NOTE: This is a guest article written by Jeffrey E. Hazlewood, M.D. Dr. Hazlewood practices Physical Medicine and Rehabilitation / Pain Management in Lebanon, TN, and is an Associate Staff Member at Vanderbilt Wilson County Hospital in Lebanon. After receiving his medical degree from the University of Tennessee, Memphis, he completed his residency at the University of Alabama, Birmingham, where he was chief resident. A Fellow of the American Academy of Physical Medicine and Rehabilitation, Dr. Hazlewood is Board Certified in Physical Medicine and Rehabilitation with a subspecialty Board Certification in Pain Medicine. He also is a Certified Lifecare Planner. He is a member of the Medical Impairment Rating Registry and has received training on the 5th and 6th Editions of the AMA Guides to the Evaluation of Permanent Impairment. He also teaches 6th Edition Impairment Rating course to doctors and attorneys. His society memberships include the American Academy of Physical Medicine and Rehabilitation, the American Association of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Physician Lifecare Planners, the Tennessee Medical Association, The Tennessee Pain Society, the American Medical Association, and the Rotary club. He is an experienced speaker on various aspects of pain management and topics in Worker’s compensation and Lifecare Planning. Dr. Hazlewood also previously served as an assistant medical director for the Tennessee Division of Worker’s Compensation. He primarily is a treating physician, but also performs Medical Record Reviews (regarding causation, ratings, and appropriate pain management per evidence based medicine guidelines) and IME’s.
It is the nature of workers’ compensation injuries that they almost always involve pain, and many workers endure pain for the remainder of their lives. Successful treatment of that pain is complicated by several factors: some medical providers who look for easy or quick answers and sometimes the patients themselves complicate their treatment. The following scenarios provide examples of how the treatment of pain can go off track and how it can be different.
Scenario #1
Ms. Smith is a sixty-year-old woman who has suffered with chronic pain after a simple lifting injury 20 years ago. The initial MRI revealed no acute structural pathology (only degenerative bulging discs and annular tears) and indicated she had no more than a soft tissue injury. She never had surgery after her injury but was sent to pain management. For two decades, she received multiple interventional procedures (trigger point injections, epidural injections, sacroiliac joint injections, and nerve ablations), and several rounds of physical therapy. She was prescribed chronic opioids early on (despite all these interventional procedures). She is now on Fentanyl patches and Hydrocodone, Neurontin, Flexeril, and Ambien through a pain clinic, and Xanax and Cymbalta from her primary physician. She is overweight, has chronic depression and anxiety, is diabetic, and has untreated sleep apnea. Despite all this medication, she reports her pain level is eight out of ten, and she spends most of her days in her recliner. When her pain clinic closed, she was “miserable” because she felt she could not manage life without her pain pills. Now she has gone to a new pain management specialist.
What can the new doctor do to manage this type of complicated case? Does the doctor just continue the “status quo” medications Ms. Smith wants even though he knows she is not doing well on them? Does he continue the drugs she is on when all the medication treatment “guidelines” question continued opioid treatment because the risks far outweigh benefits? Or does the doctor do what is best for the patient in the long run by following the updated science and guidelines and provide more proven treatment, which has a better chance to improve Ms. Smith’s quality of life and function, as well as provide her safer treatment?
Scenario #2
About 10 years ago, a heart-tugging article appeared in a paper from the wife of a chronic pain patient who had committed suicide. Her husband had been on opioids for years when suddenly his pain clinic reduced his prescription dosages from a high level of opioids to much lower dosages. His pain increased significantly as his ability to function decreased. His wife said that her husband felt “there was no remaining hope” and that life was not worth living so he ended it. His wife blamed his death on “all the new state laws” that caused his doctors to stop prescribing opioids for chronic pain. She felt the law change was inhumane.
How could this man’s treatment been different to avoid this tragic outcome?
There were definite risks to the high dose opioids he had been taking. Pain management is much more than just writing opioids. His initial treating physicians could have initiated him on a safer level of opioids. They could have carefully explained the reasons behind national and state guidelines on opioid dosages and the dangers of using opioids for treating chronic pain. This man could have been encouraged to consider “alternative treatments” that were available and provided potential solutions that could improve his chronic pain, ability to function, and quality of life. In other cases, such alternatives have resulted in the reduction and even elimination of opioid usage.
Why were these patients in these scenarios and scores of others like them not given the pain management treatment that could afford them the best chance for a life worth living?
Some possibilities are:
Patients’ unrealistic assumptions
When patients come to a new doctor they often “just assume” that the new doctor will continue the same regimen of drugs they had been on for a long time. When the doctor does not give them the drugs or dosages they were previously given, they ask “Why then did they send me to a pain specialist if you’re not going to write my pain pills?”
Or a patient has a surgery followed by a prolonged period of taking opioids (often high dosages), and then after 3-6 months, the surgeon tells them “I can’t write the prescriptions anymore because of the new laws, but the pain specialist will.”
Now, the new pain specialist must convince the patient of the risks of opioids, especially high dosages which include:
- respiratory depression, which can especially occur when taken in conjunction with other centrally acting agents that are sedating (muscle relaxers, anxiety and depression medications, sleeping pills, and nerve pain medications).
- potential addiction and physical dependency as tolerance increases for the prescribed drugs.
- opioid hyperalgesia (a paradoxical condition when the patient’s pain taking opioids over time can increase rather than decrease).
- depression caused by these medications (they can be “downers” emotionally).
- sexual dysfunction.
- cognitive dysfunction.
- and many others.
The treating provider MUST gain the TRUST of the patient to try the recommended treatments. Then the pain specialist must attempt a slow weaning of the opioids while installing alternative treatments. There are several types of non-opioid treatment in the literature to successfully manage chronic pain, which are supported by “science.” Some examples are:
- Non-opioid medications – there are anti-depressants that can work on both musculoskeletal pain as well as nerve pain, AND they work on the depression and anxiety that is so often experienced by chronic pain patients.
- Cognitive Behavioral Therapy – typically a psychologist works with patients to reteach them to accept the pain, not give in to it, and to learn how to “turn the volume down on the pain” so they can become more functional. The psychologist works on “fear-avoidance” and “catastrophizing” tendencies that so many long-term opioid using patients have.
- Acupuncture – has been shown to be beneficial in many types of pain and is much safer than taking so many pills.
- Yoga / “Mindfulness” – treatments are combination of exercise, stretching, and meditation and are safe treatments.
- Progressive exercises and nutritional management with weight loss – so many patients do not understand that movement will not harm them, but NOT moving will. Anti-inflammatory diets have also been shown to have a beneficial effect on chronic pain.
- Electrical modalities – TENS units/H-wave units are simple modalities that many times can provide excellent pain control and avoid the use of harmful medications.
Such alternative treatments have a much better chance of long-term success in treating these centralized chronic pain syndromes.
The patient’s lack of understanding that false-positive findings on imaging studies can lead to misinterpreting the “pain generator”
This misunderstanding about what exactly causes the pain can consequently lead to a patient’s demand for inappropriate treatment of their pain.
In the first scenario above, the findings on the imaging studies were probably not caused by her injury, which means, more importantly, they were probably not causing her symptoms. In cases like this, the pain specialist should explain that the findings are sometimes “normal for your age” and are not caused by the injury, much less causing the pain the patient is having. Patients often state, “I have read my report and it states I have a torn disc (annular fissure/tear) or a bulging disc.” Patients may assume the findings were caused by the work injury. If they had never had MRI’s or x-rays of their back, they would have been unaware of existing degenerative back issues. They become confused and often distrustful because the doctors “all say different things” in terms of explaining what is causing their pain. The doctor should explain to the patient that the literature clearly documents the incidence of false positives/age related changes, such as disc bulges and even herniations that do not correlate with patients work injuries. Doctors may not feel it is worth the conflict they will experience when they try to discuss these issues with their patients. Sometimes they are not aware of the literature indicating this information about “false positive imaging study findings.”
In Ms. Smith’s scenario, she had a minimal mechanism of injury, no findings on imaging studies of “acute injury” structurally, yet her life morphed into years of treatments. In the end, Ms. Smith was totally miserable and non-functional. The pain generator had become “centralized” and could no longer be identified as a structural musculoskeletal or nerve injury. Consequently, opioids and injections and even potential surgery would not be successful. The pain was driven by the opioids themselves (opioid hyperalgesia), which can happen in cases of long-term use like Ms. Smith’s.
An unwillingness of the treating providers to learn from evidence-based literature and incorporate that learning into their practice
This can lead to inappropriate treatment of their patients’ pain.
Medical providers must be educated and convinced that opioids usually do not have long-term success but do have significant risks. It is much easier and less stressful for providers (and their patients) to just continue the opioids and spend minimal time with their patients. There are even documented cases of doctors writing extremely high dosages of opioids without considering other alternatives to pain management and being resistant to any change – even when presented with “the science” indicating the danger of opioids. Patients can be very insistent about getting high dosage opioids, which also makes it difficult for providers to refuse their demands.
Also, there is the financial disincentive for spending the extensive time required to explain the problems with opioids to their patient and to discuss other options. The resistance of the medical provider to “change course” can be attributed not only to ignorance of the updated literature, but also arrogance. Some doctors do not like being told they are wrong. Overcoming this “mindset” of some medical providers can be difficult. Compounding the problem, traditional teaching in medical schools has not placed an emphasis on alternative treatments. Sadly, this mindset can have deadly consequences for patients.
In summary
The appropriate management of chronic pain patients, in workers’ compensation especially, is usually very “complicated.” However, if providers spend the appropriate time in educating and listening to patients, try to successfully determine the true pain generators, study the evidence-based medicine literature, and consider alternative treatments to opioids, successful outcomes can often be achieved for patients with far less chance of harm in the long run. Success for patients in such cases makes dealing with all the complications worth it. There is no need for patients to believe they will be condemned to lives of misery without opioids. And yes, the sad outcome of the gentleman in the second scenario did not have to happen. He did not have to “lose hope.” With appropriate care, he could have gone on to have a good quality of life and not suffer in such pain forever when his opioids were decreased. Our task is to prevent his tragedy from happening to others with workers’ compensation injuries.
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