by Beau Clark, M.D.
As many of you are aware, the United States is currently in an opioid epidemic that rivals other medical epidemics in its history. Louisiana is not immune to this epidemic. For several decades, the over prescribing of legal opioids and the easy availability of illicit opioids have created a perfect storm. The end result of this phenomenon is the opioid epidemic. The epidemic’s effects are far-reaching, especially as it relates to the state’s workforce. Statistically, the most common prescription in a workers’ comp case is an opioid. “We” have established a normalcy in this country that no one at any time should ever have pain.
It has even been claimed that this is part of the Patient’s Bill of Rights. However, if you read the Patient’s Bill of Rights (see sidebar), you will see that a patient does not explicitly have the “right” to be pain free. What is notable is that the patient has the right “to be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives.” The following is a list of alternatives to opioid use for the treatment of pain related to a work injury. These alternatives are enumerated in the Louisiana Medical Treatment Guidelines.
Acupuncture is accepted and widely used for the relief of pain and inflammation. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation and affects the release of neurotransmitters.
Biofeedback is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity.
For example, epidural steroid injections (ESI) are injections of corticosteroid into the epidural space. The purpose of ESI is to reduce pain and inflammation in the acute or sub-acute phases of injury, restoring range of motion and, thereby, facilitating progress in more active treatment programs. Other examples include selective nerve root blocks, zygapophyseal (facet) injections, sacroiliac joint injections, radio frequency medial branch neurotomy/facet rhizotomy, trigger point injections, prolotherapy/sclerotherapy, and joint injections.
The Louisiana Medical Treatment Guidelines defines this as follows: “Medication use in the treatment of injuries is appropriate for controlling acute and chronic pain and inflammation. Use of medications will vary widely due to the spectrum of injuries from simple strains to post-surgical healing. All drugs should be used according to patient needs. A thorough medication history, including use of alternative and over the counter medications, should be performed at the time of the initial visit and updated periodically. Treatment for pain control is initially accomplished with acetaminophen and/or NSAIDs. The patient should be educated regarding the interaction with prescription and over-the-counter medications as well as the contents of over-the-counter herbal products.”
Occupational rehabilitation programs
These generally accepted programs are work-related, outcome-focused, individualized treatment programs. Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability and motor control functions), patient education and symptom relief. The goal is for patients to gain full or optimal function and return to work. The service may include the time-limited use of passive modalities with progression to active treatment and/or simulated/real work.
Work hardening is an interdisciplinary program addressing a patient’s employability and return to work. It includes a progressive increase in the number of hours per day that a patient completes work simulation tasks until the patient can tolerate a full workday. This is accomplished by addressing the medical, psychological, behavioral, physical, functional, and vocational components of employability and return to work.
Both axial and appendicular skeleton bracing provide stability and symptomatic relief for affected joints by reducing movement of the affected area.
No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should be encouraged to take an active role in the establishment of functional outcome goals. He should be educated on the specific injury, assessment findings and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid, self care for exacerbation of symptoms and home exercise should also be addressed.
Psychosocial treatment is an accepted, widely used and well-established intervention. This group of therapeutic and diagnostic modalities includes, but is not limited to, individual counseling, group therapy, stress management, psychosocial crisis intervention, hypnosis and meditation. Any evaluation or diagnostic workup should distinguish between pre-existing versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as a component in the total management program. There is some evidence that early cognitive-behavioral treatment reduces health-care use in comparison to written information alone. This can be used alone or in conjunction with other treatment modalities.
Restriction of activities
Continuation of normal activities is the recommendation for acute and chronic pain. Modified return to work is almost always more efficacious and rarely contraindicated in the majority of injured workers with pain.
Therapy: Active and passive
Active and passive therapies are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion and can alleviate discomfort. At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.
In summary, symptoms are a physical or mental feature that is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient. It is important to recognize that pain is a symptom, not a disease. Because it is a symptom, it should be treated accordingly. Therefore, pain is a clue that an underlying disease process exists, and it’s the clinician’s job to discover the underlying process and correct it. Correcting the underlying problem should in turn reduce or eliminate the symptom. Oftentimes, the human body has the ability to self-correct an issue. For example, an infection may cause the symptom of fever, and the body has the ability to use its immune system to fight the infection and eliminate it, thus correcting the symptom of fever. Therefore, oftentimes certain maladies are self-correcting by the human body. Lastly, opioids should not be the first line of treatment for the symptom of pain, but the last line.