Tag Archives: pain

I’M A 10!!!!

Today’s post comes from guest author Roger Moore, from Rehm, Bennett & Moore.

This article will not be discussing Bo Derek’s memorable jog down a beach in that memorable movie of the same name.  Instead it discusses the reliability of pain scales in the context of injury cases, a much less interesting topic!

According to the Journal of the American Board of Family Medicine, “Though the accuracy of the 5th vital sign for pain assessment is moderate, it is much lower in practice than under ideal research circumstances. Uniquely, we found that nurses may not always use the 0 to 10 scale to properly quantify pain levels and that informal screening practice leads to underestimation. Efforts to improve routine pain management can confidently use NRS, but provider training, education, and monitoring in screening techniques are needed, as are efforts to link the 5th vital sign to clinician action for better pain managementReading between the lines, this organization found nurses and doctors need more education in order for pain scales to be reliably used.

Typically, patients are asked to rate their pain from 0-10.  However, how those numbers are described seems to vary widely.  One clinician may describe a “10” as the worst pain imaginable, while another may describe it as the worst pain you have ever felt.  Of course, that can result in very different ratings depending on one’s history of prior injury and pain tolerance.  The results may be further complicated by cultural distortions, difficulties in interpretation, psychological factors including depression, education level which could impact understanding and an individuals pain tolerance in general.   Additionally, many injured people may generally feel that they must exaggerate their symptoms in order to be believed or to get the necessary medical treatment they require.  It’s important for us to emphasize to our injured clients that exaggerating symptoms is never a good idea and could result in some very real credibility consequences with the Court, employer and medical professionals.  On a similar note, it’s not uncommon to have some clients underestimate the symptoms they experience, and this also can result in difficulties related to being assigned appropriate work restrictions, getting necessary medical treatment and giving a full picture of the injury itself.

It’s not uncommon in trial for defense attorneys to make light of what they characterize as “exaggerated” pain ratings of 9 or 10.  Additionally, if you are arguing that a condition has gotten worse, it’s difficult to do so when 9 or 10 pain ratings have been given previously.  One colleague recently recounted an exchange during trial which is illustrative.  A client was discussing non-operative back pain to a Judge and had told him his pain was a 10.  When told to imagine Jesus Christ on the cross as the last spear thrust that ended his life as a “10”, and to compare his pain to that the client noted again his non-operable back pain was a “10”.  One can imagine how this client’s credibility may have been negatively impacted by this statement.

Opioids And Doctor Choice

Today’s post comes from guest author Jon Rehm, from Rehm, Bennett & Moore.

Chicago Mayor Rahm Emmanuel said in 2008 that “You never let a serious crisis go to waste.” In the context of opioids and workers compensation this could mean reforms to workers compensation systems beyond drug formularies If solving the opioid crisis means limiting the number of doctors who can prescribe opioids, then there will be fewer doctors who will treat workers compensation cases.

Additional licensure and certifications aren’t unheard of in the world of occupational health. In 2016, the Federal Motor Carrier Safety Administration implemented a new rule that only doctors on their registry can perform DOT Physical Examinations for truckers and other professional drivers. This reduced the number of doctors who can perform those examinations. 

When I testified on LB 408, a bill that would have implemented drug formularies for opioids under the Nebraska Workers’ Compensation Act, some doctors were testifying that there was little training in regards to prescribing opioids. Though an opioid prescription registry like the DOT examination registry wasn’t proposed, you could certainly see it proposed as a solution to the opioid problem.

By limiting the numbers of doctor who handle workers’ compensation claims through additional licensing requirements, injured employees will have fewer choices for medical treatment and are more likely to have their employer control their care.

Evidence shows that the workers compensation system has made some contribution to the opioid crisis. According to a 2015 report by the Bureau of Labor Statistics over 3.5 million employees were injured at work. Half of those injuries required the employee to miss sometime from work. A study of employees in 25 states done by the Workers Compensation Research Institute revealed that 55 to 85 percent of employees who missed at least one week of work were prescribed at least one opioid prescription.

When I testified on LB 408 the consensus among the doctors testifying on the legislation was that injured workers were more vulnerable to narcotic addiction than other patients who are prescribed narcotic pain medication. Scientific studies give some credence to these conclusions. Workers compensation claims can cause economic insecurity. According to an article in Scientific America, Addiction rates for opioids are 3.4 times higher for those with incomes under $20,000 per year than they are for employees making more than 50,000 per year.

But that article also shared studies that state that pain pill prescriptions are not driving the opioid epidemic. Patients with pre-existing addiction issues are more likely to become addicted to opioids and 75 percent of those who develop opioids start taking opioids in a non-prescribed manner. Furthermore, only 12 to 13 percent of ER patients who are treated for opioid overdoses are chronic pain patients.

Workers’ Compensation is traditionally an area of the law that is controlled by the states. Regulation of drugs is generally an area reserved for the federal government. Any laws imposing additional hurdles or requirements upon doctors who prescribe opioid drugs may have to come from the federal government.

Hoping That the Revolution in Medical Care Reaches Injured Workers

Today’s post comes from guest author Rod Rehm, from Rehm, Bennett & Moore.

Imagine a cross between a FitBit and a TENS Unit (Transcutaneous Electrical Nerve Stimulation) that can control, on demand, issues that hurt workers face: anxiety, pain, PTSD symptoms.

That combination might not be as far-off science fiction as a person would think.

Wearable medical devices are making remarkable advances, according to respected workers’ compensation commentator Robert Wilson.

“We are only scratching the surface of what may be possible,” he predicts. “Wearable devices that can dispense medication, provide biofeedback and can both monitor and adjust a patients vitals are very real possibilities. Devices such as these will improve quality of life with real time application and treatment, and that ‘improved experience’ will help our industry drive better results at an ultimately lower cost.”

A real-life example of these advancements is an app called myBivy, which was originally developed to help veterans with PTSD sleep better by disrupting the physical “symptoms that precede night terrors.” The app is being developed by a team that “Tyler Skluzacek, a student at Macalester College” in St. Paul, Minnesota, began when he was inspired to help his father, a veteran of the Iraq War. The app is in its testing phases now and is estimated to “officially launch between March and May” of this year. Since “7-8 percent of Americans will experience PTSD at some point in their lives” and “11-20 percent of post 9-11 veterans are estimated to have PTSD,” it’s pretty obvious how the app may help those who have developed PTSD through a work-related injury sleep better. I look forward to hearing more about this particular app for sure.

This app meets Wilson’s criteria of how wearables need to evolve to be the most helpful to those who can benefit the most from them.

“To be really effective and successful, the wearable revolution needs at least one more evolution,” Wilson wrote. “An evolution that takes this medium from that of casual observer to mobile clinician; from simple data collector to partner in health. That is when we will see real benefits and results from wearable technology in all health delivery systems.”

I am hopeful that the relentless cost-containment efforts of the “Workers’ Comp Industrial Complex’ will not inhibit these creative efforts, so injured workers and their loved ones will be able to benefit from these advances very soon.