Getting Patients Back to Functionality: How to Succeed in Treating The Most Difficult Workers’ Compensation Cases

Reversing Chronic Pain, Delayed Recovery and Disability Syndromes

Tomer Anbar, Ph.D. CGP, CTC• Director, Institutes of Health, Global Pain Institute• Past Chairman, Pain Rehabilitation SIG, American Pain

Society• Treasurer, Musculoskeletal Pain SIG, International

Association for the Study of Pain• Founder and first Director, Scripps Interdisciplinary Pain &

Functional Restoration Program• Former Head, Unit of Psychobiology, National Institute of

Neurology, Research component World Health Organization, Mexico City

National Occupational Disability and Risk Management CONFERENCE & EXHIBITION September 9-10, 2019

From: Minh Q. Nguyen, DO, FACOEMVice President of Medical Operations - Pacific Zone (California/Hawaii)Concentra

Traditional approach works well for most WC cases

When red flags present, need a different approach i.e. biopsychosocial approach or integrated approach

How to select the right patient for this approach from a primary occupational medicine physician's perspective

Evidence to support this approach with ACOEM guidelines

Other factors to consider - complexity associated with cases

Red Flags

• 80-90% of injuries resolve with the occupational medicine clinician.

• For those 10-20% of chronic pain/delayed recovery cases that do not resolve as expected by the clinician, referral for a delayed recovery evaluation (= Behavioral Medicine/CBT evaluation) is recommended to identify and address red flags (see ACOEM & ODG).

20/80

20% of chronic pain/delayed recovery patients drive 80% of costs in Work Comp

Presentation Take Away

Chronic Pain and Delayed Recovery syndromes accounting for 80% of the overall cost of WC claims

are systematically reversablevia

Evidence-based, bonafide Biopsychosocial Interdisciplinary Functional Restoration Programs

Subacute Delayed Recovery

When the physician recognizes that the problem is persisting beyond the anticipated time of tissue healing, the working diagnosis and treatment plan should be reconsidered, and psychosocial risk factors should be identified and addressed. If necessary, patients should be directed to resources capable of addressing psychosocial barriers to recovery (MTUS, 2016).

Historical Factors for Delayed Recovery

Identifying Factors for Delayed Recovery

• Prolonged absence from work• Delayed reporting of injury • Job dissatisfaction• Workplace conflict [especially with

supervisor(s)]• Difficulties at Work [e.g. perception of

excessive job demands]• No modified work available• Chronic (DOI > 6 months ago?)• Pain distribution is non-anatomic or

described in a bizarre or atypical manner• Pain or dysfunction becomes widespread

involving other areas of the body• Severity of their medical symptoms and

pain • Experiences increased pain, or at the very

least, pain does not decrease over time

• Fails to benefit from any, or all, rational therapeutic interventions

• Legal representation or pending litigation• Previous negative experiences with

medical care and work-related injuries• History of delayed healing• Family history of disability • Family dysfunction• Involvement in financial / disability

dispute • Smoking• Alcoholism• Substance abuse• Victim of past abuse / emotional trauma• History of depression, anxiety• Fear of aggravation or re-injury • Multiple pre-existing and coexisting

medical conditions

Key Disability Factors

Researchers have found evidence that psychosocial variables are strongly linked to the transition from acute to chronic pain disability and that psychosocial variables generally have more impact than biomedical or biomechanical factors on back pain disability (Linton, 2000). Thus, when clinical progress is insufficient or protracted, the clinician should consider the possibility of delayed recovery and be prepared to address any confounding psychosocial variables (MTUS, 2016).

Importance of Early IdentificationRisk Stratification

• Patients not responding to initial or subacute management (see Clinical Topics section MTUS – 2016) or those thought to be at risk for delayed recovery should be identified as early as possible.

• Those at risk should be more aggressively managed to avoid ineffective treatment and needless disability.

Factors that help identify at-risk patients include:

1) Those unresponsive to conservative therapies demonstrated to be effective for specific diagnoses in others;2) The presence of significant psychosocial factors negatively impacting recovery;3) Loss of employment or prolonged absence from work (which has a high predictive value); 4) Previous history of delayed recovery or incomplete rehabilitation; 5) Lack of employer support to accommodate patient needs; and 6) A history of childhood abuse (verbal, physical, sexual, etc.) abandonment, or neglect (Adverse Childhood Experience, or ACE).

Delayed Recovery and Evaluation of Psychosocial Factors = Predictors of Chronicity

(MTUS, 2016)• Psychosocial factors have proven better predictors of chronicity

than clinical findings. Such variables/factors can and should be assessed; they include a history of abuse, anxiety, depression, fear-based avoidance of activity, catastrophizing, self-medication with alcohol or other drugs, patient/family expectations, medical-legal claims management issues, and employer/supervisor/worksite factors.

• Childhood trauma may contribute significantly to pain chronicity. A 2010 CDC Study of 26,000 Americans adults revealed that 60% reported childhood familial problems, 15% experienced physical abuse, more than 12% had been sexually abused, and nearly 9% had at least five ACE episodes, (CDC, 2010). Such events (per the ongoing ACE study) correlate with delayed recovery and poor outcomes from injury. Clearly, assessment of psychosocial factors is a critical element of patient evaluation.

When Chronic Pain and Delayed Recovery is Not Effectively Addressed

Chronic Pain is the Largest and Most Costly Health Epidemic in the U.S. and the World

100 Million people in U.S. suffer50 Million are partially or completely disabled1 in 5 are children1.5 Billion suffer worldwide

$635 Billion annual cost to U.S.

People Impacted byChronic Pain

Is more than the TOTAL affected by

StrokeCancerHeart DiseaseDiabetes

COMBINED11 Institute of Medicine (IOM)

12The materials contained herein are confidential and should not be shared without written consent from Global Pain Institute. Copyright © 2017 Global Pain Institute LLC. All rights reserved.

75 million baby boomers turning 60

Returning soldiers will add $340 Billion to the toll

Only 5 medical schools have required chronic pain course

17,722 additional clinicians needed now to meet demand & over 35K more needed

Magnitude & Growth of Problem

The Problem Continues to Grow

As the greatest global disease burden, chronic pain: • Affects 1 in 5 adults worldwide, • Is the #1 reason people go to the doctor• Is the most common cause of disability, and • Severely impacts quality of life.

There is limited or absent:• Comprehensive treatment• Holistic mobile care • Infrastructure• Standardized protocols• Medical training

13The materials contained herein are confidential and should not be shared without written consent from Global Pain Institute. Copyright © 2013 Global Pain Institute LLC. All rights reserved.

Sometimes my pain is unbearable too, the pain of not being able to do anything to help.

The pain has robbed me of the things I loved to do.

My pain has built walls around me and in me

14

Personal Impact of Chronic Pain

Some Phenomenology of the Chronic Pain Epidemic

Circulation?

CHRONIC PAIN SYNDROMEOK, Fix This!

The U.S. Congressional "Decade on Pain Control and Research" 2001-2011

On October 31, 2000, Congress passed a bill providing for the “Decade of Pain Control and Research,” which began January 1, 2001. With this designation, it was hoped that public and clinical attention and funding for research would be focused on the serious and under-recognized public health crisis of chronic pain.

The Status of the Chronic Pain Epidemic in 2000

• Over 70 million Americans were suffering from chronic pain.

• “Only 3 of the 133 medical schools in the U.S. offered courses on the treatment of chronic pain.”

10 years laterRelieving Pain In America

The 2011 Institutes of Medicine (IOM) study was mandated by Congress and sponsored by the National Institutes of Health (NIH).

10 Years Later

2000, only 3 of the 133 medical schools in the U.S. had courses on pain – (70 million sufferers)

2011, a decade after Congress passes bill Decade of Pain Control and Research, “only five of the nation's 133 medical schools have required courses on pain and just 17 offer elective courses” IOH, 2011 - (100 million sufferers)

IOM Recommendations – 10 Years Later

• IOM report calls on Medicare, Medicaid, workers' compensation programs, and private health plans to find ways to cover interdisciplinary pain care (Biomedical vs. Biopsychosocial approach).

• Individualized care (e.g. tailoring) requires adequate time to counsel patients and families, consultation with multiple providers, and often more than one form of therapy, but current reimbursement systems are not designed to efficiently pay for this kind of approach and health care organizations are not set up for integrated patient management (IOM, 2011).

IOM Recommended Solutions• Health care providers, insurers, and the public need to understand

that although pain is universal, it is experienced uniquely by each person and care –which often requires a combination of therapies and coping techniques — must be tailored, the report says.

• Pain is more than a physical symptom and is not always resolved by curing the underlying condition (biomedical). Persistent pain can cause changes in the nervous system and become a distinct chronic disease.

• Moreover, people's experience of pain can be influenced by genes, cultural attitudes toward hardships, stress, depression, ability to understand health information, and other behavioral, cultural, and emotional factors (biopsychosocial).

“Chronic Pain can be a Chronic Pain”

Managing Complex Cases

“She was managing all of

the complex cases; we think her

caseload got too heavy”

From a Biomedical to a Biopsychosocial Approach

Institute of Medicine (IOM) committee calls for coordinated, national efforts of public and private organizations to create a cultural transformation in how the nation understands and approaches pain management and prevention.

What Can We Expect?

• In 2011 IOM Report Called for Cultural Transformation of Attitudes Toward Pain and Its Prevention and Management

But…

• In 2000 Congress declared 2001-2011 the “Decade of Pain Control and Research” and…

Chronic Pain = Prescription Drug Abuse

the fastest growing epidemic in the U.S.

Implementing Solutions: Putting it all together

• Biopsychosocially-informed Early Intervention can prevent the development of chronic pain and delayed recovery

• For chronic pain syndromes and legacy cases, biopsychosocial interdisciplinary functional restoration can systematically reverse levels of chronicity and disability.

1. Evidence-based biopsychosocial approach – The Human, Clinical Approach - video

2. Individualized and tailored delivery system – The Use of Technology

3. Promoting a cultural transformation among the stakeholders – Promotion of Research, lifestyle, Education, Training and Implementation in the service of a “Cultural Transformation of Attitudes Toward Pain and its Prevention and Management” (Institute of Medicine).

Implementing TechnologyChronic pain is multidimensional. Addressing the pain epidemic requires a multidimensional approach. A PT platform can address the largest and most costly health epidemic by delivering value and relevance on a singular level.

expand access + improve quality + reduce cost

You Are Connected Live

A Pain Transformation Platform needs to transform & refocus health delivery to deliver an individualized, dynamic and tailored mobile health ecosystem providing relief to chronic pain sufferers.

Proven Clinical &

Evidence-Based

Treatment

Interactive Innovation

& Individual Behavioral

Design

Web / Mobile

Personalized care & self-directed healing through supportive,

engaging open ecosystem

Relief & RestorationSustainable Improved

Outcomes & Savings

28The materials contained herein are confidential and should not be shared without written consent from Global Pain Institute. Copyright © 2013 Global Pain Institute LLC. All rights reserved.

Biopsychosocial Functional Restoration in PracticeVideo Case Presentation

See www.institutesofhealth.org

• Jack• Referred by surgeon: Suicide plan in place. Handgun• 2 failed back surgeries, scheduled for 3rd surgery• Arrived on a walker. Spends approximately 23-24 hours a

day in bed.• Complaints: Chronic pain, disabled, sexual dysfunction,

incontinence, depression, addiction• Disabled 10 years• Outcome: Functional Restoration

Video: Chronic pain, Complex Regional Pain Syndrome, Opioid Addiction

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