Pain Management and Job Safety

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How might you treat a patient suffering from chronic pain that was employed in a safety-sensitive job? 

The issue of use of medications in the workplace, especially in safety-sensitive jobs is of widespread concern. Whether the individual uses prescription or over-the-counter medication, there is a possible risk to themselves and others.

Maripat Welz-Bosna, M.S.N.:

I believe it needs to be done on an individual basis with a comprehensive evaluation and then close titration of medication. Every patient is different and for many starting an antidepressant and possibly an anti-inflammatory can make a dramatic decrease in a patients pain. For others there may need to be the addition of another adjuvant medication or the start of an opioid. We have many patients who work both part-time and full-time and if not for the medications would not be working at all. For other patients medications have allowed them to raise their children and volunteer at an organization.

The rule of thumb in our practice is “Start low and go slow”. We explain this to the patients and state that they may not have immediate results but it is better to start medication this way to prevent side effects. We also tend to introduce one new medication at a time so we know exactly which medication a patient may or may not tolerate.

Some of our patients have applied for new jobs and have been required to take a urine test during the interview process. Often during their interview process they do mention that they have a chronic pain condition, which is being managed with medication. It is often requested of us to provide a letter to the employer on our treatment plan and the medications, which are being used. At this time we have patients who work in many fields from computer technology, nursing, and CEO’s of major companies. They realize the relationship between stress and their chronic pain, and they have been able to set limits in their present jobs and perform extremely well. Employers need to be educated and realize that most chronic pain patients want to work and realize that their pain is not going to be cured from working but, it can actually be managed much better because they are not continously focused on their pain. As one of our patients, a union construction worker, explained to me, ”The pain in my foot is always there [RSD], but if I were sitting at home not doing anything it would be a lot worse than it is”.

How might you treat a patient suffering from chronic pain that was employed in a safety-sensitive job? 

The issue of use of medications in the workplace, especially in safety-sensitive jobs is of widespread concern. Whether the individual uses prescription or over-the-counter medication, there is a possible risk to themselves and others.

Jayne Pawasauskas, Pharm.D.:

For a patient in a safety-sensitive job, I would be most concerned about the drowsiness that can occur from the use of certain analgesic medications, especially opioids. In this case, I would recommend a schedule with very slow dosage increases. Perhaps the patient can begin any dosing changes over the weekend, at times when he/she is not working, or at bedtime. Over time, many patients will usually adjust to side effects like drowsiness. Occasionally, however, a patient may need an additional medication, usually a stimulant, to manage the drowsiness that is associated with the use of opioids.

How might you treat a patient suffering from chronic pain that was employed in a safety-sensitive job? 

The issue of use of medications in the workplace, especially in safety-sensitive jobs is of widespread concern. Whether the individual uses prescription or over-the-counter medication, there is a possible risk to themselves and others.

Knox Todd, M.D.:

Any therapeutic decision involves a weighing of risk versus benefit, and many analgesics have at least the potential to cause mental status changes that could affect workplace safety. To most people this question would seem to refer to the use of opioids for chronic non-malignant pain. While in the opioid titration phase certainly many side effects of opioids, including drowsiness, are problematic. With chronic use, however, most of these effects, with the notable exception of constipation, will resolve.

I can imagine no more safety-sensitive activity than driving a motor vehicle through crowded streets and here, we have the benefit of a number of studies suggesting that chronic opioid use does not impair driving performance. On the benefit side of the equation, one must also consider the known risk of impairment resulting from sleep disturbances associated with undertreated pain. Drowsy driving is a major and well-recognized cause of motor vehicle crashes.

Thus, in general, concerns about workplace safety should not alter pain therapies, except in the opioid titration phase. However, in the care of patients with pain, individuals vary, and it is incumbent on the practitioner to monitor and carefully document the impact of his or her therapies on physical and mental function.

Charles Argoff, M.D.:

Pain management treatment options should always be considered based upon their established efficacy for the condition to be treated, the established safety of the treatment and the costs of the treatment. For a person with chronic pain who is employed in a safety-sensitive job and who requires pharmacotherapy for optimal pain control, the adverse effects of the agents being utilized clearly become very important issues to consider in choosing the agent. Agents which have been shown to be effective for chronic pain but are unlikely to cause sedation or other central nervous system side effects should be considered if possible before those agents that have these effects but which may be equally effective.A very simple example would be the construction worker with chronic low back pain following surgery. The patient is working despite the pain and may benefit hypothetically from a number of medical therapies including NSAID use, the use of opiate analgesics, the use of muscle relaxants, the use of topical analgesics and others.Since few formal studies regarding this issue exist and especially since few comparative studies exist, the clinician must choose based upon the balancing of the issues noted previously. Good initial choices here would be an NSAID combined with a non-sedating muscle relaxant and potentially the use of a topical analgesic. It is not to say that there aren’t construction workers who are using opiate analgesics regularly- my point is that agents with the likelihood of causing fewer CNS side effects should be considered first.