Economic Insecurity and Chronic Pain

Earlier this year, the estimable industry consultant Peter Rousmaniere published a report entitled The Uncompensated Worker: Financial Impact of Work Comp on Households.  In the report, Peter summarizes the realistic impact that workers compensation has on families: "The scenarios [explored in the report] show that a brief work disability often results in a sharp cut in take-home pay, after the deductibles are applied. An extended disability lasting for months can cause many injured workers to struggle to meet their household expenses, forcing these employees to dig into their savings and risk losing their financial cushion."

And in an article last week published on Insurance Business America, Mark Walls, Vice President of Communications and Strategic Analysis at Safety National, noted the economic anachronism that is our current work comp system.  "Today, there are lots of skilled craftspeople who earn more than that [an indemnity cap of $1,100/week].  For anyone who earns a good living, going on workers comp can be a devastating blow, when it should not be."

While the world certainly affords no law to make an injured worker rich, our current system doesn't even appear to allow some injured workers to avoid poverty.  These two pieces came to mind when I saw this headline recently in the Harvard Business Review: The Link Between Income Inequality and Physical Pain.  Researchers from UVA and Columbia hypothesized that there might be a link between fiscal pain and physical pain.

First, they looked at the consumption patters of over-the-counter painkillers among 33,000 US households.  Compared to households in which at least one head of household was employed, those in which both were unemployed exhibited 20% higher spend on OTC painkillers.  Next, researchers asked people how much physical pain they were currently experiencing, but did so after informing the respondent of the unemployment rate in his or her state.  Employment status again proved to be a predictor of physical pain levels and, interestingly, simply living in a state with a high unemployment rate appears to lead to higher reports of physical pain.  They also did a fun experiment involving undergraduates and buckets of ice water, but you can read the article see how that went.

The researchers sum up their findings across studies as follows: "When people encounter economic insecurity, they typically feel a lost of control.  A sense of control is one of the foundational elements of well-being.  When people lose their sense of control, their body goes a bit haywire and responds to stimuli differently - displaying a weakened resilience and a lower pain threshold."

So here's an existential question for you this Monday morning: Might the very system we've devised to address pain resulting from workplace injury actually induce pain instead?  

Michael
On Twitter @PRIUM1

When Opioids Almost Kill You, Chances Are You'll Get More Opioids

I really wanted the first post of 2016 to be positive, uplifting, inspiring... but a study I read over the break was so unnerving, I had to go and ruin "return to work" day, already a day that lives in infamy, with even more depressing news.

Researchers at Boston Medical Center used a national database of prescription information to assess the likelihood of continued opioid prescriptions after a non-fatal overdose.  They looked at prescription information from 3,000 patients who experienced a non-fatal overdose between 2000 and 2012.  These patients were all prescribed opioids for chronic, non-cancer pain. 

Think about this: These 3,000 patients have already overdosed on prescription opioids. They are lucky to be alive. Surely, their healthcare providers will find another way, another mechanism, another approach to managing their pain. The risk here isn't illness or infection or a change in blood pressure... it's death.  

The bad news:

• Over 90% of these patients continued to receive opioids after their non-fatal overdose event
• 50% of these continued to receive the prescriptions from the same doctor
• 7% of the original group experienced a second overdose
• Two years after the first overdose, those with continuing opioid prescriptions were twice as likely to experience a second overdose event compared to those who were no longer receiving opioids. 

Why is this is happening?  

First, our fragmented healthcare system doesn't make it easy for prescribing physicians to discover the clinical events experienced by their patients outside of their immediate purview.  And patients may not want to disclose an overdose event for fear of having their medications discontinued.  I get that.  And it makes we wonder whether PDMPs should also include the ability for inpatient settings to report both fatal and non-fatal overdose events to the database so doctors can see this information whether its reported by the patient or not.  Linking electronic health records to PDMP systems would be a good start down this path.    

The second phenomenon driving these sorry statistics is that doctors are not comfortable weaning opioid (and other) medications.  No one, least of all me, would ever suggest immediate cessation of opioid therapy in light of a non-fatal overdose.  That's clinically irresponsible and potentially dangerous for the patient.  But the necessary steps forward are complicated: If the patient is on multiple medications that require weaning, which should we weaned first?  What titration steps should be used?  Is medication-assisted-therapy (MAT) an option?  Should I refer the patient or try to handle this myself?  These are hard questions and the primary care community, by far the most frequent prescribers of opioids, is currently ill-equipped to handle them.

Welcome to 2016.  Once more unto the breach, dear friends.  

Michael 

On Twitter @PRIUM1  

Where Does Pain Come From?

[Part 1 of a two part guest post from Dr. Pamella Thomas, PRIUM's Medical Director]

What is Pain?

Chronic pain initially begins, appropriately, as acute pain – a biological event in response to noxious stimuli.  However, as time progresses, social, psychological, and cultural factors impede and complicate recovery. 

Pain, generally, is defined by the IASP Task Force on Taxonomy, 1994, as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.¹  The individual’s experience of pain is mediated by the brain; pain is always subjective.  Commonly the experience of pain is due to physical injury; however, it may also be caused or intensified due to emotional stress: anxiety, depression, exhaustion. The prefrontal cortex of the brain’s frontal lobe plays an important role in interpreting and mediating both types of pain perception.

Role of the Brain

Our understanding of the brain’s role in pain perception has advanced significantly.  For example, we now understand that one's prior experience involving pain, its consequences, and associated moods and stressors, plays an important role in a person’s experience of pain.   One hypothesis is that early adverse experiences and early-onset mental disorders may contribute to a chronic imbalance in hormonal and neurotransmitter mediators linked to neuronal stress response pathways.²  This in turn has been linked to a range of adverse metabolic, cardiovascular, immunological and cognitive effects.^3,4 

Adverse Childhood Events

Additionally we know that adverse experiences with pain occurring prior to age 18 heavily influence our ultimate perception of pain.  Adverse experiences such as abuse, neglect, poverty, parental death, divorce, drug use, and incarceration have been shown in numerous studies to have profound effects on a child’s temperament and psychological and physiological development.

Studies from the Centers for Disease Control and Prevention (CDC) and international surveys from the World Health Organization (WHO) provide mounting evidence and weight to the theory that Adverse Childhood Events (ACEs) predispose a person to poor health as an adult.  Of note, ACEs causing anxiety and/or depression in childhood were positively correlated with chronic pain in adulthood.  Most interestingly, these emotional stressors from childhood are directly correlated with physical disease states in adulthood. Individuals with a history of three or more ACEs were more likely to be diagnosed with each of the six physical conditions measured by the WHO: heart disease, asthma, diabetes, arthritis, chronic spinal pain, and chronic headache.  Those individuals who had suffered from childhood physical abuse had an even longer list of adult chronic disease.

These results suggest that early onset mental disorders may function as endogenous psychosocial stressors that can be associated with poor physical health in adulthood caused not only through increased risky health behaviors, but also through direct biological mechanisms.

Authors KM Scot et al., found in their study, “These results are consistent with the hypothesis that childhood adversities and early onset mental disorders have independent broad spectrum events that increase the risk of diverse chronic physical conditions later in life.”⁵

Anecdotal Experience

As a former medical director overseeing an onsite employer clinic, I had specific insight into the chronicity of some of the workers’ compensation patients filing claims.  Some employees had charts over two inches thick with frequent claims and follow-up visits. I affectionately referred to them as my frequent flyer work comp club members. Given their frequent visits and extensive charts, I began to interview some of these employees and ask questions about their work environment and about their childhood up until 18 years of age. I wanted to see if there were any common experiential themes amongst this population.

I heard frequently from the employees that they had issues with their supervisors or others in authority.  Similarly they had disagreements with those they interacted with at home.  I also frequently heard anecdotally that these employees suffered through poor in-home security, lower socioeconomic status, and circumstances that caused frequent fear and anger in their homes from an early age.

The Doctor-Patient Relationship

Though I likely missed a great opportunity to reproduce the results found in the ACE study, I found that just by taking the time to engage these injured workers in conversation, addressing factors outside those reported as part of the injury, that some seemed to have fewer ongoing problems going forward.  Being heard and validated proved therapeutic for these oft troubled employees.  Actively listening to patients may help prevent chronic pain and its complications from certain treatments. It is my conclusion that the physician-patient relationship should be seen as the critical piece in treating workers’ compensation claims, especially for workers that display a particular subset of characteristics that I will detail in a follow-up post.

1.            Merskey H, Bogduk N. Classification of chronic pain, IASP Task Force on Taxonomy. Seattle, WA Int Assoc Study Pain Press available online www iasp-pain org). 1994.

2.            McEwen BS. Protective and Damaging Effects of Stress Mediators. N Engl J Med. 1998;338(3):171-179. doi:10.1056/NEJM199801153380307.

3.            Miller GE, Cohen S, Ritchey AK. Chronic psychological stress and the regulation of pro-inflammatory cytokines: A glucocorticoid-resistance model.

4.            Chrousos GP, Kino T. Glucocorticoid action networks and complex psychiatric and/or somatic disorders. Stress. 2007;10(2):213-219.

5.            Scott KM, Von Korff M, Angermeyer MC, et al. Association of childhood adversities and early-onset mental disorders with adult-onset chronic physical conditions. Arch Gen Psychiatry. 2011;68(8):838-844. doi:10.1001/archgenpsychiatry.2011.77.

It's Not About the Meds, It's About the Pain

We are a nation in pain.  

According to the National Health Interview Survey conducted by the Centers for Disease Control and Prevention here in Atlanta, more than 25 million of us experience pain on a daily basis for a minimum of 90 days. That's 11.2% of adults in this country.  And a full 126 million adults (that's nearly 56% of us) reported some type of pain in the 90 days leading up to the interview.  

We try to fix it with drugs.  

Once upon a time, acetaminophen was a wonder drug.  And then we realized it carries significant risk of liver damage at high doses and with long term use.  At one point we thought ibuprofen was the answer.  And then we learned that heart attack and stroke risk significantly increase with its use.  At one point (hard as it is to believe), we thought opioids were the long-sought-after solution to the problem of pain.  That's led to the largest man-made epidemic in history: thousands of overdose deaths per year, more Americans addicted to pain meds, entire generations disappearing from some towns, and a lot of other scary statistics and awful outcomes.

And when those don't work, we pin our hopes to potential future drugs.  

Researchers at Memorial Sloan Kettering Cancer Center are working on an investigational compound, IBNtxA.  It's an opioid derivative that appears to provide the analgesic effects of an opioid without the risk of respiratory suppression or the "high" that comes with typical opioid use.  While this is great news for cancer patients (where pain medication is not only useful, but critical to compassionate treatment... which is why Sloan Kettering is working on it), it begs the question: what side effects and unintended consequences will result from the long term use of IBNtxA?  And to what extent are the psychotropic effects of our current opioids the real drivers of use (vs. their perceived analgesic effect)?  We have no idea, but history tells us we should proceed cautiously.

So what do we do?  

We have to find ways to manage the vast majority of chronic pain without pharmacological assistance.  Should some people with chronic pain be allowed to benefit from sustained use of medication therapy?  Absolutely.  But too many millions of patients are relying on dangerous and ineffective medications to manage an underlying issue that is only partially explained by biological factors, completely ignoring the social and psychological barriers to recovery.

Our pain, collectively and individually, is here to stay until we start thinking less about the pain and more about the person.  

Michael
On Twitter @PRIUM1

 

The Right Target in Chronic Pain Cases: The Brain

Need convincing that the key to chronic pain management lies in behavioral health?  NPR has a great piece today on the human brain's ability to deal with pain signals and what this might mean for chronic pain management.

"The brain also determines the emotion we attach to each painful experience, Linden says. That's possible, he explains, because the brain uses two different systems to process pain information coming from our nerve endings.

One system determines the pain's location, intensity and characteristics: stabbing, aching, burning, etc.

"And then," Linden says, "there is a completely separate system for the emotional aspect of pain — the part that makes us go, 'Ow! This is terrible.' "

Linden says positive emotions — like feeling calm and safe and connected to others — can minimize pain. But negative emotions tend to have the opposite effect." 

The article also references a study published in 2011 that found 8 weeks of "mindfulness" practice appeared to enhance a subject's ability to manage pain.

These articles and studies add to a growing body of evidence that suggests that when workers' compensation payers ignore the link between behavioral health and chronic pain, they do so at their own peril.  We must begin to routinely incorporate these modalities into chronic pain care, at every stage of the claim.  We have to stop being scared of psych diagnoses and begin addressing the route causes of chronic pain.

If you're focused on relief of non-specific low back pain and ignoring what's going on in the injured worker's brain (including the injured worker's emotional state), you're shooting at the wrong target.

Michael
On Twitter @PRIUM1