Don’t just order “Eval and Treat” !!
17 Case #155 yo F employee of a restaurant 20+ years who presented with axial LBP after slip and fall injury 12 weeks before presentationCompleted 8 visits of basic PT with no changeMRI negative for “structural injury”; + DDDHusband recently been very ill; alot of “stress”10/10 pain; on narcotics; non-functionalGetting worse, not better
18 Case #1Exam: no neuro deficit; tearful; significant Waddell’s signs; very slow gait; took several seconds to rise from the chairDiagnosis– ?Aggravation of DDD, ?Malingering, ?PyschosomaticGut 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 yearsNo previous claims per adjusterHad not had hands on therapyWas 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 signsExplained CBT concepts: “don’t give into pain”Local TPI to “facilitate” a manual therapy approach
21 Case #1KEYS: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 trialMinimal emphasis on passive medications (I did prescribe a temporary anti-depressant)
22 Case #1 Outcome: Excellent Completed 20 visits of PT to include aggressive strengtheningMMI 3 months after I saw her (6 months after injury)Released with 0% WP IRShe 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 signsDon’t just assume the only treatment is pain pills!!Communicate and develop a rapport with the adjuster
25 Case #255 yo M s/p MVA on job with neck pain referring to mid arm 8 months out from injury, no betterHad multiple meds, basic non-manual PT, MRI showing multiple disc bulges and HNP at C7-8PE: 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 me7% WP IR given (HNP with NVR symptoms)
27 Case #2 Treatment: Outcome: Manual PT with facet joint mobilization, minimal non-opioid medications, no injections/rhizotomiesOutcome: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 betterHe 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 #345 yo F working as cashier at grocery store with “repetitive overuse injury” 10 years agoW/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’sTreated 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 #3Next visit:Patient told me had it not been for my “sweet nurse”, she would not have come backRefused more UltramAsked for massage therapy approvalI explained nicely my concerns, UR mentality, etc but said I would try to order 6 visits (out of guilt!)
32 Case #3Outcome: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 itInsurance adjuster fortunately approved itThe research studies are not always applicable to every patient!I WAS WRONG!! (and I admitted it to the patient)
34 Case #3BUT: she was a good patient and wanted to get better without drugsMaybe there is something to this “alternative medicine”!!I’m blessed with good nurses who set me straight if I stray off course!
35 OPIOIDSIn 2011, TN had the second highest per capita RX rate for opioids in the USUnintentional overdose deaths increased more than 250% from 2001 to 2011, exceeding deaths due to motor vehicle accidents, homicide, or suicide in 2010The 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 OPIOIDSChronic 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 visits16% 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 benzodiazepines75% of drug overdose deaths are unintentional!!
37 OPIOIDS Goal of Pain Intensity Decrease: Why the Love for Hydrocodone? 30% decrease in pain scores4/10 on VASWhy the Love for Hydrocodone?Can reduce anxiety, boredom, emotional pain, and increase self esteemThere is an “on and off” reward system that can backfireMaybe 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 notNo studies have shown long term use has reliably decreased the magnitude of pain or improved overall health and functionStudies have shown the many potential adverse effects and risks
39 OPIOIDS On >100 mg MEDD On >200 mg MEDD Adverse effects risk increases 9X80% of overdose deathsOn >200 mg MEDDMortality rates increase 5XOverall addiction rates vary from 3% to 30%My biggest battle is not with addiction, but tolerance
40 OPIOIDS Positives: Negatives: “I feel better” Some patients have improvement in quality of life and functionNegatives:No research support for long term useAddiction, tolerance, dependencyOpioid HyperalgesiaSide effects: respiratory, sexual/endocrine, GI, urinary, itching, cognitive, emotional, legal, oralCosts to the system and “society”
41 OPIOIDSFacts: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 healthcareThere 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 stopDRs feel patient okay on these “if they help”DRs don’t know how to taper and are afraid of potential withdrawalDRs 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 levelsMust see improvement in functionMust continually reassess benefit vs risk ratioMust 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 yrsFailed extensive treatment—multiple blocks (still undergoing these), PT, medications, spinal cord stimulator and peripheral nerve stimulator, CBT in-patient programOn 720 mg MEDD without misuse/abusePain levels 7-8/10 and minimal function15 surgeries on one foot, 2 on other
47 Case #4Exam: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 magnificationWas 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 #540 yo F with chronic neck pain, hx of 1 level fusion 10 years ago; not working but functionalNever had problems with profiles, UDS’s, pill countsLow opioid risk assessment scoresAlways stable on Oxycontin 10 mg BIDShe never felt she could do without itExam negative except myofacial tenderness
51 Case #5Insurance company expressed concern over chronic opioids and asked me to weanOutcome:I agreed to do so but “fussed about it to my nurses”Had “gut feeling” it would not workRESULT: No change in pain off medI WAS WRONG!!!!!I learned a valuable lesson
52 Case #5 Take Home Points: Maybe there is something to this UR business!!!Maybe the studies are correctMaybe it is worth the “hassle”Maybe it is the “right thing” to do!!!!BUT, again, it takes the right kind of patient to have success!!!!!!!!!
53 Case #625 yo M with history of failed back surgery and severe “nerve damage”; 90% leg painExam: definite objective nerve damageFailed PT, ESI’s, SCS, multiple non-opioid medicationsOn chronic opioids, not working, fairly functional; mood becoming more irritableUDS problem X 2Weaned off MS Contin 30mg BID, MSIR 10 mg BID
54 Case #6 Outcome: Initially: Ultimately: Walked out cursing “I’ll never be back”“You just work for the insurance company!”Ultimately:6 months later came back smiling; hugged all of usWorking full time job; functional with kids; off opioids“I still hurt like hell, but I feel the best I’ve felt since the injury. Thank you for saving my life”
55 Case #740 yo M with history of 5 back surgeries and chronic back and leg painFailed PT, ESI’s, non-opioidsStill working and very functional on initially mg MEDDLow risk assessment, no abuse problems, “good guy”Stable dosages without escalation and pain levels 4/10
56 Case #7 UR requested weaning citing various reasons Weaned from 160 MEDD to 90 MEDD successfully but he said “I can’t come down anymore and work”We’ve weaned very slowly using adjunctive meds, “the weather”, and a lot of “blood, sweat, and tears”
57 Case #7 Take Home Points: He trusted me or we couldn’t have done it We weaned slowly and spent a lot of time explaining the risks and rationale of weaningHe was a smart guy and processed what I said
58 Case #7Take Home Points:I disagree that he should come down further in this case as long as he:Continues to have appropriate pain levels and functionHas appropriate UDS’s, profiles, risk assessments, pill counts, lack of aberrant behaviorAnd we continually reassess his “situation”
59 Case #8The patient where opioids do not work or are contraindicated (but patient has objective pathology)OR, UR has denied use of opioidsAND, UR has denied other treatment optionsWhat is one to do??!!Discharge? CBT? Formulated creams? OTC meds? More injections?
60 CAUSATIONThe doctor must utilize his/her past clinical experience and understanding of anatomy and pathophysiologyMust determine mechanism of injury and correlate with symptomsIs the association plausible biologically, clinically, and physiologically?Must know the “causation” literature (Dr. James Talmage’s book)
61 Case #943 yo M who complains of axial LBP with referral down RLE to knee after turning to pick up a part weighing 3# at workExam shows L3 sensory deficitMRI shows L2-L3 HNP to rightHas been treated thru system as “injury”Referred to me for IME with causation questions after “front line” doc referred to a surgeon (basic PT/NSAID hadn’t helped)
62 Case #9I opined legitimate pain with L3 sensory radiculopathy that matches well with MRIRecommended conservative treatment with an ESI since he is not improvingI opined this was not a work related “injury”; a surgeon who subsequently saw him stated it was “work related”Just because “the pain began at work” doesn’t mean “work caused the pain”
63 Miscellaneous PEARLS in Treatment Interventional Injection KEYS:Do not overinjectDo not shotgun injections – use the Hx and PEUse injections to facilitate PTExplain potential risks and benefits; decide togetherRemember the placebo effectPrimary goals of injections:Back to work and off the drugs!!!!
65 PEARLS In Asymptomatic LBP Patients, MRI findings: Disc degeneration and height loss: 91%Disc bulge: 64%HNP: 32%Extrusions: 1%Annular tears: 38%
66 PEARLS MRI’s in Low Back Pain: 25% of HNP’s resolve within 6 weeks 67% of HNP’s resolve within 6 monthsMost HNP’s are at L5-S1 (then L4-L5)Per JAMA 2013 article, more than 50% of MRI’s for LBP are ordered inappropriately (50% by spine surgeons!)
67 PEARLS Opioid Induced Low Testosterone LA opioids have 5X chance vs SA opioidsEspecially present on >100 mg MEDDMales are more susceptibleEffects reversible within a few weeks of treatmentSymptoms:Decreased libido, osteopenia on x-ray, fatigue, decreased muscle mass, weakness, depression, poor pain control, hyperalgesia, increased fat deposits
68 PEARLS NSAIDS have definite risks: GI, renal, CV (HTN, MI, CVA) 1 in 5 patients have endoscopic ulcers (no pain)1 in 70 patients have symptomatic ulcers1 in 150 have clinical bleedsIn especially the older population, are they safer than opioids?
69 PEARLS Drug Interactions: Hydrocodone metabolism can be impeded by use of Sertraline and ParoxetineHydromorphone may be preferred in renal impairment over MorphineDon’t use Tizanidine and Ciprofloxacin togetherDon’t use Hydromorphone if have sulfa allergyDon’t use Duloxetine with Phentermine
70 PEARLS CRPS Remember the rarity of the diagnosis Use objective, not just subjective, especially in medico- legal casesTPBS best obtained around 6 months after diagnosis to improve sensitivity and specificityDon’t forget biphosphonate trialStrong opioids usually ineffectiveWorse outcome if cold extremity and sensory deficitWeakness and stiffness usually persist whereas other objective signs often improve over time
71 PEARLSAll treatments of acute and chronic LBP are much less effective than natural history and non-specific factorsThe association of chronic LBP with DDD is weak and is much more associated with: psychological and social distresses, legal disputes, altered pain sensitivity, and drug dependency and abuse issues
72 PEARLS Concept of Cognitive Behavioral Therapy “Internal” focus vs “External” focusPain catastrophizing is linked to fear avoidanceFear avoidance leads to “disuse syndrome” which further worsens the pain problemDepression and disuse decreased pain tolerance promotes “pain experience” and worsening muscle activity viscious cycle/chronic pain syndrome
73 SUMMARY“Pain Management”, as you see, is much more complicated than just injections and narcotics!Emphasize not just “Is the pain better?” but instead evaluate objective findings, opioid risk assessment tools, aberrant behavior, risk:benefit ratio, functional gains with useAre these patients after all this “pain management” really happy people????????
74 In Closing:The essence of chronic pain management, in my opinion, is best summarized by the following quotes:
75 Sir William Osler (1849-1919) “The good physician treats the disease” “The great physician treats the patient who has the disease”“It is more important to know the patient who has the disease than about the disease the patient has”