Predicting Benefit From Pain Treatments

Friday, August 27, 2010 | 0

By Robert J. Barth, PH.D.

Psychological and social factors (e.g., mental illness, a history of being physically abused, eligibility for compensation, etc.) are extremely well-established as being predictive of the development of chronic pain. The non-credible premise that chronic pain is somehow work-related or injury-related appears to contribute to the detrimental effect that workers’ compensation has on the health of claimants because it creates a misdirected diagnosis and treatment emphasis on an injury model, instead of allowing for a focus on the non-work-related diagnostic issues and credible treatment approaches.

Given the role of psychological and social issues in the development of chronic pain, it is not surprising that such issues have also been scientifically established as predictors of whether an individual will benefit from medical treatments such as back surgery, spinal cord stimulation (SCS), implanted pumps, and the like.

For example, scientific findings have indicated that everything on the following list is predictive of a poor outcome for medical treatments for pain: eligibility for compensation, mental illness (e.g. mood disorders, anxiety disorders, personality disorders, a history of substance abuse), a history of being physically or sexually abused, a tendency to think catastrophically about pain, a low level of physical activity, job dissatisfaction, a lack of social support, unusual or extreme pain ratings, a low level of educational achievement, being widowed or divorced, a high level of perceived stress, a pessimistic attitude, a distrust of doctors, a correlation in time between pain onset or worsening and significant life events, and a history of having been abandoned or neglected in childhood. Additionally, many psychological tests and questionnaires have been scientifically validated as predictors of outcomes for medical treatment of pain.

The importance of assessing any individual’s potential for benefitting from such treatments is underscored by the fact that many of the treatments are associated with a lack of scientific support, high rates of treatment failure, and high risk of adverse effects. In other words, if the scientifically credible data has not been collected which objectively indicates that this one individual has a high probability of benefitting from the proposed treatment, then that treatment is going to carry an elevated risk of doing more harm than good. For example, the practice guidelines from the American College of Occupational and Environmental Medicine specify that SCS is likely to do more harm than good for any patient who has a presentation that is consistent with a mental illness called somatization disorder, which is actually defined by complaints of pain and other physical problems.

In order to protect the health of a claimant from treatments that are likely to do more harm than good, several options are available:

1. A comprehensive psychological evaluation is the safest course, but can be difficult to obtain for numerous reasons. In order to be comprehensive, such an evaluation should include a reveiw of health records (preferably from the claimant’s entire life), a clinical interview process, and objective psychological tests, all focused on the scientifically established predictors of potential to benefit from the proposed treatment.

2. A less comprehensive approach is often sufficient, and can be limited to any of the components listed in option number one. A model that has been taught for years in the American Association of Orthopaedic Surgeons’ courses frees the claimant from actually having to meet with a psychologist. The search for predictors of treatment outcome can be limited to:

a. Questionnaires that can be administered in the office of any trustworthy doctor, and then turned over to an independent psychologist for analysis; or

b. a records review by a clinician who is knowledgeable of the relevant science; or

c. some combination of the above.

Benefits from such efforts include:

• Maximizing the chances of a good health outcome for claimants
• Maximizing the efficient and prudent use of health resources (e.g. reducing unjustifiable costs)
• Minimizing the risks for clinicians as well as for patients (e.g. for clinicians, minimizing the risk of malpractice lawsuits that might otherwise result from having moved forward with risky, non-credible treatments in the absence of having thoroughly evaluated the patient’s potential for benefitting).

<i>Robert J. Barth Ph.D., is owner of Barth Neuroscience in Chattanooga, Tenn. This column was reprinted with his permission after being presented during the Florida Workers' Compensation Institute's annual conference in Orlando Aug. 15-18.</i>