Complex Pain Treatment Strategies

At the 2018 CLM / Business Insurance Workers’ Compensation Conference a panel discussed complex pain treatment strategies. The panel included:

• Melissa Dunn – Regional Claims Advocacy Leader, Arthur J. Gallagher & Co
• Steven Moskowitz – Senior Medical Director, Paradigm Outcomes
• Kimberly Vaughn – AVP Workers’ Compensation, Amerisure Mutual Insurance Company
• Lisa Hunter – Attorney, Pullin, Fowler, Flanagan, Brown & Poe, PC

Chronic pain claims often start with fairly common injuries that do not respond well to conventional treatments. They are highlighted by declining functional status, delayed recovery, high prescription utilization, high medical utilization, and intervention procedures being repeated without apparent benefit.

Psychosocial factors always play a role in delayed recovery. The Biopsychosocial module emphasizes disease outcome management based on the interaction between biomedical, psychological, and social factors. The psychological and social factors are ignored by traditional healthcare models that focus only on the biological factors.

Common elements of chronic pain patients:

• Catastrophizing – Seeing the worse in everything. My pain is a 10 all the time.
• External focus of control – Thought that the patient cannot make themselves better but need someone to do it for them.
• Fear avoidance – Movement hurts so people stop moving, which will only make the pain ultimately worse.

Strategies to help address chronic pain claims:

• Nurse case managers can help a lot. Making sure it is the RIGHT nurse case manager is even more important. That nurse can have direct interaction with the physical to discuss the treatment plan of the patient including the long-term goals.
• Adjusters should keep the file on a short diary to keep a close eye on how the claim is progressing. These claims get much worse with time.
• Pharmacy Benefit Managers will have resources to help identify inappropriate prescribing of medications.
• A chronic pain treatment program can be a life changer for injured workers. These intensive programs help patents learn to take control of their pain and develop comping skills. Some are hesitant to do these programs because of costs ($20-$30,000), but that figure is low when compared to a lifetime on opioid medications and all the complications that come with that.
• Spend some money to pay the physician to take the time to talk more with the patient and nurse case manager about the treatment plan.
• Most of these complex pain cases involve an injured worker that have a legitimate perception of pain. They are not faking it. You are not looking to fight their treatment, but are instead looking to find the appropriate treatment for their condition. Align with the injured worker and let them know you are trying to help them.
• Understand that pain is a natural part of life and does not usually go away. It also has a significant psychological component that is too often not addressed. Try to take the focus away from the pain and focus instead on the function. What tasks can you do? What tasks are you not doing that you want to be able to do? The focus is on behavior modifications, not suggesting that the injured worker has a “mental problem”.
• Cognitive Behavioral Therapy (CBT) is a proven method of helping to address chronic pain. It involves helping patients change their behavior and overcome their fears. Patients learn distraction techniques to keep them from focusing on their pain.
• Predictive modeling can help identify claims that are trending towards problems so an intervention can be done to change the course.
• If the employer has an EAP program, this can help to support the psychological and social challenges that are interfering with the injured workers’ recovery.