Unnecessary Obstacles in Chronic Pain Management

Posted on Monday, March the 14th at 5:29pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

One of the challenges I face as a healthcare provider dealing with the management of chronic pain is that many of my patients cannot receive certain treatment interventions that are medically indicated for their condition.  One major reason is that they are often denied needed multidisciplinary chronic pain management treatment services by their insurance company. 

In our down-sized economy many people don’t have discretionary funds for healthcare—we have forced further down the road of crisis management.  Many people without insurance or ability to pay use hospital emergency rooms when possible, which drives the cost of healthcare up even more.

The area I want to focus on in this article, are the many encounters my patients have with the California Workers Compensation system.  They often do not receive authorization for the chronic pain management services they need and deserve.  I realize the Work Comp system has been abused by workers, but the numbers are not as significant as insurance carriers propose; it is estimated that less than 10-15% of all claims are fraudulent.  Unfortunately, almost 100% of claims are assumed suspicious and makes Work Comp a very adversarial system.

To illustrate the problem I’d like to tell you about one of my patients (details changed to protect her anonymity).  Norma was injured at work and believed that the Work Comp system would help her.  Several years and three failed surgeries later she had lost his hope.  In addition, she was accused of malingering and of being an addict.  In fact, this is originally why her medical pain management provider sent her to me—for an addiction evaluation and treatment planning session.

After several months of working with Norma, I determined that she did not have an addictive disorder at all.  She had a condition called Pseudoaddiction—which is defined by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction as follows:

The term pseudoaddiction has developed over the past several years in an attempt to explain and understand how some chronic pain patients exhibit many red flags that look like addition. Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is under treated. Patients with unrelieved pain may become focused on obtaining medications, may clock watch, and may otherwise seem inappropriately drug seeking. Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

Many of the most respected leaders in pain management such as The International Association for the Study of Pain, as well as those listed above, all proclaim multidisciplinary approaches are the best practice standards for chronic pain management.  At the time of writing this article I was able to advocate for Norma who was assessed and finally authorized for treatment at a prominent West Coast multidisciplinary pain management program.

The reality of our current system is that many people only receive medication management because it is much less expensive in the short term.  For Norma this meant being on several different pain management medications that were not adequately addressing her underlying problem.  Employees representing Work Comp got angry with Norma; they blamed her that she wasn’t getting better and accused her of being an addict.  They called ahead to number of her healthcare providers and cautioned them about Norma with their preconceived bias.

Using only a medication management approach is very short-sighted because the underlying problem or pain generator frequently gets masked—not treated.  In addition, many of the medications used some pain management providers were developed for acute pain conditions, not prolonged chronic pain such as Norma has.  This leads to tolerance developing with higher and higher does needed for the relief of pain.  Increased doses mean increased side effects, including substance abuse or addiction problems that show up, conservatively, in 10-15% of the population.

In addition, since pain has biopsychosocial components, the medication only addresses one third of the pain management problem.  What about the other two thirds?  Many people do not fully understand that the other two components are as real as the physical perception transmitted from the pain receptors.  For example, the medication only masks the psychological/emotional components of pain.  In addition, the social/cultural component rarely gets addressed—yet this is an area that for many people living with chronic pain has a huge impact on their perception of pain.

People want and deserve effective pain management, but many providers overlook, or don’t understand the emotional and social components of pain.  There are different definitions for pain. The most widely accepted is the one used by The International Association for the Study of Pain. It defines pain as “An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.”

I tell my patients that using pain medication for these symptoms is like having an infected cut on your hand and all you do is put a nice looking Band-Aid on it; you don’t clean the cut or use appropriate antibiotics to fight the infections.  I believe that separate cognitive, behavioral, affective (feeling) and social treatment plans are necessary for positive treatment outcomes and  improved quality of life.

One of the assessment instruments I developed and have refined since 1996 is my ascending and descending pain symptom assessment.  This instrument helps both the patient and me understand how much of their pain is physiological and how much is psychological/emotional.  In addition, this worksheet can help us determine the presence of neuropathic pain symptoms. 

During our initial session I used this instrument and discovered that Norma experienced both physiological and psychological/emotional pain symptoms with the physiological being slightly more predominant (88-86 out of a possible total of 90 in each area, which is one of the highest scores I’ve seen on this instrument).   She rated most of her pain levels as 9-10 on the 0 to 10 pain scale on bad pain days and 7-8 on most days even with medication.  At this point we determined she was also experiencing several neuropathic symptoms.

Since that initial session Norma experienced an extensive back surgery.  As a result, she developed a major bacterial infection that required more surgery to remove it.  After getting up to walk after surgery her leg collapsed and she experienced debilitating pain.  Since that time most of Norma’s left leg has been numb and she continues to experience significant pain even with medication.  Norma is coping, due largely to the cognitive behavioral work we have been developing, as well as her increased motivation to be proactive.  She is very guarded about trusting this new program and is concerned that they also will be biased against her by the Workers Compensation Case Manager.  I plan to write a follow-up article at the end of her treatment.