PAIN MANAGEMENT BEST PRACTICES and CORE COMPENTENCIES Provided by Safety National
Pain management means many things to each of us; the purpose of this best practices document is to better explain what pain management encompasses and what to look for when managing a pain management patient. Pain can be a simple ache or a debilitating experience that takes over one’s life. It can require a few interventions (medication and exercise), the utilization of an outpatient multidisciplinary team or even inpatient rehab. Pain is difficult to understand as everyone’s perception of it is different. The following information is a guide to be used by claims technicians in the management of the pain patient. The goal is to provide information to the claims adjuster on pain management standards that will assist in proactive management of the pain patient. Early identification and intervention of pain is essential. The information in this document begins with the initial findings and treatments and flows to the more invasive and costly procedures that arise in the management of a pain patient. They include:
o Physical Therapy o Occupational Therapy o Work Hardening
o Psychology o Rehab o Complementary and Alternative
ASSESSMENT OF A PAIN MANAGEMENT PATIENT Initial Assessment Findings - This is a comprehensive evaluation of the patient at the first visit and should include, but is not limited to, the following:
• History and Physical – includes mechanism of injury, past medical history,
current complaints and the physical assessment of the patient (which should include subjective and objective findings)
• Identification of any co-morbidities and/or psychological issues – some co-
morbidities can increase the treatment and recovery on a claim. These can include, but are not limited to, diabetes, obesity and depression.
• Description of pain – location, onset, intensity, duration, quality, aggravating
and alleviating factors, effect on function and quality of life.
• History of prior drug/alcohol abuse – helps the provider and adjuster understand
what alternative treatments may need to be considered.
• Employee’s goal for pain control and response to prior treatment – this gives the
provider and adjuster an understanding of what the individual’s expectation is regarding his or her pain management program.
On-going Assessment Findings - should include the following:
• Ongoing physical exam – includes current complaints and physical assessment.
• Description of pain – same as above.
• Assessment of how current treatment is working – this is important as it helps the
adjuster identify red flags if nothing seems to be helping.
• Management of any side effects (if appropriate)
A thorough assessment helps the treating physician, individual and adjuster understand the many variables involved in the management and treatment of a pain patient. It communicates all issues, which allows full participation in the treatment and care of the individual. It should identify any co-morbidity or red flags that help the treating provider, adjuster/analyst develop a plan of action to facilitate improvement of the individual’s functional restoration and reduce pain and the costs associated with pain management. If expectations are not available early on in the claim or in follow-up visits, it is advantageous for the adjuster or nurse to communicate these to the treating physician and build the rapport to facilitate return to work and full participation. This information is within the standard of care for practitioners of pain management; therefore, you are not asking for anything outside the norm.
Without a thorough initial and ongoing assessment from the provider, the adjuster will be challenged to make important decisions on their claim regarding causal relationship, reserves, lost time, medical management and possibly permanency issues. PHARMACOLOGY
There are three classifications of medications used in the treatment of pain management: non-opioid analgesics, opioid and adjunctive.
• Non-opioid analgesics are medications used for mild to moderate pain. These are
NSAIDs (non steroidal anti-inflammatory drugs) such as ibuprofen, acetaminophen and aspirin.
• Opioids are narcotic medications that act on the central nervous system to relieve
pain. Examples include codeine, morphine and Oxycodone.
• Adjunctive medication is used in conjunction with other medications to increase
the changes of relief of pain (anti-depressants, antiepileptic agents and topical therapies). These will be reviewed in detail below.
When medications are prescribed, the standard protocol would be to start with lower level medications, which have less side effects and a lower risk of addiction, before moving up to heavier meds such as opioids. When a physician prescribes medications early on in treatment it should involve non-opioids and may include an adjunctive therapy and then move toward opioids. Non-opioid Analgesics
Non-narcotic medications are the first line medication for treating any strain/sprain injury. They usually consist of non-steroidal anti-inflammatory drugs (NSAIDs) or other medication such as acetaminophen. The goal of these medications is to reduce inflammation, thus reducing pain and increasing function. Sometimes a steroid (such as a medrol dose pack) may be prescribed if the NSAID is not helping to facilitate reduction of the inflammation. By prescribing non-opioid medications early in the treatment plan, the patient’s inflammatory process will ideally be reduced and he or she will have increased function. If narcotics are prescribed early in the treatment, the adjuster should consider placing more resources on the claim, such as a nurse case manager to intervene and oversee the course of treatment. Opioid Medication
The consensus of the members of the American Pain Society is that the primary goal in treating chronic pain patients with opioids is to increase the level of function rather than just to provide symptom relief. (ACPA Consumer Guide to Pain Medication & Treatment).
Opioid medication is utilized in control of moderate to severe pain. These can be taken orally, through IV, injection or transdermal (patch). Opioids are morphine-like substances used to relieve pain. There are numerous opioids available and each is unique in its potency, speed of onset and duration. They are formulated as short or long acting.
• Short-acting opioids are called immediate release (IR) because they exert a rapid-
onset but short lived therapeutic effect (starts working in 15-20 minutes and lasts about 2-4 hours). These may be utilized for acute pain or breakthrough pain (examples: Percocet, Pecodan, Combunox, Lorcet, Lortab, Vicodin).
• Long-acting are described as sustained, extended or controlled release (SR, ER or
CR respectively). They exert a slower on-set but provide prolonged, steady pain relief (8-12 hours of pain relief). These are the opioid treatment of choice for patients with moderate to severe chronic pain (examples: MS Contin, OxyContin, Duragesic, Methadone, Opana).
Opioid use for chronic pain can help some people; this requires careful review of the medications and its therapeutic effect on the patient. If the patient continues to rate his or her pain as high, is unable to complete ADLs, has adverse side effects and/or appears to show signs of abnormal drug behavior, then other alternatives should be explored. Of note, prolonged use of opioids may result in problems including tolerance, hyperalgesia, hormonal effects, depression, impaired sleep patterns and suppression of the immune system, all of which may impair functional recovery. Ideally, when an opioid is prescribed, the treating provider and the patient should enter into a Drug Contract/Agreement, this can be initiated by the treating provider or the adjuster/analyst can ask that one be initiated. Contracts lay out the expectations of the patient and the doctor and can include random drug screens, pill counts and if non- compliant the treating provider might cease treatment. Although these are not done routinely by physicians, it is suggested to ask the provider to establish a contract with the patient. The goal is to ensure compliance and keep everyone informed and accountable. If a Drug Contract is not welcomed by the treating physician, then a request for a random drug screen should be made of the treating physician to determine if the patient is compliant with the medication protocol and treatment plan. Again, this is a tool that holds everyone accountable. Adjunctive Analgesics
Adjunctive Analgesics in pain management are medications where initial use is not for pain, although used together with non-opioid or opioid medications they facilitate positive response. Examples of some adjunctive analgesics include: anti-depressants (Amitriptyline, Despramine, Imipramine, Nortiptyline, Duloxetin), anticonvulsants (Carbamazepine, Gabapentin, Pregabalin), and other agents (Lidocaine Patch, Clonidine, Capsaicin cream).
• Antidepressants help by increasing levels of chemicals (norepinephrine and
serotonin) at nerve endings to strengthen the system and inhibit pain transmission. They can also effectively reduce anxiety and improve sleep without the risks of habit-forming medications. Norepinephrine antidepressants seem to have better pain relieving capabilities than serotonin.
• Anticonvulsants medications have been found to be widely effective in various
• Other agents such as sodium channel blocking and oral anti-arrhythmic agents
have been shown to be effective in some uncontrolled studies for neuropathic pain. Topical agents such as Lidoderm are absorbed through the skin for neuropathic pain relief. Muscle relaxants have limited efficacy in chronic pain but may be used to treat acute flare ups.
Adjunctive Analgesics are utilized in chronic pain management and require some adjusting to find the correct medication and dosage. They provide pain relief with fewer side effects and increase functionality. Drug Utilization Review
Drug Utilization Review (DUR) is used by the adjuster to help better understand if the claimant is receiving appropriate medications in the management of his or herchronic pain. It is usually completed by a PharmD who reviews the interactions and chemical processes involved and then makes recommendations as to appropriateness of medications. When a claimant is on multiple narcotic and adjunctive medications and/or has co-morbidities which may affect the efficacy of the medications, a DUR may be appropriate. When the DUR is completed, it should be shared with the treating provider via the vendor who did the workup, or a letter from the adjuster to the provider asking for a change in the treatment plan if warranted. Treating providers will be most likely to respond to the PharmD over a letter from the adjuster. REHABILITATION
• Physical Therapy – treatment of musculoskeletal and neuromuscular problems
that affect one’s abilities to move and function in his or her daily life.
• Occupational Therapy – treatment of conditions that are mentally, physically,
developmentally or emotionally disabling to improve the ability to perform tasks in daily living and working environments.
• Work Conditioning/Hardening – highly structured individualized treatment
program designed to return a person to work.
• Functional Capacity Evaluation (FCE) – A series of tests measuring physical
strength, range of motion, stamina and tolerance to functional activities, including lifting and carrying. These tests can be used to evaluate work tolerance, and the necessity for work restrictions.
Rehabilitation plays an important role early in the claim and throughout the life of the claim. Early on in the claim it provides the patient with treatment in order to return to pre-injury status in conjunction with medications and follow-up with his or her provider. Later, it is utilized to increase functional restoration and allows patients to be active participants in their treatment program. Depending on the injury, physical therapy or occupational therapy should be ordered early on in the claim, especially if the patient is not working. Once the patient has reached an end point of treatment, work conditioning/hardening may be ordered to help condition the patient to return to work. Usually an FCE will be ordered to determine the patient’s work capabilities and if a return to work is possible. In chronic pain management, there will most likely not be work conditioning or an FCE, as the goal of rehab at this stage is functional restoration. Rehab in the chronic pain patient utilizes a Multidisciplinary Functional Recovery Team approach; it will include PT, OT and other disciplines (see Multidisciplinary Functional Recovery Program for more detail). INVASIVE INTERVENTIONS Injections
• Epidural Steroid Injections (ESI) – used for pain relief in selected patients with
• Facet Joint Injection – used for symptomatic relief of facet-mediated pain.
• Trigger point injections – used to alleviate myofascial pain syndrome.
• Nerve and nerve root blocks (lumbar sympathetic blocks or stellate ganglion
blocks) – used as component of multimode treatment of CRPS/RSD. Should not be used long-term for non-CRPS/RSD neuropathic pain.
• Medial branch blocks – used in the treatment of facet-mediate pain.
• Radiofrequency Ablation –blocks the nerves that supply impulses to facet joint.
Does not relieve all back pain but pain associated with facet joint arthritis. Nerves regenerate over time so this is not a permanent procedure and may need to be repeated.
These are a few of the many injections that may be utilized in pain management. They can be used diagnostically or therapeutically. These procedures are used to alleviate or reduce pain and should be used in conjunction with a comprehensive treatment plan. Each injection has a different purpose. There is a limit to the number of injections an individual should undergo and it is determined by the kind of injection. The treating provider should document the outcome of the injection (i.e. relief of pain complaints and duration of this relief). If the individual appears to be receiving a number of injections without relief of complaints, alternative treatment should be considered. Implants
• Spinal Cord Stimulator, Peripheral Nerve Stimulator – small device implanted
under the skin that sends electrical signals to the spinal cord to relieve pain.
• Intrathecal Medication Delivery System (Pain Pump) – pump implanted into the
body, which is filled with narcotic medication delivered directly to the spinal cord or nerve roots to provide pain relief.
Implants are used when conventional and less invasive procedures have failed. They require a psychological evaluation prior to a trial phase. The adjuster should obtain the evaluation with a qualified and objective provider to acquire an unbiased assessment, which will determine success or failure of the device if or when it is implanted. It is recommended the adjuster thoroughly research the provider who will be implanting the device to determine the likelihood of a positive outcome on this expensive, and often times unsuccessful, treatment option. In order for an implant to be successful, the patient should report at least 50 percent pain relief during the trial before a permanent pump is implanted. Anything less would most likely not produce the desired pain relief.
1 Review of literature finds that Spinal Cord Stimulators are moderately successful in relieving pain and further studies are needed.
MULTIDISCIPLINARY FUNCTIONAL RECOVERY PROGRAM
A Multidisciplinary Functional Recovery Program (MFRP) is a team approach to the care and treatment of an individual in chronic pain. It utilizes a number of specialists using multiple modalities working closely together to provide the individual with the educational tools and resources to manage his or her pain and provide a functionally improved quality of life. An MFRP can include, but is not limited, to the following specialties: psychiatry, physical medicine, social work, physiotherapy, occupational therapy, nutrition and alternative treatment. It is usually an intensive all-day program (programs vary from 4-12 weeks). It entails a detailed assessment of the individual with four goals in mind: functional, psycho/social, medication management and on-going/relapse education. These programs can be very effective if the individual is receptive to participating in the program. On occasion, detoxification may be required or needed prior to initiating this program. The goals of the program are to:
1. Reduce the employee’s dependency on medications. 2. Develop coping mechanisms for dealing with pain. 3. Provide a sense of independence and ability to provide a productive life.
Psychology Sometimes it may be necessary to utilize a psychologist/psychiatrist in management of chronic pain clients in order to help them develop and understand the various treatments to manage their pain in a healthy way. Early referral to a reputable psychiatrist/psychologist should provide positive outcomes in pain management of chronic pain patients. Depression is often seen in chronic pain patients in their complaints of pain, having a higher impact on quality of life. Therefore, treatment of the underlying depression is necessary to bring the complaints to a more reasonable and functional level. Cognitive-behavior therapy (CBT) is an approach that may be needed in the treatment of the chronic pain patient. The goal of CBT is to improve physical function, reduce disability, reduce pain related to fear/avoidance and reduce psychological distress and depression. There are various types of CBT available, including cognitive techniques and relaxation therapies.
¾ Cognitive Techniques – based on the notion that how one thinks about himself or
herself and the future can have a major impact on his or her mood, behavior and physiology. It helps patients notice and modify the negative thought patterns that increase pain, stress and pain behavior and avoidance activity. Some examples are:
o Cognitive restructuring – involves several steps that help modify the way a
patient views pain and his or her ability to cope with pain.
o Problem-solving – Four-step approach:
Identification of the problem Generation of possible solutions to the problem Prioritization of the solutions Implementing a single strategy and determine effectiveness.
¾ Relaxation Therapies – aimed to lower general arousal and promote a state of
relaxation, which is believed to reduce levels of anxiety and enhance pain tolerance. These therapies allow patients a greater ability to expand their coping strategies for pain management. Some examples include: biofeedback, meditation, imagery, diaphragmatic breathing, progressive muscle relaxation training and hypnosis.
Rehabilitative Early on in the work injury, some physical therapy should be ordered for the patient. This provides ongoing treatment for the work injury and keeps the individual active in his or her care. The benefit of therapy is two fold; it keeps the individual active in care and also provides a second set of eyes assessing the patient. The key here is to make sure the individual is seen by a therapist who is familiar with workers’ compensation and understands the expectations of Return to Work. Early intervention with therapy will keep the individual active and engaged in his or her recovery. It allows for ongoing assessment of pain issues so the adjuster/analyst can intervene early in the treatment to obtain the best outcome for the individual. Complementary and Alternative Complementary and alternative treatments are used more frequently today than in the past. Some examples of these types of treatments are acupuncture, massage, chiropractic, nutraceutical/botanical, energy therapy and non-Western therapy (Tai-Chi). This treatment can provide a sense of wellbeing and wholeness. It is not a cure but an ongoing process in which the individual becomes more aware of his/her personal role in his/her health. In the workers’ compensation environment, this treatment is not a first line of treatment. It would best be utilized once the individual is permanent and stationary and used for ongoing maintenance.
If you would like recommendations for multidisciplinary recovery programs in your area,
Below are some red flags to be aware of while managing the pain management patient. If you should identify any of these, then intervention is recommended. This can be as simple as a letter or call to the treating provider or placing a medical manager on the claim to follow-up or attend the next appointment.
• Narcotics prescribed early in the claim
• One or more prescribers of narcotics
• Frequent visits to emergency rooms • Unresolved pain complaints with changes in treatment
• Pain catastrophizing (pain that is exaggerated or blown out of proportion) • Unrealistic expectations of treatment and outcomes
• History of prior drug/alcohol abuse • Long-term pain management patient without a drug contract
• Physician not willing to initiate drug contract or random drug testing
Behaviors that may indicate opioid misuse:
• An overwhelming focus on issues relating to their opioid medication during office
• A pattern of early repeat prescriptions, escalating opioid requirements, or both,
without any evidence of acute change in the patient’s medical condition.
• Making multiple telephone calls or visits to the clinic to request more opioids or
problems associated with the opioid prescription.
• A pattern of prescription problems for a variety of reasons that may include lost or
spilled medication or stolen medications.
• Obtaining alternative sources of opioids from other doctors, hospitals, family
When is it appropriate to refer a patient to a pain management program?
• Pain syndrome or unclear diagnosis that is unresponsive to conservative treatment
• Severe functional impairment. • Psychological disorder (depression, anxiety).
• Previous history of drug or alcohol abuse.
Are there early warning signs where we may ask the treating doctor to consider pain management? If the following is found early on in a claim, then referral to pain management may be appropriate:
• Complaints of unrelenting pain early in the claim.
• Requests for narcotic pain medication by the patient. • Ongoing reports by employee of inability to perform any type of work activities
due to pain, without objective findings.
Are there certain steps the primary doctor should perform before making a referral to pain management? Pain is different to everyone; therefore, it is difficult to determine when it is appropriate to refer to pain management versus in the primary setting. When early signs or red flags are identified, a referral to pain management should be considered. It is better to initiate earlier rather than later to avoid pain behaviors to build. Are all pain management providers the same? No, there are many doctors who call themselves pain management specialists but the education they receive and the treatment options they offer vary. A physical medicine and rehab specialist is different than an anesthesiologist in their method of treatment. The key, as an adjuster, is to thoroughly review and understand what the doctor documents and question any red flags (see Assessment section) and to know the appropriate providers in your jurisdiction. Are there resources for more information about pain management? There are a number of additional pain management resources, including:
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