Pain Assessment, Opiates, and the Workplace: Medical, Legal, and Practical
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
A significant body of research on the effectiveness of opiates
in CNP was published. The results generally support the conclusion
that opiates produce long term pain relief, but are less clear about the
effects of opiates on the ability of patients with CNP to improve their
physical functioning and/or return to work.
Regulatory agencies generally relaxed their prohibitions
against the prescription of opiates for chronic nonmalignant pain. Many
jurisdictions now have guidelines or policies that specifically permit the
use of opiates for these patients.
Physicians and medical societies made formal statements
supporting the appropriateness of long term opiate therapy for at least some
patients with CNP.
Groups representing patients with chronic pain became
advocates for the availability of opiates.
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
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
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.
Since August 29, 2004