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While the necessity for opioids to treat some patients is not in dispute, medical professionals say these medications are being overprescribed, abused, and often ignored in the workers' comp system. A pair of highly regarded medical experts on the treatment of chronic pain will discuss prevention and mitigation strategies to address the problem.

"We're seeing a lot of chronic pain patients -- patients who are not progressing, not achieving resolution of their pain issues, not returning to work (either timely or at all) with escalating interventions for pain management, including repetitive injections, drugs, opioids, etc.," said Dr. Jacob Lazarovic, chief medical officer of Broadspire. "We're essentially seeing continued difficulties coping with the problem of pain."

"Physicians tend to take the easy route and prescribe opioids. They are not educated about opioid use. . . . They are seeing numerous patients a day. It's easy to write a script," said Dr. Steven Feinberg, chief medical officer of American Pain Solutions. "The other side of the coin is that the reimbursement structure for physicians does not really provide adequate time for cognitive services. Yet, it reinforces surgery and other procedures over spending time and learning about the patient, so we have a real conundrum."

An additional challenge that is often ignored is the diversion of opioids among injured workers. "A tremendous number of patients are not taking them as prescribed," Feinberg said. "Clearly, there is a problem in the way physicians are monitoring or, in some cases, not monitoring their patients' drug use," Lazarovic added.

Proper use of opioids. The use of opioids to treat pain can be beneficial -- if done properly, the physicians say. Medical professionals need to understand that these medications should be prescribed judiciously and based on simple things.

"One is less pain, another is increased function, and another is that there are either manageable or no side effects," Feinberg said. "The point being, there is no reason to prescribe them if only to 'narcotize' them."

One key to effective use of opioids to treat patients with pain is to ensure those using them are not at-risk patients. "We'll be talking about ways to identify and screen for potential problems," Lazarovic said. "There are tools such as using standardized screening questionnaires, urine monitoring, evaluating the progress of patients in terms of their return-to-work, and looking at pharmacy data to identify potential problems. Essentially, there is a whole set of tools one can use to identify the problem- or potential problem-claimants."

Non-opioid treatments. Understanding the effective use of opioids is important in helping those patients who can benefit from the short-term use of the drugs. However, many people are able to function with chronic pain without the medications.

Feinberg related the recent case of a 30-year-old firefighter who had fallen off a ladder and sustained two compression fractures to his spine. The worker was put on opioids and told he would never work again.

"I took him off [the opioids], put him in rehab, and sent him back to work," Feinberg said. "How is that possible?"

It is possible because of what the injured person believes. As Feinberg explained, the old adage that 'pain is all in your head' is not so far-fetched.

"Pain is in the brain," Feinberg said. "It's how we perceive things. We can help people get physically fit, not be depressed and get busy, and the pain doesn't seem to matter anymore."

Using evidence-based medicine to approach chronic pain can be very successful.

"In a lot of situations, the goal isn't to cure pain but to cope with pain and do it in a way that minimizes the effects of medications or other more invasive therapies," Lazarovic said. "There are a lot of tools that can be applied to achieve that goal."

Read more at the WorkersComp Forum homepage.

November 3, 2011

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