Psychosocial issues can influence chronic pain just as much as the biologic damage from an injury. Job or financial concerns, depression and anxiety, feelings of helplessness, family problems, enabling environments, substance abuse, and past physical or sexual abuse top the list of factors contributing to extended disability. Yet, workers’ compensation has traditionally downplayed psychosocial impacts on the claimant’s motivation to get better and focused instead on “medicalizing” treatment through physician visits, surgery, chiropractic care, a round of physical therapy, and especially drugs that, ironically, often make the situation worse.
About 19 percent of the medical cost of a workers’ compensation claim goes to pharmacy, and a disproportionate amount of those drugs—between 21 and 34 percent—are opioids. Although neither the Food and Drug Administration (FDA) nor any other treatment guideline recommends opioids for long-term chronic pain, 55 to 86 percent of claimants are taking them just for that, according to the white paper “Opioids Wreak Havoc on Workers’ Compensation Costs,” published by Lockton Companies’ Keith E. Rosenblum in August 2012.
Its research also found that one-third of claimants who start taking opioids are still on them after a year. Studies show that claimants who take opioids longer than 90 days are not likely to return to work. Patients using prescription painkillers for a long time typically suffer side effects, such as opioid-induced constipation, and experience related diseases such as kidney and/or liver damage from non-steroidal anti-inflammatory drugs.
There also are side effects from the medications prescribed to combat the side effects of the original prescriptions (for example, Nuvigil often is prescribed to wake patients from over-sedation). Ironically, opioids themselves can create an increased sensitivity to pain (hyperalgesia), thereby feeding the exact problem they are designed to solve. There needs to be a better way.
All patients bring psychological baggage—both good and bad—to their workers’ compensation injuries. Self-motivation, discipline, self-esteem, a sense of entitlement or victimhood, addictive behaviors, and a true desire to get better are factors in recovery.
Some claimants recover and return to work with medical treatment alone; many do not. Claims with unaddressed psychosocial issues are the ones that go off the tracks, drag on for years, and pile up costs. In workers’ compensation, “psych” is a four-letter word, but unless you consider it in the treatment plan, the chances of full restoration are reduced.
Workers’ compensation is just beginning to venture into the psychosocial realm with cognitive behavioral therapy (CBT). Its use is fairly new because of the deep-seated, industry-wide phobia of owning a psych claim. Payers fear never-ending psychiatrist visits and a new set of drugs and costs likely to accompany a psych diagnosis.
However, CBT is not the same as traditional psychotherapy. It is a psychotherapeutic treatment tool that does not produce an additional diagnosis. Plus, CBT is surprisingly affordable. Provided in-person or telephonically—both requiring extensive “homework”—it is usually limited to eight to 12 visits at $100-$150 per visit. In many cases, a payer’s total investment in CBT is less than the claim’s monthly drug spend.
The science and success of CBT are still evolving, but some studies and anecdotal outcomes show that it is a helpful tool, both in workers’ compensation and the healthcare industry in general. The focus is on patients who seem “stuck” in their treatment plans. CBT works on the concept that a person’s thoughts are the primary cause of that individual’s behaviors and feelings. Thought patterns—not circumstances, events, or other people—dictate the individual’s motivation and sense of well-being.
A psychologist or other therapist asks questions and poses statements to help patients open up and self-identify the psychological elements standing in the way of their recovery. In that way, CBT gets to the root of motivation issues. Some claimants hate their jobs or bosses and consciously or subconsciously resist returning to work.
Family members can be motivation-killers and enablers, as in a case where a claimant took so much Celebrex that he developed cirrhosis of the liver. He and his doctor wanted to reduce his opioid intake, which also was damaging his liver, but his wife resisted. She said he was easier to manage when sedated and had to be convinced that he would die prematurely before she acquiesced.
The belief that “I don’t deserve to feel better” churns the cycle of pain for some. Many pain patients have low self-esteem that stems from any number of factors, including: hyper-critical parents, absent or neglectful parents, past sexual or physical abuse, or other traumatic experiences.
The goal of CBT is for the patient to self-identify the issue through prompting by a professional and then correct fundamental errors in thinking, such as victimization, generalization, or catastrophizing.
To be clear, CBT does not cure motivation problems. Instead, this “talk therapy” helps patients identify barriers to recovery and replace negative thoughts with positive, empowering ones.
While CBT is provided as a standalone, it also figures prominently in functional restoration programs (FRP), which help patients work through psychosocial issues while detoxifying and participating in physical therapy and other exercise programs that increase their physical activity and functionality.
The whole functional restoration process enables individuals to acquire the knowledge and skills to make the behavioral changes needed to take primary responsibility for their own physical and emotional well-being after an injury. The ultimate goals of FRP and CBT are to implement lifestyle changes to manage pain that will last a lifetime
A functional restoration clinic should be multidisciplinary, preferably with an addictionology, orthopedic or pain management and rehabilitation (PM&R) specialty, a psychologist, and licensed physical therapist acting as a team to customize and coordinate treatment for the patient. Other treatments such as yoga, chiropractic, and biofeedback also can be included, along with services like vocational counseling. The best programs involve between 120-160 total hours of therapy.
An initial assessment should predict the person’s anticipated compliance, and the better functional restoration clinics have high denial rates (50 percent or more). Applicants may not be in good enough health, or they may lack the motivation to change. There’s no point in spending $30,000 on a program if the claimant refuses to work or accept responsibility for his health and outcomes. A pre-emptive CBT program can help weed out unmotivated patients.
Vital signs and physical capabilities need to be measured and objectively managed, and a baseline should be taken upon admission, followed by daily to weekly measurements and adjustments. Following patients upon discharge is just as important. Best practices show one year of follow-up, telephonic and/or in-person, achieves the best results in cementing lifelong change. Without consistent encouragement and personal instruction, claimants may relapse and turn back to drugs.
When selecting an FRP, access to an inpatient program or a strong alliance with a hospital or other inpatient detox facility can be critical. It cannot be overstated how vital the appropriate venue for detoxification is to overall success. Often, the treating physician who prescribed the drug cocktail in the first place is ill-equipped to develop a discontinuance strategy or provide the clinical oversight needed to wean patients off the drugs. Initial inpatient care may be needed if the patient is so addicted or dependent upon the drug cocktail and/or has other health co-morbidities that respiratory depression or cardiac issues could significantly complicate the weaning process.
Power of Yoga
Many functional restoration programs offer yoga, an interesting combination of physical and mental/emotional exercise. Studies show that it improves flexibility, strength, and balance on the physical side. Its focus on “centering” helps participants calm their minds and relax their bodies, relieving pain and giving them an empowering sense of control.
An Austin, Texas clinic saw such a positive response to its once-a-week yoga class that it expanded it to five days a week. Not only was patient satisfaction high, but also overall functional outcomes improved. Patients say it helps them cope with pain, improves flexibility, and increases their functionality, and they plan to make it a permanent part of their lifestyle. Yoga by itself is typically not sufficient, but incorporating it into the multidisciplinary functional restoration strategy can yield very positive results.
A holistic pain management approach can get runaway claims back on track. Weaning a claimant off an opioid-laden cocktail, which often does much more harm than good, is a great thing. Stopping the financial losses on a claim is a great thing. Returning a clear-headed, self-directed employee to work is a great thing.
The focus of workers’ compensation, when it was originally created over 100 years ago, was to return an injured worker to health and function and work as quickly as possible. Historically, it has been an insurance function; after all, workers’ compensation is part of the property/casualty industry. However, over time, workers’ compensation became part of the healthcare industry because restoring function and health is entirely related to the competency of the clinical and psychological strategies employed.
As evidence mounts that patient motivation is vital to actual recovery, it’s time for another transition from a “medicalization-only” mindset to a holistic approach that takes into account all of the variables that affect recovery. It’s time for all stakeholders within the system to think more broadly and be open to new concepts that comply with best practices and correspond with treatment guidelines.
In other words, maybe the injured workers are not the only ones that need to have their motivations adjusted.
Prevention Is Key
Keep claims from going off track in the first place by having treating physicians conduct risk management before prescribing opioids. Some questions include:
Has there been past substance abuse?
Is the patient receiving narcotics from other physicians?
How many other physicians are prescribing medications?
Is there depression or anxiety involved?
Did the claimant experience sexual or physical abuse (a prime predictor of addictive behavior)?
Will the patient submit to random urine drug tests?
Additionally, there are a number of screening tools to identify potential drug dependency and addiction. Some examples include:
For prior substance abuse: Diagnostic Criteria for Substance Dependence – DSM-IV from the American Psychiatric Association
For potential addiction/dependence issues: Opioid Risk Tool (ORT) or Screener and Opioid Assessment for Patients with Pain (SOAPP)
For depression: Patient Health Questionnaire (PHQ-9)
For general psychological analysis: Minnesota Multiphasic Personality Inventory (MMPI)
Unfortunately, most payers do not have a mechanism for reimbursing physicians for conducting a detailed risk analysis. This needs to change. Payers could assign a CPT code for physicians to use to conduct a thorough risk analysis. Spending a few hundred of dollars up front can save hundreds of thousands of dollars on a long-term, opioid-laden claim. The assessment would also shed light on the physician’s capabilities to manage a chronic pain situation.