Chronic Pain Syndrome in Nova Scotia. Donald Haigh, M.Sc, MDCM, CIME, CCBOM Atlantic Offshore Medical Services

Transcription

1 Chronic Pain Syndrome in Nova Scotia Donald Haigh, M.Sc, MDCM, CIME, CCBOM Atlantic Offshore Medical Services

2 Agenda 1. Introduction 2. Medical Aspects of Chronic Pain 3. WCB Aspects of Chronic Pain in Nova Scotia 4. Preventive Strategies 5. Socio-political aspects 6. Related Compensation Issues 7. Questions & Discussion

3 Medical Aspects of Chronic Pain: What is Chronic Pain? After an accident everyone has PAIN from time to time but in up to 25% of people it lasts well past the normal recovery. Occasionally it becomes life-long! Pain of excessive duration is called Chronic Non-Malignant Pain. Acute Pain usually indicates a traumatic structural or functional breakdown in the body. Acute Pain usually means Harm. Chronic Non-Malignant Pain is an aberration in the normal recovery process, and usually is not associated with Harm.

4 Lessons from Acute Pain (Ronald Melzack s Gate) What opens the Gate: Extent of Injury Inappropriate activity level Anxiety Tension Depression Focusing on Pain Boredom What closes the Gate: Medications Heat, massage Positive emotions Relaxation Distraction Involvement in life activities

5 What about Chronic Pain (Dr. Jock Murray, 1996) Reviewed over 1700 scientific citations and produced a report for the WCB Mind body dichotomy doesn t apply; pain on a spectrum from neuralgias to somatic depression equivalents No specific neurological anomaly detected. Many cases do not have a specific traumatic event There don t appear to be Pain Prone people Positivity and movement are the only hope, Deal with the whole person

6 The Eight D s of Chronic Pain (AMA 4 th ed) Duration Dramatization Diagnostic Dilemma Drugs Dependence Depression Disuse Dysfunction Need 2/8 or 4/8??

7 WCB Aspects of Chronic Pain: Chronic Pain is legally defined (section 10A) as: (a) continuing beyond the normal recovery time for the type of personal injury that precipitated, triggered or otherwise predated the pain; or (b) disproportionate to the type of personal injury that precipitated, triggered or otherwise predated the pain, and includes chronic pain syndrome, fibromyalgia, myofascial pain syndrome, and all other like or related conditions, but does not include pain supported by significant, objective, physical findings at the site of the injury which indicate that the injury has not healed.

8 The Timeline 1996 New WCB Act Dr. Jock Murray s report 1999 Amendments to legislation FRP regulations limited benefits for workers with Chronic Pain provided limited benefits for Chronic Pain to a small sub-group (transitional group) 2003 Supreme Court of Canada Decision

9 The Old system Applied to workers after April 17, 1985; after March 23, 1990 income replacement applies Initial response of NS WCB was a 2 phase Functional Restoration Program (FRP I{prevention} & FRP II{claim closure}) based on a Sports Medicine Approach. This was followed by a more focused prevention program called the Pain Disability Prevention Program (PDPP) with a Functional Restoration Program at claim closure (FRP). PMI of 12.5% for window cases. All were struck down as unconstitutional by the Supreme Court Chronic Pain decision in Oct., 03.(not same access to compensation, not individualized assessment) New Chronic Pain Policy on Sept.9, 04

10 The WCB s New Chronic Pain Approach (Policy ): Worker is eligible if he had a work injury after April 17, 1985 (date of Charter of Rights) and developed chronic pain. Highly modified version of the AMA Guides to Evaluation of Permanent Medical Impairment, 5 th ed. Applies to special populations such as old CRS pension recipients Decisions are Appealable FRP is still offered List of 4000 injured workers who are requesting eligibility assessment as of Sept., 04

11 To be adjudicated by a special Transition Team 3 categories: No impairment meriting compensation Slight pain-related impairment; PRI 3% Substantial pain-related impairment PRI 6% Categories based on: Medical Info (pain at rest, needs meds,etc.) ADL (movement, sleep, sex, etc.) Emotional state Functional abilities (ROM, pushing, pulling, lifting, etc.) reviewed by WCB Medical Advisor

12 The Consequence of Policy increase the benefits liability by approximately $220 million According to Annual Report unfunded liability in 2003 was $412 million($350.3m. in 02, $290.6m. in 01) ongoing annual costs of approximately $11 million 3% increase in average assessment rate effective Jan.1, 2005.

13 PREVENTION!!

14 PrimaryPrevention

15 2 0 Prevention : After the Accident watch out for RED (medical complications) and YELLOW (Psychosocial complications) Flags. If present they must be addressed IMMEDIATELY Needs a Team Approach

16 Red Flags: On immunosuppressive drugs Other medical conditions (diabetes, etc.) which will slow healing History of drug abuse Pain is unrelenting and getting worse despite adequate therapy Previous history of slow recovery Diagnostic dilemma Female (???)

17 Yellow Flags: Fearful Angry Resentful Depressed Future is threatening Poor job satisfaction Preoccupied with illness Litigation involved

18 Treatment is the Sports Medicine Approach: "Management must change from a negative philosophy of rest for pain to more active restoration of function." Gordon Waddell MD, orthopedist "If something is injured and you start to slowly move it under controlled conditions, the structure heals quicker and better." Alf Nachemson MD, orthopedist

19 More Treatment Pain-centered psychological services may be a useful adjunct to the Function-Restorative Approach. Still being researched but a parallel short Cognitive-Behavioral Therapy has shown promising results Treat underlying psychological problems if present

20 Thoughts on the Socio-political aspects How do other places handle this?: AB, BC, MB, NF, NWT, & ON WCB s define Chronic Pain in their Acts AB, NF,ON, & PEI have a formal Policy on Chronic Pain AB has a written procedure pertaining to Chronic Pain More legal challenges? Injured workers groups have indicated that they preferred the Major Life Disruption evaluation method and some have threatened another Charter Appeal. (It is speculated that this course might cost $400+ million in NS.)

21 Some Other Related Compensation Issues Repetitive Strain Injuries (RSI s) Are we repeating the Australian Epidemic? Telecom Australia data, Job Telephonist Keyboard staff Telegraphists Process workers # of cases # per per per per per 1000 Hocking B, Med. J. of Australia, 1987, 147 pp

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23 More Telecom Australia 644 people (16%) were off of work for > 26 weeks Total cost was >$15 million (Aus) Medical costs >$1.8 million (Aus) Suggested reading: Whiplash and other Useful Diagnoses, Andrew Malleson MD, McGill-Queens University Press, 2002 Occupational Musculoskeletal Disorders, 3 rd ed, Nortin M Hadler MD, Lippincott Williams & Wilkins, 2005

24 Questions or Comments?