Pain Management Center In The Department of Anesthesia

International Association for the Study of Pain (IASP)

The 2002 International Association for the Study of Pain (IASP) Official Satellite Symposium "Pain Assessment and Opiates in the Workplace: Medical, Legal, and Practical Issues" was held August 12th and 13th at Stanford University.

We are pleased to offer the lectures from that event in an online format for those who were unable to attend. The format requires Microsoft Internet Explorer V6.X or higher. It may work with other browsers, but has not been tested, and probably will not be. The video production was intended for CD distribution, and as such, requires a fairly high speed connection to the internet. It may not play well over a dial up modem. If you are interested in having a 2 CD set, please email my assistant at . The cost is $50 which goes to educational purposes in the Pain Center.

The purpose of the symposium was to host a 2-day international conference addressing major issues in chronic pain management centered around the use of opiates and the dilemma of separating out subjective and objective factors in making an accurate pain assessment. Our goal was to bring together physicians, psychologists, nurses, attorneys, and members of law enforcement to present the current data and engage in productive discussion on these topics. In that regard, I believe we succeeded.

The meeting was held on our sunny scenic campus in warm Northern California several days before the main meeting of the IASP in San Diego.

Scroll down further to read more about the rationale behind this conference.

Thank you,

Sean Mackey, M.D., Ph.D.
Director, Division of Pain Management

“Pain, Pain Assessment, Opiates, and the Workplace: Medical, Legal, and Practical Issues”

Background and Rationale

Day 1 - “Opiates, Cognition, and Work - Clinical and Legal Issues”

During the 1990s, significant changes occurred in many countries regarding the use of opiates in the treatment of chronic nonmalignant pain (CNP). The changes occurred at several levels:

As an expected consequence of the above changes, long term opiate therapy is being provided more frequently now than it was ten years ago. There is every reason to expect this trend to continue - i.e., to anticipate a significant increase in the number of CNP patients on long term opiate therapy during the upcoming decade.

From a clinical standpoint, long term opiate therapy is usually considered successful if patients receiving it indicate convincingly that they are getting substantial pain relief. From a societal standpoint, however, different questions come to the fore. Even if opiates produce long term pain relief, disability agencies, businesses, and other segments of society have a legitimate interest in the effects of opiates on patients’ ability to function - particularly in the workplace. From this perspective, several questions become pertinent:

  1. Is there evidence that in addition to providing pain relief, opiate therapy improves the physical functioning of patients with CNP?
  2. Is there evidence that opiate therapy permits a significant proportion of CNP patients to return or to remain in the work force?
  3. What are the effects of opiates on cognitive functioning? Do they impair cognitive functioning to such an extent that they preclude employment even in patients who are getting significant pain relief from them?
  4. Do opiates have other adverse effects - such as deleterious effects on mood or sleep - that negatively affect the ability of patients taking them to work?
  5. How do the impairing effects of opiates compare to those of other groups of prescription medications - such as benzodiazepines, SSRI antidepressants, antihistamines, or beta blockers?
  6. What liability issues are raised when patients taking opiates perform poorly or cause accidents at work or during activities such as driving automobiles? What is the legal responsibility of the patient, the employer, and the prescribing physician in such situations?

These issues will be addressed during Day 1 of the symposium.

Day 2 - “Assessment of Pain in the Settings of Clinical Care, Medicolegal Proceedings, and Disability Evaluations”.

The dilemma of pain assessment is easy to state, and extremely difficult to resolve. It is that there is a fundamental divide between the personal, private data available to a patient suffering pain and the objective, public data that are available to external observers who try to understand and respond to the patient’s pain. In clinical, forensic, and disability evaluation settings, chronic pain patients routinely complain of severe suffering and functional limitations because of their pain. Typically, physicians who evaluate these patients cannot identify tissue damage/organ pathology that makes these complaints seem inevitable or even plausible. The physician then has the dilemma of integrating the subjective reports of a patient with the objective evidence of tissue damage/organ pathology to come up with some final judgment about the extent of the patient’s suffering and incapacitation. At one extreme, a physician might simply ignore a patient’s self-assessments, and make determinations based strictly on objective findings of tissue damage/organ pathology. At the opposite extreme, the physician might provide treatment or award disability based on the patient’s pain reports, without any requirement for associated evidence of tissue damage/organ dysfunction. Most physicians feel uncomfortable with either extreme, but it has proved extremely difficult to find some middle ground in which both objective data and self-assessments by patients can be incorporated into clinical and disability evaluations for patients with chronic pain.

As a result of this conundrum, the assessment of pain is fraught with ambiguity, and distrust frequently develops between chronic pain patients and the physicians or adjudicators who try to assess them.

Pain assessment is the theme of Day 2 of the symposium. The morning session is devoted to the problems of pain assessment that arise in clinical and forensic settings. In the afternoon, we will consider methods for assessing pain among individuals seeking work disability benefits, and the ways in which different disability agencies conceptualize the role of pain in work disability.

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