Pain and Disability Clinical, Behavioral, and Public Policy Perspectives (1987) / Chapter Skim
Currently Skimming:
13. Conclusions and Recommendations
13. Conclusions and Recommendations
Pages 261-284
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 263... ...
was asked by the SSA to follow up on the work of the Department of Health and Human Services (HHS) Commission on the Evaluation of Pain to further elucidate the factors that influence the course of development from acute to chronic pain, to explicate the concept of illness behavior as applied to chronic pain, to review the state of the art of assessing and measuring pain, to consider making recommendations about how the SSA disability programs might better evaluate claimants with chronic pain and provide incentives for rehabilitation, and to make suggestions about research that holds promise for improving our understanding of chronic pain and the disability process.
|
From page 264... ...
These include, for example: · inconsistencies in definitions and measurement that make it difficult to generate reliable estimates about the numbers of people in the population with chronic pain and associated dysfunction; these are the people at risk for becoming unable to work and applying for SSA disability benefits; · lack of data about the numbers and characteristics of SSA cIaimants and beneficiaries in the disability program whose primary complaint is pain and how they fare over time; · lack of reliable methods for predicting which patients with acute and subacute pain will develop chronic disabling pain; although many factors are known to correlate with chronic disabling pain, predictive models have not been developed;
|
From page 265... ...
1. The SSA should develop a better system for routine data collection and information retrieval for the disability programs in order to know more about the numbers, characteristics, and outcomes of claimants and beneficiaries generally and to know more about pain claimants and other troublesome categories of claimants specifically.
|
From page 266... ...
This should include at least one major longitudinal epidemiological study to identify the determinants of chronic disabling pain; clinical studies on the efficacy of commonly used treatment modalities and the optimal timing of interventions to prevent chronic disabling pain; methodological studies to develop and validate measures of clinical phenomena, psychosocial variables, and pertinent outcomes relevant to chronic pain and disability; and health services research to elucidate the contributions of important sociocultural variables to illness progression and illness behavior and to study the interactions of the health care delivery system and disability programs with patient/ claimant behavior.
|
From page 267... ...
· Is the SSA a last resort or a first resort for chronic pain patients? To what extent do Social Security Disability Insurance pain claimants also seek and receive benefits from Workers' Compensation or other public and private disability programs?
|
From page 268... ...
On the contrary, as discussed throughout this volume, the committee believes that pain should be attended to in a more thorough and systematic fashion in clinical practice and in the determination of eligibility for disability benefits. Recommendation 3 SIGNIFICANT PAIN SHOULD TRIGGER AN ASSESSMENT The committee recommends that significant pain as a primary complaint should trigger a functional assessment, even in the absence of objective clinical findings that could reasonably produce the pain.
|
From page 269... ...
In the comm~ttee's view, an increased emphasis on functional assessment of claimants early in the evaluation process holds promise for preventing some errors of commission and omission in eligibility determinations and for averting at least some of the later appeals for higher review and adjudication. Moreover, while recognizing that government agencies and programs con never be shielded finally from politics, it is important to protect individual disability
|
From page 270... ...
to compare several methods of evaluating pain and associated dysfunction, and (3) to determine and compare the impact of each type of assessment on the following kinds of procedural and outcome variables: ~ allowance and denial rates for pain claimants in general and to determine whether certain types of pain claimants are more likely than others to be found eligible with each method; · appeal rates for each method among pain claimants who are found ineligible for benefits at the initial determination; · reversal rates for cases appealed to the administrative law judge level; · average length of time to final decision for each method; · overall costs to the program for each method; and · claimants' and evaluators' views of the fairness of the process, and evaluators' views of the ease with which the assessment can be done.
|
From page 271... ...
Second, although a number of sophisticated means of assessing chronic pain claimants have been developed, as discussed in Chapter 11, it has not been demonstrated that these methods provide more accurate measures of pain or of the relation between pain and functional impairment than some simpler methods, such as systematic observation of the claimant directly or using videotape recordings. Third, the committee believes that assessment for clinical purposes and assessment for the purpose of certification/eligibility are and should be distinct processes.
|
From page 272... ...
The TOM committee recommends a demonstration project that goes beyond procedural feasibility issues to evaluate the consequences of an early personal hearing as detailed previously, and to determine the extent to which such an approach could be standardized and would yield consistent decisions. Integrated Functional Assessment The third method to be tested is an integrated functional assessment at the initial determination level for pain claimants.
|
From page 273... ...
Demonstration Project: Does Early Rehabilitation Work? The TOM committee was charged to examine possible disincentives to rehabilitation and to consider making recommendations about how rehabilitation could be better incorporated into the SSA disability programs.
|
From page 274... ...
Finally, although the details go well beyond the scope of this inquiry, the committee notes that the lack of coordination between agencies providing disability benefits and those providing rehabilitation services in terms of their eligibility requirements, administration, and funding does not encourage rehabilitation. Furthennore, the committee notes that several basic features of the SSA disability program, including the definition of disability and the 5-month waiting period, may preclude rehabilitation as a realistic goal on a large scale because most of those who qualify for disability may simply be too impaired to return to work.
|
From page 275... ...
The committee recommends a demonstration/evaluation project to identify pain patients before they apply for disability benefits and to over them a package of multidisciplinary rehabilitation, time-limited cash benefits, and medical benefits. Several critical questions must be addressed in planning such an effort.
|
From page 276... ...
A Note About Research with Human Subjects The committee is aware that the Social Security Act gives the Secretary authority to suspend the normal rules for purposes of demonstration projects without institutional review board review and all that that entails. Although the federal requirements for research with human subjects are not strictly applicable to testing modifications of entitlement programs, the committee voiced concern that in implementing the demonstration projects the Secretary should be sensitive to the needs of the claimants regarding appropriate notice, ir~forma
|
From page 277... ...
Results of research and demonstration projects can be useful in designing an equitable system, but they must not substitute for the personal assessment and adjudication to which claimants are legally entitled. Recommendation 5 RESEARCH AGENDA Throughout its work, the committee found critical information lacking about every aspect of the chronic painJ6isability problem.
|
From page 278... ...
Although it is certainly possible that receiving benefits could be a deterrent to rehabilitation, as discussed in Chapters 4 and 12, many other equally plausible explanations have little to do with compensation itself. Related to the need for clinical trials of commonly used interventions is the need to apply promising findings from laboratory research to the treatment of pain patients.
|
From page 279... ...
Such studies would also elucidate the process of illness behavior and hold promise for identifying critical elements or stages in the process for successful intervention. It is generally asserted that features of the health care and disability systems, and the nature of the interactions with health care professionals and disability examiners, affect the behavior of pain patients/ciaimants.
|
From page 280... ...
Epidemiological studies to identify people at risk for chronic pain before negative outcomes are apparent, methodological research to develop and test ways of identifying people early in the pain trajectory who are likely to go on to chronicity, controlled trials of particular treatment techniques alone and in combination, and studies of the optimal times to intervene all hold promise for preventing chronic disabling pain. It is not possible to estimate the cost of this research without designing the individual studies.
|
From page 281... ...
is needed that includes attention to multiple variables including psychological, sociocultural, and behavioral factors. Pain patients, regardless of the duration of illness, should have a comprehensive assessment.
|
From page 282... ...
In the long run, repeated surgery for chronic back pain is likely to cause more harm than benefit (see Chapter 101. Attention must be paid to any psychological or psychiatric disorders discovered in chronic pain patients, particularly depression, anxiety, and alcoholism or other substance abuse.
|
From page 283... ...
examine their accreditation processes to assure that these programs attend to a number of educational goals so that primary care providers: · appreciate the complexity of the chronic pain progression and associated illness behavior and understand the contributions of psychosocial and cultural factors to the process; ~ are aware of commonly overlooked psychological concomitants of pain, and physical and psychiatric disorders that may account for the pain or contribute to it significantly, and of the variety of treatment modalities that may provide pain relief; · know about the work of practitioners in other disciplines, are able to make appropriate referrals, and can participate effectively in multidisciplinary teams; · understand the potential for an inadvertent adverse impact of health care providers on the course of chronic pain problems and disability; and ~ understand the processes by which the medical records of the treating physicians are used in the disability evaluation process to determine eligibility for disability.
|
From page 284... ...
In this report, the Institute of Medicine study committee has attempted to elucidate the issues and to provide some guidance to the Social Security Administration and other disability insurers about how pain complaints might be better handled. In addition, the committee hopes that its analysis of the many facets of chronic pain and the disability process provides useful information to researchers, clinicians, and others about this complex problem.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.