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Managing Pain and Pain Medication Wisely

Pain — on or off the job, associated with a work-related injury or not — has very strong psychosocial characteristics. Risk managers, plant nurses and doctors, supervisors, and administrative personnel often have to take it into consideration as they deal with reducing lost time, both for the office overall and in the individual worker’s case.

From an objective perspective, it is often extremely difficult to judge the severity of an injury, the extent of pain it causes, and, most importantly, when an employee is ready to return to work and what job accommodations may be needed.

This is especially true with minor injuries, where bones are not broken and where the degree of impairment is marginal. For example, what should be expected of an employee if he or she has a strain or a sprain, a scratch or a bruise, or a bump? How can the extent of loss of function or the degree of pain be measured? The truth is that they really can’t! They can be only approximated by a trained professional based on past cases and the employee’s own reports. Nonetheless, there are some basics that you should learn in order to better work with and manage the return to work of employees’ experiencing pain.

What Is Pain?

This is not a neuropsychiatric discussion. It is intended to be a practical explanation of how to deal with negative realities. If a person complains that “it hurts,” the pain is real, even if it is only in his or her mind. Actually, all pain is in the mind of the person experiencing it. Even if Wally Worker says that his right wrist hurts, the actual pain is in his brain at the point of neurotransmission that tells Wally where it hurts and how badly.

If, in the mind of Wally, the pain prevents him from doing his job, his supervisor and his therapists must start their approach to his disability from that point. Pain is almost always a symptom of an underlying problem, so a professional has to take on the responsibility, absent the patient’s cooperation or ability, to determine its source and make every effort to eliminate the cause.

In a situation where an acute inflammation (from a bump or a bruise, for example) is the cause of the pain, anti-inflammatory drugs (e.g., ibuprofen) may work to eliminate the cause and the symptom. Since ibuprofen, in small dosages, can be bought over the counter, many acute pains are “treated” and “cured” by the person who sustains them. Chronic (long-standing) pain is a different matter. It has to be evaluated by an appropriate health-care practitioner and interpreted in the context of its origin, with individual consideration for the patient who has it.

Headaches and the Burden of Migraine

Headaches are one of the most underplayed causes of lost time from work, even when they are not directly a result of workplace injuries. Most headaches are of undetermined origin, but related to stress. They can be very debilitating and have a profound impact on productivity. Of course, the “cure” for stress-related headaches is to get rid of the stress; however, medications as interim modifiers of headaches are an acceptable, even if only a symptomatic, relief from the discomfort.

Migraine, a term frequently used incorrectly to refer to head pain, is a specific type of headache. Classically, it involves one side of the head and is accompanied by irritability, nausea, and, not infrequently, vomiting and constipation or diarrhea. Its treatment is different from the more common stress-related headache and should be handled medically.

According to Lipton and colleagues, “migraine imposes an enormous health burden on individual headache sufferers and society…. Because prevalence peaks during the most productive years, between the ages of 25 and 55, migraine is an important cause of lost work time…. Add to this the indirect costs, in the form of absenteeism and reduced productivity at work, and the overall burden of migraine becomes apparent. Work loss is not uniformly distributed, with the most disabled half of migraineurs accounting for more than 80% of all work loss.” There is good news, however. Lipton reports that there have been recent improvements in migraine treatment, which, while increasing medical and drugs costs, will probably be balanced by improving productivity and decreasing lost time from work.

Dental and Facial Trauma Pain

As an oral and maxillofacial surgeon, I would be remiss if I failed to discuss dental and facial trauma and pain. Surprisingly, this trauma tends to be overlooked in the general scheme of workplace injuries, even though it is among the more common injuries that occur. The pain can be extremely debilitating, involving difficulty in swallowing and chewing and neuralgia (i.e., pain along the course of a nerve) of the facial muscles and the jaw joints.

The challenges of treatment, the emotional distress associated with possible disfigurement, and the cost of these injuries in terms of lost time and reduced productivity have led Gassner and colleagues to strongly recommend “widespread and manifold prevention efforts.” These efforts should include the use of seatbelts when driving, the use of face masks when using certain types of machinery, and the use of mouth and tooth protectors in activities that can cause blows to the mid-face or jaws. Such precautions will also minimize the impact of reverberative injuries to the skull.

How Is Pain Treated?

The treatment of pain is as complex and varied as there are different types of pain. There may be no harm in treating a toothache, a headache, or a backache with drugs, as long as it is understood that an evaluation of the causes should be undertaken as soon as possible. Long-term, definitive care for chronic pain often requires highly sophisticated techniques that should be undertaken by a therapist who is familiar with the patient’s lifestyle and psychosocial characteristics.

While a chronic pain management program is recommended, it must be handled sensitively and should be carried out as part of an injury management program. Often, this can be linked to an employee assistance program (EAP), especially since employees who are already attending EAP sessions are often the ones who have the greatest propensity to chronic pains.

Medicine in the Workplace

Any discussion about pain must address the matter of medicine or pills. With the aging of the world’s work forces, and the propensity of doctors to rely on chemical agents to control pain, like it or not, needed or not, people are more inclined than ever to depend upon pills to relieve their symptoms.

Pain is probably the main workplace problem that tends to be treated with pills — analgesics, anti-inflammatories, narcotics, herbal remedies, barbiturates, tranquilizers, anti-depressants — all aimed, whether appropriate or not, at central nervous system pain points. More often than not, such pills are self-prescribed — the person has acquired unused prescription drugs from a family or friend, or just found the pills in the household medicine cabinet, in order to treat the pain. Other times, a doctor is writing the prescription, but the patient had made the appointment for the express purpose of obtaining relief from pain and the doctor, who had 15 minutes with the patient, obliges. Health-care providers share in the responsibility for prescribing the strongest among these pills and then failing to admonish their patients about tapering off — or failing to follow up at all.

I have found workers, at work, taking everything from Percodan, to codeine, to Vicodin, to Prozac, and even Demerol and morphine. And I am not including those who are using illegal drugs like cocaine or marijuana, or suffering the effects of alcohol abuse. The trend of legal drug use is an extraordinarily dangerous one, especially with people who hold down jobs requiring hand-eye coordination, clear minds, and manual dexterity. There are no statistics that reveal the seriousness of this problem, but I am convinced that many accidents occur with workers who are inappropriately self-medicating themselves.

While workers’ rights to privacy prevent individual interrogation of employees, there is nothing to prevent employers from instituting educational programs in the workplace, explaining the seriousness of this problem. Many people taking such pills simply don’t realize the extent of the danger to which they are exposing themselves and others.

Some employers attempt to impose medication-free workplaces, requiring that prescription medications be maintained in the company health clinic, under nurse supervision. That can be effective, but requires careful and difficult-to-enforce control techniques. Companies should at least establish a medication-usage policy that limits when certain pain-killing — especially narcotic — drugs can be taken. Devising the policy, of course, will require medical input and probably legal counsel as well.

Compliance with Prescription Directions

In addition to the matter of pills in the workplace is the issue of whether employees are taking them correctly. Numerous studies have indicated that patients are notoriously non-compliant in the way they take prescription medications and the way they dispose of them after the symptoms or disease has been eliminated. This includes a large number of patients who share unused prescription medicine with a friend or family member who is seemingly suffering from their former ailment. This is especially true with pain medication. Employers, risk managers, and occupational health nurses must take this fact into account as they develop medication usage policies.

Developing a Pain Management Program

Pain management must be a part of your overall workers compensation or disability risk management because pain, in one form or other, is usually what keeps workers from doing their jobs or, for that matter, from returning to work after they have been hurt. Injuries, generally speaking, are visible, while pain is not. This creates issues of credibility and maybe even depression. A pain management program should foster an open and frank relationship between employer representatives and workers necessary for a successful return to work.

Within an overall pain management program, employers and medical personnel should not shy away from admonishing their employees to avoid the use of medications to shield the underlying cause of their pain. For successful medication control — and employees' actual recovery from what is causing their pain — the program will require the assistance of a trained occupational health-care provider.

ABOUT THE AUTHOR

The Journal of Workers Compensation is a quarterly review of risk management and cost containment strategies published by Standard Publishing in Boston, Massachusetts. For more information, please visit our web site, www.standardpublishingcorp.com, or contact the editor at 800-682-5759, extension 222, or subscription services at extension 228.

riskVue | The webzine for risk management profesionals
May 2001