by Geralyn Datz, PhD
The Opioid Epidemic has forced providers and insurers to re-evaluate the way chronic pain is treated both short and long term. As a result, there has been a renewed interest in non-medical based treatments that restore pain patients, particularly injured workers, to health and optimal function.
Chronic pain is a common presentation in work injury. Functional restoration, or Interdisciplinary Pain Rehabilitation (IDPR) is a non-medication based option that can restore patients with pain to higher function and return to work. This is an intensive treatment that occurs during a full day, and typically for 20 consecutive days (programs may vary slightly in their duration). The programs are coordinated by a group of skilled healthcare providers, all of whom have experience in treating patients with pain.
As Director of a functional restoration program in Mississippi, a question I am often asked is, “Does it really work?” And, “more importantly, Is it worth it?” Treatments are all about value and return on investment (ROI). And if there is no perceived value, why would insurance pay for something that is fairly expensive compared to a single, stand alone treatment?
The use of chronic opioid therapy for all patients with pain is a good example of high expense and low return on investment. While opioids can be appropriate in some circumstances, the consensus is that they are currently overprescribed as the only therapy for pain by physicians and are overused by patients. In addition, they can be easily obtained by non-medical users https://www.cdc.gov/drugoverdose/data/prescribing.html .
In the case of non-specific low back pain, neck pain, or “whole body” (musculoskeletal) pain, for example, opioids are not the recommended first line treatment, but are nonetheless often used as the only treatment. Extended use of opioids can contribute, ironically, to greater physical pain (in a process called opioid induced hyperalgesia), and reduced activity level, depression and greater disability. Opioids have been under scrutiny for contribution to addiction and overdose risks, and death.
These challenges all translate to poorer care of injured workers, increased time off work, and increased costs and difficult claims handling for employers and insurers.
With respect to cost, expenses related to opioid prescriptions per claim continue to grow in the United States. The National Council on Compensation Insurance (NCCI) indicates that medical costs are now approximately 59 to 60 percent of workers’ compensation claims costs. Opioid prescriptions account for at least 25% percent of these costs.
As problematic as medication-only approaches are, at least they are familiar. For some insurers, and providers, the ‘Devil they know is better than the Devil they don’t know’, to borrow from an old saying. For some, it became “comfortable” to prescribe opioids as a sole therapy for chronic pain, as other treatments were either not known, understood, nor appreciated. We now know that no one treatment is best for pain. Using a multimodal or biopsychosocial approach, where the whole person is addressed, leads to the best recovery from pain.
When I speak to carriers and employers about functional restoration, this thinking style and their discomfort with change is often obvious. Their initial confusion is related to wondering how could a treatment last ALL DAY, when we are “simply talking,” (or worse, “watching movies”, or “coloring”, also fears I have heard) for 20 consecutive days in a row. What a rip off!! If that were what functional restoration was, I would have to agree.
However, true functional restoration could not be more different. True functional restoration is the combination of two highly skilled services: Cognitive Behavioral Therapy (CBT), a type of specialized psychotherapy, and intensive Physical Therapy (PT). Note the word “intensive”, because ordinary, 1 hour a day, run-of-the-mill PT won’t pass muster in a functional restoration program. On Day 1 of our program, we tell patients, “You WILL have a flare up in this program. If you don’t, we are doing something wrong.” Amazingly, the majority of our patients go from barely moving to walking the equivalent of walking five miles a day at program’s end. It is not unusual for patients to also increase their strength by 500%. Now that’s PT!
Here’s some straight talk on what functional restoration is and isn’t.
Characteristics of Functional Restoration
- Functional restoration reduces medication intake, in particular opioids. This is perhaps the most important feature of functional restoration. Rule of thumb: If a patient’s medications did not change during a functional restoration program, you definitely just wasted a lot of money.
Functional restoration is about reducing reliance on medication and teaching patients to self manage pain. Some patients need to be treated prior to program enrollment to wean medications, either inpatient or outpatient. It is not unusual to reduce patients from 400mg of opioids a day or more to zero opioids at the end of these types of program. This is done through appropriate weaning or detoxification, counseling, coordination with prescribers, and lots of coaching and education.
Many patients would prefer not to be on the medications they are on, and are yearning for a solution that restores their previous way of living. However, with few choices and alternatives, they fear change. When given an alternative for a fuller, restored, healthier and more active life, many patients will jump at that chance.
- Functional restoration is very focused on Return to Work and Activity. If return to work or former job is not feasible, then it’s about Return to Life. As the name implies, these programs are about restoring function.
Effective programs spend time teaching patients about Return to Work (RTW). The literature shows that functional restoration has 75 to 88% RTW rates. This is because the program is designed to help patients overcome the mental and physical obstacles that prevent their recovery. Research shows if the employer is willing to work with the client, there is more success in returning the client to their original position, or some modified version of it.
- Functional restoration is an alternative to surgery, particularly when a patient doesn’t want, or doesn’t qualify for surgery. Many studies have shown that functional restoration is an effective alternative to spine surgery and other surgical procedures, and can produce greater benefits.
Spine surgery is far more costly than functional restoration, and while it is often touted as an effective means to RTW, the data do not support this. Several well-performed studies have demonstrated that RTW rates after spinal fusion are relatively poor. In a 2011 Ohio Work Comp cohort, only 26% of those who had surgery RTW, compared to 67% of patients who did not have surgery. Of the lumbar fusion subjects, 36% had complications, 27% required another operation. Even more troubling, the researchers determined there was a 41% increase in the use of painkillers, with 76% of surgery patients continuing opioid use after surgery.
One very interesting study allowed injured workers to enter a functional restoration program for 10 days, even despite being elective spine surgery candidates. After 10 days in the program, they could either continue the program, or quit it and have surgery. After 10 days, a whopping 74% of the enrollees voluntarily decided to stay with functional restoration and declined surgery.
What this and other studies keenly show is that when people are given other options, more often than not, they will take them. Injured workers have no idea how to rehabilitate themselves. But when shown how to do so, this is when true recovery is possible.
Typical functional restoration programs have a team of highly qualified providers. These providers deliver up to 3 hours of physical therapy a day, in addition to 3 hours of cognitive behavioral therapy a day, plus another one to two hours of other adjunctive treatments like yoga, meditation, mindfulness and self massage. The team should have meetings about patient progress, and should be available for consult. Many programs use a combination of Physical Medicine Physician (DO), clinical pain psychologist (PhD), Doctor of Physical Therapy (DPT), Physical Therapy Assistant (PTA), Licensed Clinical Social Workers (LCSW), certified yoga therapists (RYT), licensed massage therapists (LMT), and sometimes nutritionists (RD).
That’s a lot of people and there’s definitely no time for coloring!
- Functional restoration facilitates claim closure.
In the past functional restoration has been primarily used on tail claims, as a last resort. However functional restoration can be used at any time (early, middle or late) in the claim cycle, but is most beneficial for RTW within the first 8 months of injury. One study showed that the average cost savings of using functional restoration early in the claim cycle, total economic cost savings was $170,000. This translated to cost savings of 64% and productivity loss savings/disability savings of 80%.
In functional restoration, patients are taught to refocus their mind on recovery, return to life and return to work. Work gives us purpose, resources, and makes us feel worthwhile. Psychotherapy techniques used in these programs help empower patients to reclaim their lives from pain.
Incidentally, beware of functional restoration programs that, at discharge, immediately refer for other medical treatments, like spinal cord stimulators, spine surgery, or medication, and report that the program “didn’t work.” While there are some exceptions, these should be rare, and functional restoration is not designed to become a referral program for surgeries or other interventions. The goal of functional restoration is to stabilize the patient, improve their mental and physical functioning, and make them LESS reliant on the medical system and more reliant on themselves. Hopefully more insurers will be open to referring for multidisciplinary approaches as the tides change in pain treatment.
Geralyn Datz, PhD, is a licensed clinical health psychologist in Mississippi and Louisiana, and immediate past president of the Southern Pain Society. She is the Clinical Director of the Pain Rehabilitation Program as well as the President of Southern Behavioral Medicine Associates, PLLC, in Hattiesburg, MS.
Dr Datz has authored scientific articles and book chapters on the topics of health psychology, pain treatment, the mind-body connection, and treatment of injured workers. She can be reached at firstname.lastname@example.org