pain a primer for adjusters

Pain is a universal human experience. TheInternational Association for the Study ofPain (IASP) defines pain as "an unpleasantsensory and emotional experience associatedwith actual or potential tissue damage ordescribed in terms of such damage." Painmay be a symptom of an underlying diseaseor disorder, or a disorder in its own right.

Multiple definitions

Google - The English word 'pain' probably comesfrom Old French (peine), Latin (poena - meaningpunishment pain), or Ancient Greek (poine - a wordmore related to penalty), or a combination of allthree

Bing - unpleasant physical sensation:

› the acutely unpleasant physical discomfortexperienced by somebody who is violentlystruck, injured, or ill feeling of discomfort a sensationof pain in a particular part of the body emotionaldistress: severe emotional or mental distress

Pain is difficult to define and describe.

Essentially, pain is the way your braininterprets information about a particularsensation that your body is experiencing.

Information (or "signals") about this painfulsensation are sent via nerve pathways toyour brain. The way in which your braininterprets these signals as "pain" can beaffected by many outside factors, some ofwhich can be controlled by specialtechniques.

Back pain accounted for 40 percent of absences from work, second only to the

common cold. (Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg. 2006;88A(suppl. 2):21-24.)

Acute pain is of short duration, usually theresult of an injury, surgery or illness. Thistype of pain includes acute injuries, post-operative pain and post-trauma pain.

Chronic pain is an ongoing condition, suchas back and neck pain, headaches, complexregional pain syndrome Type 1 (reflexsympathetic dystrophy), neuropathic pain(nerve injury pain), musculoskeletalpain, and pain related to illness.

Nocioceptive

Neuropathic

Psychogenic

Idiopathic

Nociceptive pain is caused by stimulation ofperipheral nerve fibers that respond only tostimuli approaching or exceeding harmfulintensity

Pain that is associated with tissue injury inthe presence of normal neurological function

Pain that is associated with abnormalneuronal function in either the centralnervous system or peripheral nervous system

Pain that is associated with emotionalconflict or psychosocial problems (akasomatoform pain) that are sufficient to allowthe conclusion that they are the maincausative influences. Exclusion of organicdisorders is not sufficient on its own towarrant the diagnosis.

Pain that is present in the absence ofidentifiable physical or psychologicalsubstrate or is considered excessive for theexisting organic process.

Difficult to explain why there is pain

It is believed to be of psychological origin butmay involve both cerebral and peripheralphysiological mechanisms.

Chronic pain is widely believed to representdisease itself. It can be made much worse byenvironmental and psychological factors.Chronic pain persists over a longer period oftime than acute pain and is resistant to mostmedical treatments. It can, and oftendoes, cause severe problems for patients.

Nocioceptive Pain

› Anti-inflammatory agents (nonselective)

› Anti-inflammatory agents (selective)

› Strong non-opiate preparations

› Weak opiate preparations

› Strong opiate preparations

Anti-inflammatory (nonselective)

› Ibuprofen (Motrin)

› Naproxen (Aleve or Naprosyn)

› Etodolac (Lodine)

› Ketoprofen (Orudis)

› Ketorolac (Toradol)

Anti-inflammatory- selective (Cox II inhib)

› Celecoxib ( Celebrex)

› Lumiracoxib (Prexige)

› Parecoxib (Dynastat)

› Etoricoxib (Arcoxia)

Strong non-opiate

› Tramadol

Weak opiates

› codeine, hydrocodone (Vicodin) – usually in combination with aspirin or acetaminophen

Strong opiate preparations

› Oxycodone (Oxycontin)

› Morphine sulfate

› Methadone

› Meperidine (Demerol)

› Buprenorphine (Buprenex)

› Fentanyl (Duragesic, Actiq)

Neuropathic pain

› Anticonvulsants

› Tricyclic antidepressants

› Selective serotonin reuptake inhibitors (SSRI)

› Other antidepressants

› Antispasmodic agents

› Other agents

Anticonvulsants

› Gabapentin – Neurontin (drug of choice as are low side effects)

› Oxcarbazepine (Trileptal)

› Topiramate (Topamax)

› Levetiracetam

› Zonisamide

› Lamotrigine

› Carbamazepine

› Phenytoin (Dilantin)

Tricyclic antidepressants

› Amitriptyline (Elavil)

› Nortriptyline (Pamelor)

› Doxepin (Sinequan)

› Imipramine (Tofranil)

› Desipramine (Norpramin)

SSRI – Selective serotonin reuptake inhibitor

Generally less effective for the management of pain, then tricyclic antidepressants Fluoxetine (Prozac)

Paroxetine (Paxil)

Sertraline (Zoloft)

Others

› many additional medications have been tried to varying degrees of success.

In summary, pain is a particularly complexand challenging issue to deal with.

Sorting out what is real versus not real isnearly impossible.

All pain is real to that individual perceivingthat unpleasant situation.

Add to this the tangent factors of indemnitybenefits, what is felt is owed, and the restmakes this a particularly difficult situationfor the workers compensation professionalto deal with.

Several things are essentialA. A comprehensive physical evaluation of the

individual

B. A comprehensive assessment as to identify the type of pain

C. Development of a treatment plan protocol that is consistent with national published parameters (ODG) N v. Y drugs. Past messages from the Division notes that 48% money spent of meds, were for drugs listed as “N” drugs.

D. Use of appropriate medications, particularly sustained release reparations when dealing with chronic pain

E. Adjunctive medications should be considered at every level

Thank you