By Peggy Sugarman
Grancell, Lebovitz, Stander, Reubens and Thomas
 
Treating pain in workers' compensation patients has always been challenging.  Recent studies released by the California Workers Compensation Institute (CWCI) chronicle an alarming use of Schedule II opioids, which includes such substances as morphine, oxycodone, hydrocodone (Dilaudid), and fentanyl (Actiq). Schedule II substances have accepted medical uses but carry a high potential for abuse which may lead to severe psychological or physical dependence. While strong medicine is helpful when controlling break-through or cancer pain, the CWCI researchers found that that one-half of the prescriptions for Schedule II opioids were for minor low back strains and sprains. 
 
Given that all medical treatment must be consistent with the Medical Treatment Utilization Schedule (MTUS) adopted by the Division of Workers' Compensation administrative director, the Chronic Pain Guidelines subsumed in these regulations are helpful when it comes to understanding how to deal with claims where pain complaints have gone beyond the time expected for an injury to heal.  
 
The Chronic Pain MTUS distinguishes between the biomedical model and the biopsychosocial model in how we are to assess potential treatment options. The biomedical model has been predominant for most of us; a model where pain can be directly tied to identifiable biological variable. According to the MTUS, this model has generally failed in the treatment of chronic illness including persistent pain(p.4). For these ituations, the regulations require that the provider embrace the biopsychosocial model that considers the patient first and the disease second, understanding that both cognitive and emotional responses play a critical role in the patient's ability to manage their post-injury lives. When clinical progress is insufficient, the clinician should always be prepared to address confounding psychosocial variables, in a coordinated, multidisciplinary manner.
 
Patients in this sub-acute phase of an injury are at the proverbial fork in the road. According to the MTUS, prolonged absence from work is the most predictive variable for delayed recovery particularly when coupled with other identified factors. These include: Failure to respond to conservative treatment that is accepted for the specific diagnosis, significant psychosocial factors, previous history of delayed recovery, a history of childhood abuse, and absence of employer support or lack of employment to which the patient can return. It is the complexity and interconnectedness of these variables that lead to the need for a multidisciplinary intervention.
 
What should we be looking for in a multidisciplinary approach when dealing with patients experiencing "delayed recovery" (i.e. those who are not progressing as expected under the biomedical model), particularly when admission to a functional restoration program (FRP) has been approved through the utilization review process?
 
According to Safeway Medical Director Melvin Belsky, MD, there is currently no way to certify that a physician is an experienced multi-disciplinary treater and thus he recommends a healthy dose of caution and even cynicism  before approving the use of a particular program/facility.

Relevant questions include asking about the specific types of disciplines in which the physician claims experience and the length of time spent in those disciplines. Are there regular team meetings with other medical professionals such as a registered physical therapist and clinical psychologist? Is the program team-leader actually meeting with patients and involved in establishing mutually-agreed upon functional goals?  What outcome measures are tracked to gauge success? And, most importantly in my opinion, are patients properly evaluated to ensure that they can benefit from the program? Are patients expected to set and meet personal goals or risk dismissed from the program? Finally, is the program flexible? Because patients have different needs, a cookie-cutter approach is unlikely to address their particular needs.  
 
Inadequate responses to these questions should raise red flags. Finding a reputable FRP should go a long way towards making sure that the patients who undergo such treatment are appropriate candidates and that the facility is going to be consistent with a biopsychosocial model as required by the MTUS. 
 
Many thanks to Melvin Belsky, MD and Steven Feinberg, MD for their contributions and editorial advice in the preparation of this article.
 
To read the DWC MTUS Chronic Pain Guidelines, go here.
 
To read the CWCI report, go here. 

Peggy Sugarman is training director for Grancell, Lebovitz, Stander, Reubens and Thomas, a California workers' compensation defense law firm. This column was reprinted with permission from the firm's Quarterly Review.