New research supports a relationship between stress and chronic pain. The encouraging findings of a study appearing in the Oxford University journal Brainsuggest that attention to stress management techniques can improve the symptoms of chronic pain. Whether pain is caused by surgery, accident, injury or chronic pain disorders like fibromyalgia, pain can be intimately linked with stress. Learning to manage that stress can have a positive physical effect on the experience of pain.
Understanding Pain and Stress
University of Montreal research team Vachon-Presseau et al. titled the pain study “The Stress Model of Chronic Pain: Evidence from Basal Cortisol and Hippocampal Structure and Function in Humans.” The researchers found stress management to be top priority for individuals with a smaller-than-average hippocampus. They also found a strong correlation between the size of the hippocampus and vulnerability to stress. Dr. Pierre Rainville told Rick Nauert of Psych Central, “Our research sheds more light on the neurobiological mechanisms of this important relationship between stress and pain.”
The researchers found links between cortisol, size of the hippocampus and pain in 16 individuals with back pain (compared to an 18-person control group). Cortisol, also known as the “stress hormone,” was higher in individuals with smaller hippocampal volume—and patients with higher cortisol levels were more likely to report chronic pain.
The Feedback Loop between Anatomy, Stress and Pain
In addition, the study found that patients with higher cortisol levels and smaller hippocampal size also experienced more activity in a region of the brain related to anxiety over the anticipation of pain. Patients who experience more chronic pain and higher levels of stress also tend to manifest heightened anxiety that can lead to greater pain experience, in a feedback loop that links anticipation of pain, stress and pain itself.
The study supports a theoretical “chronic pain vulnerability model” in which some people with a confluence of physical, hormonal and psychological proclivities are more likely to develop chronic pain. Those same characteristics can lead to greater suffering due to chronic pain over time. Breaking the feedback loop by learning to manage stress through meditation, writing, exercise or other classic stress management techniques can physically alter a vulnerable patient’s experience of recurring pain.
Paradigm Outcomes is always ready to assist with managing your company’s emerging and chronic pain claims. Fill out our contact form if you have a case you would like to refer to Paradigm. Make sure to follow us on LinkedIn and Twitter.
Roberto Ceniceros recently published an article in Business Insurance titled, “Yoga may become an alternative to pain meds in workers comp claims.” In it, he poses the idea that yoga “could help address a formidable workers comp problem: how to resolve complex claims involving patients with chronic pain treated with addictive narcotics.” It’s certainly worth considering alternative therapies such as these as tools in the functional restoration process.
Mr. Ceniceros’ article is a refreshing reminder that ultimately, recovery from chronic pain involves restoration of function. Yoga is a great example of a therapeutic exercise which provides structure, technique and initiative to an injured person. In fact, the Official Disability Guidelines (ODG) recommends yoga as an option for low back pain, in “highly motivated patients.” They note that studies have shown that yoga can improve function, even if it does not change the pain complaint. By helping to motivate patients to take an active role in the care of their body, yoga can be an invaluable tool.
Still, we are faced with many injured workers who are not in the “highly motivated” stage and who are entrenched in a passive approach (e.g. medications, procedures). To get the most out of yoga, it makes sense that it be seen as a valuable resource and incorporated into a strategic treatment plan for the best outcomes. The ideal result is that an injured worker learns this new self-care technique, focuses more on physical ability and uses it in lieu of side effect prone medications and injections. The danger is recommending yoga before an injured worker is ready or invested, as they may see it as something that made them worse or did not help.
Yoga offers the potential for an intervention that combines physical exercise, better body awareness and stress reduction. Before recommending this important alternative, it may be wise to consider the particular instructor’s credentials and the type of yoga to ensure the injured worker embarks on a safe and restorative practice. Instructors who help motivate injured workers to carry over body awareness and mindfulness may be particularly helpful to this population.
I would be interested in hearing from others how they have parlayed an interest in yoga into greater injured worker participation in self-management and decreased reliance on medications and interventional medicine.
For more information about how Paradigm Outcomes uses a Systematic Care ManagementSM model to address the entire chronic pain condition, including the biological, psychological and social aspects, please complete the contact us form to the left or connect with us on LinkedIn, Twitter and YouTube.
Chronic pain can render traditional pain management techniques ineffective. For example, opioids (medications derived from or having a similar function as morphine) are frequently prescribed for acute pain management and in severe or intractable chronic pain cases. However, in many instances of chronic pain, opioids do not work as expected. Here are the reasons opioid failures occur, and what other options may be available to help control a patient’s pain.
When opioids are prescribed for a case of chronic pain, it’s often because other drugs have failed to provide relief or the physician hopes for a pain “killer.” Opioids are more traditionally used for severe acute pain. Chronic pain patients who are given opioids sometimes claim to be unable to lead productive lives and desperate for pain relief. However, there is little high quality research validating that chronic opioids resolve these complaints. In fact, in some instances, opioids can trigger an increased pain response rather than pain relief. When this occurs the toll on both the body and the brain of the patient can be debilitating.
Understanding Opioid Tolerance and Hypersensitivity
For some patients, a small dose of opioids ceases to provide adequate relief, so the physician may decide to increase the dosage. Over time, this practice results in an increased tolerance for opioids such that higher and higher doses are required often with unsatisfactory results. In many instances increasing opioid doses paradoxically induces more pain, a response called opioid induced hyperalgesia. This often leads to an endless cycle of escalating opioid dose, increased pain, and mounting side effects and health risks.
New Research May Have Implications for Chronic Pain Treatment
Researchers have recently identified pathways by which opioids may induce pain and hypersensitivity, as well as pathways for opioids tolerance. A new study, published in the online edition of Nature Neuroscience and reported on Psych Central, identified the molecular pathway by which opioids induce pain. The authors believe that understanding this pathway is the first hopeful step to making opioids more effective for more patients.
This study also shows for the first time that the pathways that induce hypersensitivity are quite different from those that induce tolerance—the two are not simply two sides of the same coin, as previously thought, though they are linked. Specialized cells in the spinal cord seem implicated in hypersensitivity, as well as a protein called KCC2 that may help trigger pain signals when it functions improperly. Because of these findings, researchers at the Université Laval are testing molecules that may have the effect of preserving normal KCC2 function, preventing the mis-signaling that can worsen rather than improve pain.
This promising molecular research is aimed toward promoting the use of opioids in those with opioid induced hyperalgesia. It does not address many of the other reasons that opioids may not be an ideal effective long-term treatment for non-cancer chronic pain, such as the lack of proven lasting objective functional benefits and the cascade of common side effects like addiction.
Paradigm Outcomes is always ready to assist with managing your company’s emerging and chronic pain claims. Fill out our contact form if you have a case you would like to refer to Paradigm. You can also connect with us on Linkedin and Facebook.
A new research experiment may have implications for how patients manage chronic nerve pain in the future. Psych Central reported on a study that found significant differences in pain experience and response in mice that were socially isolated versus those that had companionship. For people who struggle with chronic pain, the chance that increased social interaction could change biological inflammation and pain responses would be life-changing.
Living with Chronic Nerve Pain
Chronic nerve pain, most often in the form of peripheral neuropathy, plagues more than 20 million Americans each year, again according to Psych Central. It affects sufferers’ abilities to enjoy normal work activities and personal lives, and can be a lifelong source of frustration and discomfort. Neuropathy can result from nerve damage common in diabetes and several other ailments, spinal cord injury, or other types of bodily trauma. Neuropathies and other types of chronic nerve pain can be difficult or impossible to cure because many types of nerve damage are permanent.
The New Pain Study
A pain study undertaken on mice by Ohio State University researchers found that mice provided with companionship experienced less pain from nerve damage. Researchers gave some mice a surgical procedure to mimic neuropathic pain, while others were not surgically altered (as a control). They then paired some mice with a “cage mate” and left others in solitary cages, testing them over the course of a week. On three days of the test week, some mice were exposed to “brief stress” while others were left “unstressed.”
The social contact among mice with cage mates seemed to lower biological responses to pain, including allodynia—a specific type of chronic nerve pain that produces a response when most non-sufferers would have none. Researchers tested for allodynia using a light touch to the paw, to which most normal tame mice would have no response. Mice with allodynia would withdraw sharply.
Those who were alone had more inflammation and increased allodynia responses compared with mice that had cage mates. Those who had regular social interaction were better equipped to handle stress without increased pain, and also had significantly lower levels of genetic markers for pain as compared with subjects who were isolated and stressed.
The results of the study were revealed by Adam Hinzey, a neuroscience graduate student at Ohio State, during a press conference on October 15 at the “Neuroscience 2012,” annual meeting of the Society for Neuroscience.
Implications for Sufferers of Chronic Nerve Pain
It can be difficult to extrapolate from mice to humans, but this neurobiological evidence suggests that isolation and stress may directly and medically affect pain responses in mammals. For people living with chronic nerve pain, these findings can provide hope that regular social interaction may improve a person’s response to chronic nerve pain.
Courtney DeVries, Ph.D., a professor of neuroscience at Ohio State University and principal investigator in the study, said, “We believe that socially isolated individuals are physiologically different from socially paired individuals, and that this difference seems to be related to inflammation.”
Paradigm is always ready to assist with your pain claims. Fill out our contact us form if you have a case you would like to refer.
At the National Workers’ Compensation and Disability Conference in November, there was an emphasis on various strategies to manage the prescription opioid epidemic. I led one such session with my colleague Fernando Branco, MD, of the Rosomoff Comprehensive Pain Center, titled “Pain Forensics: Finding Missed Opportunities for Positive Outcomes.” It was encouraging to see that despite the scale of the problem, there was a resolve among attendees to make a difference. As Dr. Sanjay Gupta wrote in a November 15 post on cnn.com, “With accidental deaths due to prescription drugs… we have an opportunity to fix the problem and end this large man-made epidemic.”
The problem has multiple causes, including successful marketing of drugs, rampant prescribing, and lack of adequate consequences for overprescribing. Proposed solutions vary, too, and include changes to health care policy, regulation, prescription drug monitoring programs, workers’ compensation formularies, utilization reviews and peer review. As noted in this blog before, no one solution is likely to be the “quick fix.” Rather, all these initiatives used in concert are likely to bring about durable change.
In our zeal for improvement, we must be wary of what one may call “opioid myopia”—a hyper-focus on opioid solutions that ignores the larger problems in pain care, namely polypharmacy, inappropriate interventional care, and the lack of proper rehabilitation.
Consider a recent opinion piece in The New York Times Sunday Review titled “How Back Pain Turned Deadly.” Following up on the recent meningitis outbreak due to tainted spinal steroid injections, the writer explores the effectiveness and dangers of spinal steroids themselves. This procedure has increased in use dramatically over the last decade without a proven benefit. Reviewing typical workers’ compensation chronic pain cases with poor outcomes will commonly reveal a series of interventional procedures and escalating medication use with little functional gain and no coherent process to measure effectiveness.
This type of review may be called a “forensic” review because of its methodical gathering and analysis of evidence to establish facts. In a case review context it denotes an assessment using evidence based medicine to see if the medical facts support the treatment given. The process also helps determine how things might be done more effectively in the future. In cases with poor outcomes, we often find that providers did not adhere to evidence based medicine, but rather veered toward a trial and error biomedical approach instead of a biopsychosocial approach.
In a strictly biomedical approach there is often a belief that you can “turn off pain” if you get just the right combination of procedures or medications. If the injured worker complains the pain is worse, this leads to more interventions. In a biopsychosocial approach, there is a calculation that psychosocial issues may be increasing pain behaviors that magnify pain reports, and that no procedure or increase in medicine (short of sedation) is likely to change the complaint. Instead, physicians need to address beliefs and behaviors to improve coping, thus avoiding polypharmacy and fruitless procedures. An injured worker who is made to believe there is a quick fix available will often remain in treatment years post injury without knowing the unscientific nature of his care.
There are several important questions that should be asked when reviewing a case in retrospect. Is the care excessively biomedical versus biopsychosocial? Is there a trial and error approach at work rather than evidence-based? Have treatments been given despite evidence based medicine suggesting they would not be effective, or despite complications or side effects which then require treatment?
The discovery of problematic factors signifies the care is not systematic. The way to prevent this type of care, or to turn it around, is to use a methodical, systematic approach to understand the case and then implement targeted interventions that will appeal to the injured worker by helping them recover. By helping a worker objectively monitor and measure his response to a treatment, we can help him differentiate a fleeting response from a meaningful one. This may require an approach and interventions that are counter-intuitive to the routine adjudication approach, but there comes a time in some cases where the simpler, quick solutions cannot impact a maladaptive treatment trajectory.
In the last installment of our three-part blog series on opioid misuse, we’ll examine the relationships between biology, psychology, social interaction, and pain management. Patients that experience chronic pain are at a particular risk for opioid misuse, especially in cases where depressed mental states and a lack of support combine with a physical malady to slow recovery.
Cognitive Behavioral Therapy and the New CPT Codes
Cognitive behavioral therapy (CBT) is an innovative biopsychosocial approach to pain management that can short-circuit potential opioid misuse in chronic pain cases, getting injured workers back on their feet more quickly and with fewer lasting side effects. Helping injured workers facing chronic pain to manage psychosocial factors can be one of the strongest predictive factors for recovery and return to work. However, psychological treatment carries implications for psychological diagnosis and related claims costs that leave insurance companies unwilling to cover the therapy.
Fortunately, new American Medical Association CPT codes allow CBT to treat psychosocial issues without assigning a psychological diagnosis and initiating long-term psychotherapy. This makes CBT the solution of the future. CBT offers a short-term treatment with concrete, functional goals for disability management. As a structured, directive, and time-limited therapeutic option, CBT is a collaborative, active effort between therapist and chronic pain sufferer. CBT offers discrete and measurable rewards for reasonable investment, and holds the patient accountable through homework and an educational model.
Contrasting Treatment Models
There are two major ways to view medical therapy for chronic pain:
The Biomedical Approach, in which doctors view pain as a purely biological problem often with a single cause, which can be treated physically with no regard for social or emotional factors.
The Biopsychosocial Approach, which understands chronic pain as a dynamic and complicated interaction of multiple factors—biological, psychological, and social—which perpetuate and influence clinical symptomatic presentation. Deconditioning, fear avoidance, and maladaptive coping mechanisms can all counteract productive treatment protocol.
Physicians following the biomedical approach will often increase physical treatments to combat pain behaviors, rather than recognizing the many convoluted steps that can exist in the human form between pain generator and pain behavior. By increasing opioid dosage in the presentation of maladaptive behavior, these same physicians have written a prescription for opioid misuse or opioid addiction.
In contrast, CBT recognizes that pain behaviors don’t always just represent pain generators:
“Cognitive” addresses internal mental/emotional beliefs and fears about pain, as well as the individual understanding of pain as influenced by learned behaviors, cultural variables, and even personality.
“Behavioral” addresses the external actions and reactions to pain, frustration, and adversity. Chronic pain can lead to documented psychosomatic effects like symptom magnification, fear avoidance, and unexpected secondary gains. Injured workers may have hidden beliefs that influence the ability to heal and resume normal function.
Benefits of Cognitive Behavioral Therapy
If our thoughts cause our feelings and behaviors, we can change the way we think and therefore the way we feel and act, even if our external situation does not change. Changing the internal landscape and introducing coping mechanisms can actually limit pain presentation and necessary drug therapies, putting the patient on the path to recovery without the dangers of opioid misuse hovering in the wings.
A 2010 study in The Lancet found that cognitive behavioral therapy was effective in reducing low-back pain, and also more cost effective than other comparable interventions. CBT can be effective as part of a concerted approach to pain patients, offering a structure and design for a therapeutic plan that is short-lived, attainable, and effective.
To listen to the full replay of this webinar go to www.paradigmcorp.com. Paradigm is always ready to assist with complex medical needs. You can also follow us on Facebook and LinkedIn.
In the second installment of our three-part blog series, we’re exploring the relationship between chronic pain and opioid misuse in the wake of our “Anatomy of Chronic Pain and Opioid Misuse” webinars. Here, we’ll explore how opioid use and misuse can be ameliorated through effective treatment decisions and active case management.
The Webinar: Clarification of Diagnosis and Opioid Misuse
On May 17, 2012, we aired a webinar prepared by Drs. Moskowitz and Branco, Paradigm Medical Directors, and Bill McAweeney, Associate Vice President of Clinical Operations. During this presentation, we emphasized the importance of a clear diagnosis in understanding chronic pain and opioid misuse—particularly for rerouting patient treatment regimens from opioid misuse toward improved health and functionality. Here are the key points:
An inaccurate pain diagnosis or a reliance on subjective reports of pain rather than objective measures can lead to poly-pharmacy, and narcotic escalation, which in turn leads to opioid misuse.
That inaccurate diagnosis and narcotic escalation tend to represent an overall treatment trajectory that impedes progress and worker functionality while often doing little to combat the pain experienced by the patient.
Tolerance to the analgesic effects of an opioid is not, by itself, a sufficient reason to institute high-dose opioid treatments.
Dependence and higher tolerance thresholds can lead to hyperalgesia and withdrawal symptoms, which often perpetuate a cycle of side effect, escalated use, and even aberrant use.
“Substance abuse disorders,” as a term, includes all types of problematic opioid use, not only opioid addiction.
What If Opioids Aren’t Helping the Injured Worker?
Sometimes opioids are ineffective for treating chronic pain. If symptoms, functionality, or quality of life aren’t showing significant improvement—or when additional medications are being added regularly and/or dosages are increasing rapidly—the therapy is ineffective. These drugs can also harm the patient due to side effects, use disorders, or injury risks.
In fact, there are few long-term, reliable studies supporting opioid use for chronic pain. They are actually not recommended for headaches due to the risk of medication overuse headaches, and are inadequately supported for neuropathic pain, chronic back pain, and osteoarthritis. Opioids can occasionally, but rarely, be beneficial for mechanical or compressive etiologies, though orthopedic treatments are often more effective in the long term.
If, as a physician, you take a step back and determine that opioid use is not effectively treating your patient’s chronic pain—or if the risks of opioid misuse behaviors are outweighing moderate benefits that can be achieved through other therapies—it becomes necessary to responsibly terminate opioid use. There are four ways to achieve this goal:
Inter-disciplinary pain program(s).
To find out which detoxification regime is most compatible with your patient’s health/support system and needs, or to learn more, check out the complete webinar viewable online at www.paradigmcorp.com. Paradigm is always ready to assist with complex medical needs. You can also follow us on Facebook and LinkedIn.
In the year 2000, Congress declared a “Decade of Pain Control and Research” in response to rising instances of chronic pain among Americans. More than a decade later, though new treatments and drugs continue to proliferate, chronic pain still plagues the American population and the problem of prescription medication abuse has escalated. Part of the problem is that many chronic pain solutions are misguided, aiming for quick fixes that do not do justice to a problem as complex as chronic pain. Though the statistics are often lumped together for effect, there is a significant difference between having a chronically painful body part and a lifestyle disrupted by a chronic pain complaint.
Even with recent advances, uncontrolled pain and lifestyle dysfunction are on the rise; and evaluating chronic pain is an increasingly necessary skill among physicians and medical professionals. To properly identify and treat chronic pain, it is important to understand that pain is not a “vital sign” like blood pressure or temperature, but rather a complex biopsychosocial condition. An injured worker may transition from experiencing acute injury-related pain to chronic pain following a seemingly ordinary physiological trauma. Understanding the biological and psychosocial factors that cause or promote suffering in chronic pain is vital to providing effective treatment.
Three Interconnected Elements
Even as treatment options increase, uncontrolled or poorly controlled chronic pain cases remain on the rise because the condition is not treated in an integrated manner. During the progression from acute to chronic pain, biological, psychological and social components intertwine to create a unique, individual experience.
1. Biological: Biological pain responses may be the best understood component in chronic pain management, yet they’re still quite complex and difficult to treat. Physiological disturbances can stimulate pain receptors incorrectly, as in the cases of nociceptive and neuropathic pain. The nervous system can become sensitized and its ability to modulate pain adequately can fail. Pain may also occur due to old, poorly maintained injuries or to degeneration of the body with increasing age combined with lack of adequate physical fitness.
Finding and managing the biological basis for the pain is important, yet biological management alone won’t end a patient’s chronic pain. There is danger in overemphasizing the biomedical model (i.e. searching for a “pain generator” and extinguishing it). This approach often results in escalation of multiple medications and other interventions of questionable effectiveness. Medications that should work theoretically based on biology or laboratory results, or in carefully selected patients, often do not succeed when used in the masses or as a quick fix.
2. Psychological: Psychology can both affect pain and be affected by pain. One’s psychological state can impact one’s perception of pain, understanding of its meaning, behavior, and precision of reporting. Emotional components like catastrophic thinking and symptom magnification can make it difficult for a physician to properly diagnose and treat a disease, while pain-related anxiety, dependence, and addiction can be results of living with long-term pain. Many who experience pain deal with concurrent anxiety, depression, and substance abuse, among other conditions.
Clinicians who do not actively take into account these aspects of pain may incorrectly ascribe all of a patient’s distress to the pain and treat only the symptoms with little functional gain. The most effective treatments in managing chronic pain–therapeutic exercise, physical adaptation, independent self-care and healthy coping–take long-term motivation that is often difficult for many people to muster. This often requires a cognitive behavioral approach which reframes the pain dilemma and promotes a better sense of self-care and effectiveness (self-efficacy).
3.Social: Culture, lifestyle, and personal demographics can also contribute to chronic pain problems. The cultural milieu in which the patient moves can positively or negatively impact recovery, and lead to workplace problems and possible litigation. These social variables can both exacerbate chronic pain and create trouble during recovery, or, conversely, encourage a person with chronic pain to seek help and support. Though we have all heard of “secondary gains,” such as not having to work and financial rewards, as motivations to stay in the sick role, injured workers often experience “secondary losses,” such as loss of work identity and placing one’s life on hold, as well. The injured worker is often not conscious of either.
If the treating physician does not recognize each of the biopsychosocial components in his or her patient, instead choosing to focus on medical remedies only, the injured worker is unlikely to achieve the best outcome. Thus, many cases of chronic pain persist despite new medical innovations. We invite you to read our whitepaper titled “Addressing Chronic Pain Cases” to learn more about distinguishing chronic pain and the characteristics of a multidisciplinary treatment plan.