Contending with Chronic Pain

In Canada, insurers are under fire due to the reports of chronic pain post motor vehicle accident collision. Recent findings have further complicated the chronic pain issue in Canada.

The World Health Organization has stated on recommendations set forth by the International Association for the Study of Pain that chronic pain treatment is a basic human right.¹ The Canadian Pain Coalition at the September 3, 2010 International Pain Summit in Montreal stated that “access to pain management is a fundamental human right.² And court judgments, including Martin vs. Workers Compensation Board of Nova Scotia, addressed severity of pain as a violation of the Canadian Charter of Rights.³

These findings provide further evidence of the struggles insures have when trying resolve motor vehicle accident claims in a timely and efficient manner. These current findings are then complicated further by the current legal system that acknowledges chronic pain to be a primarily subjective experience thus allowing any doctor to make a comment on need based on patient response.

The truth is that In Canada an estimated 6 to 7 million people suffer from chronic persistent pain.⁴ The Canadian Pain Study in 2002 reports that chronic pain patients make up to 40% of the population, and most doctors are ill-equipped to assess or treat these conditions due to an overall lack of education and training.

Dr. Jovey, president of the Canadian Pain Society, reported that two-thirds of physicians and two-thirds of patients believe chronic pain is not well managed, and that due to the shortage of pain specialists, family physicians are forced to provide the bulk of pain management care.⁵

The overall lack of whiplash and chronic pain specific training is leading to an environment in which providers (DCs, psychologists, GPs, neurologists, physiatrists, orthopedic surgeons) are stepping into the gray area of their scopes in order to make medical opinions. These medical opinions can then lead to further expenditures and disability. If a plaintiff chronic pain doctor indicates to a patient that a chronic pain process is present, this changes the ideology of the injured person, their belief in their functional abilities and their long-term outcome. Research has shown that a patient’s perception of pain is as important as the actual pain present.⁶

On the same hand, if the insurer prematurely denies benefits for those suffering from pain, research has shown that the cause of pain can continue to exacerbate. In general MVAs, the majority of initial pain symptoms are due to nociceptive input, such as tissue damage resulting in a painful response. However, if this tissue damage is not appropriately and timely treated, continued nociceptive input can lead to neuropathic pain, compressive pain or psychogenic pain, further complicating the overall recovery outlook.⁷

Whiplash and chronic pain research has evolved greatly over the last two decades. We now know how occupants react inside a vehicle during specific vector collisions at different speeds dependent on crash variables, speeds and risk factors. We also know that chronic pain can be objectively found through specific orthopedic testing and special tests such as fMRI and PET scans.

Whiplash and chronic pain education is the key to overall reduced liability in regards to chronic pain and motor vehicle trauma. Doctors who deny benefits based on assumption and opinion, allow for increased litigation potential, as well as reduced client retention on the insurer’s part. Doctors without specific training who freely deliver chronic pain diagnosis based solely on subjective reports allow for flooding of the claims process as well as psychological related adverse effects on client.

As insurers, the answer is simple. Require specific postgraduate training from both the plaintiff IME and defense IME firms chosen doctors. Those requesting chronic pain assessments related to motor vehicle trauma or denial of chronic pain benefits related to motor vehicle trauma should have post graduate training in whiplash traumatology as well as in chronic pain from a CME (continuing medical education) or CCE (continuing chiropractic education) approved organization.

The current standard in Canada is the Canadian Academy of Pain Management. Those recognized with a Diplomat in Pain Management have obtained this through several qualifying control steps (completed through the AAPM). First, the doctor must have enough CME or CCE training in pain management to be approved to sit for the qualifying examination by a panel of pain experts. Secondly, the doctor must pass a rigorous and comprehensive multidisciplinary pain management test. Thirdly, and most importantly the doctor must maintain 100 hours of continuing education per cycle.

In my view, this is just as important as pain medicine, as medicine in general is every changing and continued maintenance of education is required to ensure the best possible outcomes for those injured.

By requesting this specific education from your IME assessors, the overall quality of care will be enhanced and the overall duration of symptoms along with overall disability, and need for additional benefit will be reduced.

Dr. Jason Mazzarella, DC, DAAPM, DCAPM, DAAETS, FIAMA, MVC-FRA, CBIS, CMVT, CATSM, CPM, is a specialist in chronic pain and one of only 26 Pain Management Diplomats in Canada.

1. World Health Organization.
http://www.who.int/en/
Retrieved May 28, 2013.

2. The Status of Pain in Canada – moving toward a Canadian Pain Strategy Recommended by theCanadian Pain Coalition, The National Voice of People with Pain.
http://www.canadianpaincoalition.ca

3. Judgments of the Supreme Court of Canada. http://scc.lexum.org/decisia-scc-csc/scc-csc/scc-csc/en/item/2088/index.do Retrieved May 28, 2013

4. Definition of Chronic Pain from the Supreme Court of Canada. http://ontarioinsurancelaw.blogspot.ca/ 2009/07/definition-of-chronic-pain-from-supreme.html

5. Health Canada Meeting Re: Scheduling of Tramadol Ottawa, December 5th 2006. Roman D. Jovey MD, President Canadian Pain Society.

6. Barry L, Guo Z, Kerns R, Duong B, Reid MC: Functional self-efficacy and pain-related disability among older veterans with chronic pain in a primary care setting. Pain 104 (2003) 131-137

7. Woolf CJ: Central Sensitization: Implications for the diagnosis and treatment of pain. Pain 152 (2011) S2-S15