Pain and disability

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ledo99

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I don't see a ton of chronic pain patients but I do see some migraine & chronic headache patients so wanted to get your opinion regarding the issue of pain and disability. from time to time I get questions (or paperwork) from patients or referring providers (PCPs, etc) asking if the patient qualifies for disability due to chronic pain (in these cases usually it's chronic migraine). Some of them do have refractory migraines, chronic daily headaches, etc. So far my opinion/position has been that I don't believe this alone justifies somebody to be on total permanent (or even total temporary) disability. I've been providing some instructions regarding what to do when there is a headache during work (rest in a dark quite spot, use OTC analgesics, etc), may be leave early if pain is really bad. This is as far as I would go in terms of job restrictions, etc. But haven't been that open to placing people on disability or retirement benefits due to their chronic pain. I don't personally see it as reasonable or justified, in fact I believe it's probably detrimental to their overall health and long-term outcome to be on disability from my limited experience with these cases.

What are your thoughts, opinions and experience regarding this issue?
 
ledo99 said:
I don't see a ton of chronic pain patients but I do see some migraine & chronic headache patients so wanted to get your opinion regarding the issue of pain and disability. from time to time I get questions (or paperwork) from patients or referring providers (PCPs, etc) asking if the patient qualifies for disability due to chronic pain (in these cases usually it's chronic migraine). Some of them do have refractory migraines, chronic daily headaches, etc. So far my opinion/position has been that I don't believe this alone justifies somebody to be on total permanent (or even total temporary) disability. I've been providing some instructions regarding what to do when there is a headache during work (rest in a dark quite spot, use OTC analgesics, etc), may be leave early if pain is really bad. This is as far as I would go in terms of job restrictions, etc. But haven't been that open to placing people on disability or retirement benefits due to their chronic pain. I don't personally see it as reasonable or justified, in fact I believe it's probably detrimental to their overall health and long-term outcome to be on disability from my limited experience with these cases.

What are your thoughts, opinions and experience regarding this issue?
Click to expand...

Agree in 99.9% of cases. I have this paperwork come across on a nearly daily basis. I bring the patient in to discuss face to face. I am frank in discussion with them that chronic pain/HA does not warrant disability, and that gainful employment is part of the rehabilitation plan. Of course, not often what they want to hear.
 
They will shop until they find someone who endorses it. 35% of patients with a Dx of FMS
are awarded SSDI. Think about the skew of that curve.

Arthritis Care Res (Hoboken). 2014 Sep;66(9):1354-63. doi: 10.1002/acr.22305.
Social security work disability and its predictors in patients with fibromyalgia.
Wolfe F1, Walitt BT, Katz RS, Häuser W.
Author information

Abstract
OBJECTIVE:
To determine prevalence and incidence of US Social Security Disability and Supplemental Security Income (SSD) in patients with fibromyalgia and to investigate prediction of SSD.

METHODS:
Over a mean of 4 years (range 1-13 years), we studied 2,321 patients with physician-diagnosed fibromyalgia (prevalent cases) and applied modified American College of Rheumatology (ACR) 2010 research criteria to identify criteria-positive patients.

RESULTS:
During the study, 34.8% (95% confidence interval [95% CI] 32.9-36.8%) of fibromyalgia patients received SSD. The annual incidence of SSD among patients not receiving SSD at study enrollment was 3.4% (95% CI 3.0-3.9%), and 25% were estimated to be work disabled at 9.0 years of followup. By comparison, the prevalence of SSD in rheumatoid arthritis (RA) patients with concomitant fibromyalgia was 55.6% (95% CI 54.3-57.0%) and was 42.4% in osteoarthritis (OA). By study conclusion, 31.4% of SSD awardees were no longer receiving SSD. In univariate models, incident SSD in patients with fibromyalgia was predicted by sociodemographic measures and by symptom burden; but the strongest predictor was functional status (Health Assessment Questionnaire disability index [HAQ DI]). In multivariable models, the HAQ DI and the Short Form 36-item health survey physical and mental component summary scores, but no other variables, predicted SSD. Fibromyalgia criteria-positive patients had more SSD, but the continuous scale, polysymptomatic distress index derived from the ACR criteria was a substantially better predictor of SSD than a criteria-positive diagnosis.

CONCLUSION:
The prevalence of SSD is high in fibromyalgia, but not higher than in RA and OA patients who satisfy fibromyalgia criteria. The best predictors of work disability are functional status variables.
 
But doc I don't want to work..... I neeeeeeed my disability.
 
ledo99 said:
I don't see a ton of chronic pain patients but I do see some migraine & chronic headache patients so wanted to get your opinion regarding the issue of pain and disability. from time to time I get questions (or paperwork) from patients or referring providers (PCPs, etc) asking if the patient qualifies for disability due to chronic pain (in these cases usually it's chronic migraine). Some of them do have refractory migraines, chronic daily headaches, etc. So far my opinion/position has been that I don't believe this alone justifies somebody to be on total permanent (or even total temporary) disability. I've been providing some instructions regarding what to do when there is a headache during work (rest in a dark quite spot, use OTC analgesics, etc), may be leave early if pain is really bad. This is as far as I would go in terms of job restrictions, etc. But haven't been that open to placing people on disability or retirement benefits due to their chronic pain. I don't personally see it as reasonable or justified, in fact I believe it's probably detrimental to their overall health and long-term outcome to be on disability from my limited experience with these cases.

What are your thoughts, opinions and experience regarding this issue?
Click to expand...
I've found the perfect solution for this,

"Sorry, it is office policy that Dr emd123 does not fill out disability paperwork."

[emoji4]
 
Thanks for the replies. it does become tricky sometimes when they start talking about specific job duties or tasks they can't do because of their pain. e.g. my pain is triggered by sitting at my desk for several hours, those office lights are triggering my migraine, etc. Do you allow any restrictions or job modifications to accommodate that? to me personally, again these cases are not very convincing to allow stuff like that. I simple say "if you have a migraine at work, you may rest in a dark/quite spot for a while, or leave early if persistent" but not sure it makes sense to say stuff like "no prolonged sitting, no heavy lifting, no bright desk lights, etc" which technically would be putting them on partial disability (I think?). it's not like they have a back/spine injury.
 
emd123 said:
I've found the perfect solution for this,

"Sorry, it is office policy that Dr emd123 does not fill out disability paperwork."

[emoji4]
Click to expand...

Yes that's actually my policy too. I am not worried about the paperwork, that I can handle. I was asking to get some thoughts; does pain in these cases justify disability. because I get asked about this regularly by other providers.
 
On a somewhat related note. FMLA paperwork. There is a large local employer that asks

"how many times will the patient need to miss work over the next 12 months for this condition."

I now reply that I do not have a crystal ball
 
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I don't consider pain alone an intermittent or permanent disability. Part of the goal of pain management is to teach people to manage their pain, and minimize flare ups. So I would not fill out FMLA or disability paperwork for migraines. I don't do it for chronic back or neck pain either.

Think about your own life and I am sure somewhere in your memory banks you will recall the day you worked with a splitting headache, or neck spasms. People cope. Teaching coping skills is one of the best things we can do for chronic pain patients.
 
emd123 said:
I've found the perfect solution for this,

"Sorry, it is office policy that Dr emd123 does not fill out disability paperwork."

[emoji4]
Click to expand...
I have found that you can post this in your lobby, on a neon sign outside your building and even on freeway billboards. A good number of patients will STILL think that they can talk you into it. The paperwork comes across my desk and before I know it my MA has received 30 messages and I'm getting numerous calls from the referring doc since their phone is blowing up too.

The answer is still no however it's not always so easy in my region.
 
Yo GabbaPentin said:
I have found that you can post this in your lobby, on a neon sign outside your building and even on freeway billboards. A good number of patients will STILL think that they can talk you into it. The paperwork comes across my desk and before I know it my MA has received 30 messages and I'm getting numerous calls from the referring doc since their phone is blowing up too.

The answer is still no however it's not always so easy in my region.
Click to expand...
Exactly. It's a big pain in the butt. But really, it's up to you what you decide to focus on. If you decide you want to fill out disability paperwork for patients, do it. There's nothing wrong with that. Just know that it means you're going to spend a CRAP TON of time doing it, mostly uncompensated.

That's one thing that makes me very grateful to be in Pain Medicine, in an outpatient physician-owned setting. I can decide what I want to focus on or not. I'm not forced by law (EMTALA) to see, treat and please every single patient that walks in the door, every day of the week, every hour of any day, holidays included, like I used to be. Trust me, that's a very, very painful thing, especially considering people can walk in with an insane demand, and then get pissed of and give you a crappy patient satisfaction score because you didn't comply with the insane demand, and then you get punished by administrators that care about nothing but the hospitals cash flow. I (and you) have the option to say, "Sorry. I don't do that," and I don't have to have a reason. It's great. So take advantage of this. You didn't go into this to be miserable, and hate your job.

I did a lot of this paper work the first couple years I was in practice, because I had the time, I was building my practice, and also a little naive about how out of control it would get. Then I found I was the only guy around doing this courtesy and the mountains of paperwork were piling up. I made the decision to change policies.

"Dr emd123 does not do disability paperwork."

They can have their PCP do it, ortho, or whomever wants to spend all day filling out forms instead of being a doctor. Or I can refer them for a FCE or to whomever wants to do this work. And I realize I may lose a potential patient over it. That is a patient who is going to demand of me, that I spend lots of time filling out papers instead of treating patients. I'm okay with that. That being said, I grandfathered in anyone who I had done this for in my first year or so, and I'll continue to help them with this stuff, but it keeps it to a manageable level.

Are you worried about your referrers getting upset you won't fill out these forms? If so, realize they've already made the decision to have a, "Doctor Referrer does not fill out disability paperwork" policy, themselves. Lol. Trust me, FPs, Internists, Orthos and everyone else realize a 14-yr-old high school pre-med could fill out these forms. But they've already beat you to the punch.
 
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The potential patient you will lose will also never "improve from
Meds or interventions" since that might get them better and therefore have to hold down a job.
 
I've been dropping some good lines at the end of my notes for disability seeking patients. Seeing me will set them back years in their quest for premature retirement. Can't wait to see the results on my healthgrades.
 
"Sorry, only Primary Care can do those forms."
 
emd123 said:
"Sorry, only Primary Care can do those forms."
Click to expand...

Sorry my
License won't allow it. You need a referral to a PCP. I will only give you enough disability until you see them.
 
I fill them out here and there but I have to admit it is a low priority in my day. If everything else is done (pts seen, notes done, crap cleared off my desk, beans/buckets in the EMR addressed) then I might look at them. MA does 90% of the form and we leave a lot of it blank. "get an FCE" is a common answer
 
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Jitter Bug said:
Sounds like an exercise in masochism. I would suffer far more than they would correcting their pre-filled out disability forms.
Click to expand...
Actually it would be easy. Just stamp with giant red DENIED TRY AGAIN stamp. Or a green APPROVED stamp. Just don't own the green one. It would be fun to turn the tables and watch them get frustrated with the paperwork while spinning them on a never ending wheel of DENIED...
 
LBP, we are doing such a great job treating it.
 

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  • MSKDisability.png
    MSKDisability.png
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um... its all about money.

5.
Conclusion
This paper presents an analysis of the effect of a compensation reform on work absence due to whiplash injury in Denmark. The reform resulted in
a significant increase in the compensation for temporary loss of earnings and permanent loss of earnings capacity. Learning about claiming behavior after whiplash injury is important because it is the most
common traffic injury and can result in prolonged disability
Click to expand...
The results from this study show that propensity to be on temporary disability is increasing with the level of compensation. Specifically, the propensity of temporary disability increased up to 7.5 percentage -points on average within the first year after the whiplash. Compared to the level of temporary disability, this amounts to a relative increase of about 18 percent. The increase is heterogeneous across the sample increasing with age, education and earnings. Remarkably, the increase in temporary disability is not accompanied by an increase in the use of prescription drugs that can match the increase in temporary disability, and there is no increase in the use of health services such as GPs, specialist, chiropractors and physiotherapists. This suggests that the disability effect is not rooted in poorer actual health.
Click to expand...
 
Yet another reason to explicitly ASK about pending disability/litigation/work injury/attorney involvement on our intake questionnaires.
 
I appreciate your feedback guys. Again I am not asking if I should fill out this paperwork or not, and I am not concerned about losing referrals or anything like that. I don't fill out any of that paperwork anyway. I wanted to know your opinions if you think that chronic pain (including chronic daily headaches or migraines) justifies being on disability. Because I have been asked this question before. if a patient does not have evidence of nerve, muscle, brain or spine injury, is there any reason to allow them to go on disability. My answer has been "not really", unless there is objective neurological injury or deficits that justifies it.
 
ledo99 said:
I appreciate your feedback guys. Again I am not asking if I should fill out this paperwork or not, and I am not concerned about losing referrals or anything like that. I don't fill out any of that paperwork anyway. I wanted to know your opinions if you think that chronic pain (including chronic daily headaches or migraines) justifies being on disability. Because I have been asked this question before. if a patient does not have evidence of nerve, muscle, brain or spine injury, is there any reason to allow them to go on disability. My answer has been "not really", unless there is objective neurological injury or deficits that justifies it.
Click to expand...

Pain from thalamic stroke. But they will have evidence on imaging and usually physical deficits.
 
ledo99 said:
I appreciate your feedback guys. Again I am not asking if I should fill out this paperwork or not, and I am not concerned about losing referrals or anything like that. I don't fill out any of that paperwork anyway. I wanted to know your opinions if you think that chronic pain (including chronic daily headaches or migraines) justifies being on disability. Because I have been asked this question before. if a patient does not have evidence of nerve, muscle, brain or spine injury, is there any reason to allow them to go on disability. My answer has been "not really", unless there is objective neurological injury or deficits that justifies it.
Click to expand...

Opioid seeking patients know just what shift the 'candy man' is on in the ED. They will call admitting
to ask his/her schedule and wait until he's back on shift before they show up.

And so it is with the Binder/Binder, work comp, and PIP crowd. They and their entourage quickly learn who will say what they want. If you are ethical, word will get out before long and they will avoid you.
 
101N said:
Opioid seeking patients know just what shift the 'candy man' is on in the ED. They will call admitting
to ask his/her schedule and wait until he's back on shift before they show up.

And so it is with the Binder/Binder, work comp, and PIP crowd. They and their entourage quickly learn who will say what they want. If you are ethical, word will get out before long and they will avoid you.
Click to expand...
Calling is too complicated. And many ERs dont give out that data.

In most small town ERs - well, at least 4 out of the 4 i worked out of - patients knew the physician's cars, and would check in accordingly.
 
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101N said:
Opioid seeking patients know just what shift the 'candy man' is on in the ED. They will call admitting
to ask his/her schedule and wait until he's back on shift before they show up.

.
Click to expand...
EDs are not stupid and they don't give out this info. Seekers do call trying to find this out all the time, but the secretaries and nurses are smart enough to not give out doctors schedules. After one shift in an ED, all know that addicts are swarming to get drugs, at all times. It's also strictly prohibited as a security risk because many ED patients are crazy, dangerous, under arrest or otherwise a threat to come back and assault staff.

What they often will do is go into the ED entrance/waiting/exit area and ask discharged patients what doctor they saw. That's how they get the info. Then they go in if Candy Man is on, or leave if Dr DontWasteYourTime is on.
 
i used to get a good amount of sleep during my night shifts at the community hospitals i worked at...
 
ledo99 said:
I don't see a ton of chronic pain patients but I do see some migraine & chronic headache patients so wanted to get your opinion regarding the issue of pain and disability. from time to time I get questions (or paperwork) from patients or referring providers (PCPs, etc) asking if the patient qualifies for disability due to chronic pain (in these cases usually it's chronic migraine). Some of them do have refractory migraines, chronic daily headaches, etc. So far my opinion/position has been that I don't believe this alone justifies somebody to be on total permanent (or even total temporary) disability. I've been providing some instructions regarding what to do when there is a headache during work (rest in a dark quite spot, use OTC analgesics, etc), may be leave early if pain is really bad. This is as far as I would go in terms of job restrictions, etc. But haven't been that open to placing people on disability or retirement benefits due to their chronic pain. I don't personally see it as reasonable or justified, in fact I believe it's probably detrimental to their overall health and long-term outcome to be on disability from my limited experience with these cases.

What are your thoughts, opinions and experience regarding this issue?
Click to expand...
 
Aside from experience, are there any courses (weekend/online) that can teach a pain physician the best way to navigate the disability world/patient? Any societies that have classes?
 
I have a follow up to this topic;

I do see some chronic neck/back pain patients from time to time. if a patient has some abnormality on imaging (lets say spondylosis, foraminal narrowing, facet disease, disc disease, etc), but patient does not have an objective deficit on exam besides tenderness, pain signs, numbness, etc, but no significant loss of function, no weakness, etc. is there any reason to allow them to go on disability based on symptoms and abnormal imaging? some patients unfortunately are train wrecks, they've had multiple surgeries based on the above (symptoms plus abnormal MRI), then they end up with a chronic pain syndrome on polypharmacy and all the package that comes along with that, and even more abnormal imaging with scarring, granulation tissues, etc. I still don't see a justification for disability if there is no objective loss of function, even with these imaging findings. what do you guys thing and what's your experience?
 
No permanent disability without three things, 1-objective, 2-severe, 3-permanent, loss of function.

I've never given a pain patient permanent disability as they've never had all three criteria.

If they didn't have a complete spinal cord injury or a severe stroke that paralyzed half their body or more, they can work.

I was a PM&R doctor before becoming a pain physician, so I know true disability when I see it.

Just back pain, heachaches, FMS etc, doesn't qualify you live off everyone else's labor and taxes.
 
Last edited:
Here are some sources:

Learn about disability and provide evaluation (IME) services: http://www.seak.com

AMA Guides 5th edition is what is used in California workers compensation to rate injured workers. There is a pain-specific chapter (18) which would interest you. Page 571 table 18-1: Illustrative list of well-established pain syndromes without significant, identifiable organ dysfunction to explain the pain. Headache (most), postherpetic neuralgia, tic doulourex, erythromelalgia, CRPS-I, any injury to nervous system.

Headache is a potentially disabling condition. Know the difference between totally temporarily disabled, partially disabled, permanent disability, exacerbation and aggravation.

With regards to rating impairment according to the AMA guides, it is not a matter of being able to work or not. It's about Whole Person Impairment (WPI) which is different. @bedrock stated he knows true disability and when someone can work. I am stating that according to AMA Guides a partial permanent disability can be granted for some headaches which require work restrictions of some type. Might be "No working in loud environments" or "Take visual breaks every 3 hours". TOTAL DISABILITY means you can't work. Unless its "own occupation total disability" then it means you can't work in your own occupation at all.

I learned this stuff this year since becoming a QME as it generates income while building up my practice instead of Rx'ing oxy 🙂

If you want to get your feet wet contact NMRco.com and tell em you want to review disability files. These are patients who insurance doesn't feel should be collecting disability and you review records and decide and give rationale.
 
Last edited by a moderator:
lobelsteve said:
HA is only a disabling from a Neurology standpoint. Pain/PMR no way.

TN, Thalamic CVA, SCI, TBI, CRPS when clinically definite and objective findings present, some cancers.
Click to expand...

TN would have to be severe, unrelenting, and failed every treatment under the sun, including invasive options.

I disagree on CRPS. By definition this only affects one limb. If its the arm, they can learn to the other arm just like an amputee, if its the leg, they can certainly do office work, including working from home.

I've seen a number of patients with CRPS, disabled by someone else, who live rather active lives once their treatment is optimized, and they could work and contribute to the tax system.
 
bedrock said:
TN would have to be severe, unrelenting, and failed every treatment under the sun, including invasive options.

I disagree on CRPS. By definition this only affects one limb. If its the arm, they can use to use the other arm just like an amputee, if its the leg, they can certainly do office work, including working from home.

I've seen a number of patients with CRPS, disabled by someone else, who live rather active lives once their treatment is optimized, and they could work and contribute to the tax system.
Click to expand...

Agree with most of that. There are patients whose CRPS pain when acute is so severe they are incapable of work. This usually lasts 3 months. Temp total for those folks.
 
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