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Pain drugs are risky. Consider the treatment guidelines of the American College of Occupational and Environmental Medicine, now the bible in California. They read, "Pain medications are typically not useful in the subacute and chronic phases [of injury] and have been shown to be the most important factor impeding recovery of function."

We need alternatives to addressing persistent pain complaints. But we're not engaged as we should be.

The report shows that you spend heavily on powerful pain killers, with brand names such as Oxycontin, Neurontin and Celebrex. Your report says you are paying for many brand prescriptions over less expensive generic substitutes. Also, there have been some fatal drug overdoses. Which of the following pain-drug proposals would you choose to make an impact on your incurred losses?

Aggressively enforce generic substitution rules; promote the availability of drug-detox vendors; screen for possible illicit usage and refer cases for investigation; promote among employers substance abuse/ EAP services; contact high-volume pain-med-prescribing doctors to discuss treatment philosophy; promote alternative, non-drugfocused treatments for chronic-pain issues; try to reduce estimated losses by increasing the forecast of fatal drug overdoses, thereby eliminating reserves for these claims; require prior approval and peer review of all narcotic prescriptions ongoing for more than 90 days; require claimants receiving narcotics to participate in a drug education program; and promote pain-management treatment guidelines.

Working directly with medical providers can pay off. It is labor intensive, demands a lot of specialized skills, and may not bring results in the current fiscal year. Thus, it's tempting to avoid it. Yet it may be the only means to address the problem in the long term. You cannot simply outsource this task entirely to a pharmacy benefits manager.

Some insurers are digging a big hole by acting as if pain medication is the only valid way to address chronic pain. Consider the pain-management statement stored at the American

Association of State Compensation Insurance Funds' Web site. It explains controls for dispensing of pain medication. It implies that chronic pain is a nail for which there is only one hammer: the drug cabinet. This is not just ineffective and in violation of ACOEM guidelines. This is equivalent to grabbing the loose football and scoring--against your own team.

Many occupational medicine doctors and seasoned case managers know quite a little about chronic pain among injured workers. I think we should listen to them. They tell me that chronic pain among injured workers is a jumble of pain perception, reinjury fear, secondary gain, deconditioning and poor coping. They tell me that medication-only solutions are often bogus.

So why do we keep on acting as if they work, and as if they're the only way?

PETER ROUSMANIERE, a Vermont-based consultant and writer, is the workers' comp columnist for Risk & Insurance®.

July 1, 2005

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