The high prevalence of chronic pain in the United Statescontinues to require discussion about what are really the mosteffective ways to help individuals with chronic pain while, at thesame time, limiting the risks for complications commonly seen withthe use of pain medications, particularly opioid analgesics.

These medications have dominated the chronic pain discourse overrecent years, not because of their effectiveness, but because oftheir potential side effects and risks of misuse and abuse,including overdose and death.

When approaching the treatment of injured workers with chronicpain, a strategy to better understand their individual risk factorsand a multifaceted treatment plan afford the greatest opportunityto bring about a meaningful reduction in pain, improvement infunction, and a decrease in medication-associated risks and costs.This type of strategy is best afforded when ten factors influencingchronic pain are considered.

1. Comorbid conditions

Comorbid conditions (or comorbidities) are medical conditionsthat either accompany or can affect the primary condition or injuryand, as such, can negatively impact a Workers' Compensationclaim.

Common comorbidities include obesity, diabetes mellitus, highblood pressure, heart disease, depression, insomnia, arthritis,tobacco use and alcohol abuse.

The prevalence of comorbidities associated with work-relatedinjuries is increasing, as can be seen through national trends, aswell as through individual, claimant-level chart reviews. The earlyidentification and treatment of comorbidities is essential tosuccessfully managing the care of an injured worker, but the issueof work-relatedness should also be acknowledged and appropriatelyaddressed for compensability purposes.

2. Body part and nature of injury

Injuries that result in Workers' Compensation claims can takemultiple directions with respect to outcomes.

It is not just the catastrophic diagnoses, such as amputation,spinal cord injury and traumatic brain injury that can lead tohigher costs and more medically complex claims. A study from theOhio Bureau of Workers' Compensation in 2010 found that commoninjuries, such as those to the lumbar spine, the shoulder, andcervical spine represent some of the highest costs per claim bybody. Being aware that certain injuries, based on the body partinvolved, are associated with higher costs allows for an earlierrecognition and a more proactive, hands-on approach to thosehigh-cost claims.

3. Plan of care

Establishing a patient-centered plan of care (or treatment plan)with specific, measurable and attainable goals is vital in treatingany illness and is a requirement for the workplace injury.

This allows the treating provider and the injured worker to worktogether in developing a realistic and mutually agreed upontreatment plan. Patient education on the natural history of theinjury, that is, how the injury typically heals over time, providesthe foundation for more practical expectations.

Furthermore, the plan of care should be well-documented by allactive providers, e.g., physical therapists, chiropractors, homehealth nurse, etc., and should be updated on a regular basis toreflect the most recent changes in the injured worker's medicalstatus. If treatment plans are not being regularly documented orupdated, they should be requested from the active providers.

4. Prescriber demographics

Demographics of the prescriber may have an influence on thetypes of medications prescribed, their dosages, and the timing ofthe prescription.

As an example, a study in the February 2009 issue of theAmerican Journal of Industrial Medicine analyzed thedifferences in the prescribing of opioid analgesics for acute,work-related low-back pain by geographic region. The study foundsignificant variation between states, with 5.7% of the injuredworkers in Massachusetts receiving early opioid prescriptionsversus 52.9% in South Carolina.

Similarly, a study in the 2012 issue of the Journal ofPain found that the counties having the highest prescribingrates for opioid analgesics were disproportionately located inAppalachia and in southern and western states. Therefore, beingaware of the geographic variation in prescribing patterns allowsfor an earlier identification of potentially high-risk claims basedon opioids being prescribed in a higher-risk region of the city,county or state.

5. Medication patterns

The timing and types of medications being prescribed may provideinsight into the path of a claim, especially when prescribing isoutside of best-practice standards or even the standard ofcare.

For instance, the prescribing of multiple long-acting opioidanalgesics is not appropriate and their presence significantlyincreases the risk of adverse events. The same can be said forclaims that involve multiple sedating medications that, whencombined, can contribute to lethal outcomes. The concomitantprescribing of opioids, benzodiazepines, muscle relaxants andsedatives is an example of a medication pattern that, onceidentified, should be intervened upon to decrease the risk ofoverdose.

6. Multiple prescribers and pharmacies

The use of multiple prescribers and/or pharmacies clouds thevisibility into the injured worker's medication therapy regimen andcan result in serious safety concerns, such as increasing the riskof dangerous drug interactions and therapeutic duplication.

Therefore, it is important to look for signs indicative ofcontrolled substances being prescribed by multiple prescribers,such as frequent emergency room or urgent care visits, ormedications being dispensed by multiple pharmacies. A study in theJune 2012 issue of Medical Care found that of patients inWest Virginia who were receiving prescriptions from four or morepharmacies, based on the state's prescription drug monitoringprogram, 55% were also receiving prescriptions for controlledsubstances from four or more physicians.

7. Medication monitoring

Medication-monitoring programs and tools help confirm thatinjured workers are adhering to their medication treatment plan andcan identify cases of possible misuse, abuse, diversion andfraud.

Methods for medication monitoring include pill and/or patchcounts and urine drug testing with the frequency of each beingbased upon the individual worker's level of risk.

National Workers' Compensation treatment guidelines, such as theAmerican College of Occupational and Environmental Medicine and theOfficial Disability Guidelines, firmly support and recommend thatregular medication monitoring is performed when opioid analgesicsare being prescribed.

The use of prescription drug monitoring programs, which trackprescriptions for controlled substances, is also essential.

Finally, medication agreements that outline the risks andbenefits of the medications being prescribed, the expectationsnecessary to maximize their safe use and consequences fornon-adherence to the agreement should be contained in the medicalrecord.

8. Nonpharmacologic treatment

The medical management of injuries should include more than justmedications as nonpharmacologic treatments can be extremelybeneficial, not only in pain relief but also in injury healing andin the prevention of further injury.

Examples of nonpharmacologic treatment options include physicalmedicine, heat and cold therapy, electrotherapy and cognitivebehavioral therapy. If nonpharmacologic treatment has not beenattempted in the past, it may be considered as there might beenough resultant improvement in pain and function to decrease atleast some of the injured worker's medications.

However, if pain medication usage remains the same or increases,the actual effectiveness and clinical appropriateness of thenonpharmacologic intervention may be lacking and further therapyshould be reevaluated.

9. Interdisciplinary care

Interdisciplinary treatment programs consist of multipleprovider specialties, such as physical therapy and chronic painpsychology, with the common objectives of decreasing pain,restoring function and improving quality of life.

Working toward common goals and collaborating on the creation ofthe most practical and effective treatment plan, specialists focuson their own area of expertise yet incorporate and build upon theskills and functional gains the injured worker has obtained fromother providers within the team.

This also serves as a valuable tool in assessing how medicationsare contributing to or hindering recovery. For instance, thephysical therapist on the team can provide useful feedback to thetreating physician about the effects any new medications are havingon the patient from a functional standpoint, that is, if thepatient is now more fatigued or somnolent as a result of recentlyadded medications.

For injured workers who have not shown any significantimprovements in pain or function with medications alone, aninterdisciplinary pain management program may be considered.

10. Effective and open communication

Communication between the injured worker and all professionalsinvolved must be well-coordinated and consistent. Care decisionsand clinical updates should be provided in a timely fashion to allhealthcare professionals, the claim manager and the injured worker.Any barriers to return-to-work, whether perceived or actual, shouldbe communicated to the employer to help level-set expectations andreinforce the process of developing a meaningful and realisticreturn-to-work program.

Finding the way to better outcomes

Identifying areas of risk and opportunity within a claimprovides a heightened level of awareness of just how “on-track” theclaim is for successful resolution.

Having a detailed road map of the most important factors toconsider in the treatment of chronic pain can help guide injuredworkers, clinicians, claims managers and employers to betteroutcomes more efficiently and with less obstacles and complicationsalong the way.

Robert Hall, M.D., is the corporate medical director atMemphis, Tenn.-based Helios, where he advises on evidence-based clinicaltherapy and rehabilitation. He is also a practicing physician andserves as an adjunct assistant professor of Physical Medicine &Rehabilitation at The Ohio State University Wexner MedicalCenter.