by Gerry Stanley, M.D., FAAFP, P-CEO
We have all felt overwhelmed when dealing with patients suffering from pain…so many choices and so few options. We try to do what is best for our patient, but are confined to options that feel like the lesser of two evils: Drug A vs Drug B or Procedure A vs Procedure B. Our historical focus has been on which drug or procedure we should choose or not choose and is entirely focused on treating pain as a disease and not treating the patient as a person.
Many in healthcare act as if we are in the pill and surgery business. We are not, we are in the healing business. We need to think “outside of the box” and be open to novel ways of thinking about our patients and how to help them. We are not in the pills and surgery business; we are in the healing business. The Bio-Psycho-Social Model of Healthcare was described by George Engel, M.D. and acknowledged the interplay between the biologic, psychologic, and social aspects of a person and illness. Historically we treated pain as a purely biologic function fixating on the pathologic root to treat with drugs (Rx) or procedures (Injections or surgery). Approaching patients through the lens of the bio-psycho-social model allows us to shift from treating pain to treating patients. The underlying psychologic and social issues which are unique to a patient are as unique as the method by which they adapt or maladapt to pain. No person is better positioned to understand the underlying social and psychologic conditions than a nurse case manager who takes the time to process and comprehend the patient and their unique illness and condition.
Vx Therapy is a textbook example of innovation and a novel therapeutic approach. It combines proprietary virtual reality technology with personalized behavioral health interventions as a resource for treating workers compensation patients suffering from pain. Vx therapy focuses on the bio-psycho-social aspects of the patient’s condition and offers a non-pharmacologic and non-surgical tool to not only treat acute and chronic pain but also create more pain resilient patients. By engaging patients with the virtual reality headset and having telephonic consultations with specially trained personal clinicians, Vx Therapy is achieving pain reduction equal to opioids, without the side effects, and is also driving a tremendous increase in the duration and quality of sleep reported by patients. Furthermore, patients are reporting a decrease in their symptoms of depression, anxiety and are engaging in more of their normal social, physical and behavioral activities of daily living. A recent cohort analysis demonstrated a 69% reduction or cessation in opioid use because of the Vx Therapy. Essentially, when given the right stimuli, the brain will de-prioritize pain signals and thus begins the healing process for patients. Using a series of Vx experiences, the headset begins to educate patients about their pain, teach awareness and mindfulness as well as create specific distractions and events designed to create neuroplastic change within the brain. This neuroplastic change is what leads to long term pain mitigation and enhanced pain resiliency.
The role of a case manager is difficult. Often times it can be frustrating to watch treating providers sub-optimally manage a patients’ care journey. The vast majority of workers compensation patients will proceed from injury to recovery in a reasonable and expected manner; however, 15-20% do not improve. As you approach patients that are not progressing the question to answer is “why”. The goal of the case manager is to identify these patients early and then proactively work to get the patient back on track. Patients suffering from the trauma of a workplace injury deal with a constellation of symptoms: pain, sleep disturbances, anxiety, PTSD, and/or depression. As you approach your patients dealing with these issues, remember that you have effective tools to positively influence the trajectory of a patients’ clinical progress and recovery. In most instances, it is possible to treat these patients without narcotics and procedures. Below is a list of some simple indicators to help you identify these patients:
Opioids
- We can all acknowledge that opioids are a problem of epidemic proportions so when you see patients seeking early medication refills, those on high Morphine Milligram Equivalents (MME’s), or those that need to be tapered down on their opioid consumption for any reason, consider your non-pharmacologic options.
Underlying Psycho-Social Issues
- Patients with underlying issues such as depression, anxiety, PTSD or socioeconomic factors have significant barriers that need to be addressed for the patient to progress in healing and returning to work.
Patients dealing with trauma
- Whether it is physical trauma associated with an onsite injury (e.g. a fall) or emotional trauma (e.g. COVID exposure at work), patients dealing with traumas need additional psycho-social support.
Prior to Interventional Pain Referrals
- The need for interventional pain referrals is often the result of the primary care team having limited resources and/or capabilities to deal with a specific patients’ pain. They often cannot attribute the patients reported pain to an identifiable underlying biological issue. It also materially increases the cost of the claim and has not been shown to enhance a patients’ capacity to return to work. Furthermore, it can lead to unnecessary testing and procedures.
In conjunction with specific surgeries
- Patients who are scheduled to receive surgery on their shoulder, spine, foot or ankle have been linked to a higher risk of post-surgical opioid addiction and a lower ability to return to work.
Patients looking for a non-pharmacologic alternative
- Many patients are seeking non-pharmacologic alternatives in their care plans and will simply ask you for other options.
Potentially volatile claims
- When cases remain open for long periods or their cost begins to spiral upward, underlying psycho-social issues are often to blame. These are the cases in which the adjusters look to you, as the case manager, to help address and mitigate these issues.