2.  Pain is a universal human experience. The
International Association for the Study of
Pain (IASP) defines pain as "an unpleasant
sensory and emotional experience associated
with actual or potential tissue damage or
described in terms of such damage." Pain
may be a symptom of an underlying disease
or disorder, or a disorder in its own right.

3.  Multiple definitions
 Google - The English word 'pain' probably comes
from Old French (peine), Latin (poena - meaning
punishment pain), or Ancient Greek (poine - a word
more related to penalty), or a combination of all
three
 Bing - unpleasant physical sensation:
› the acutely unpleasant physical discomfort
experienced by somebody who is violently
struck, injured, or ill feeling of discomfort a sensation
of pain in a particular part of the body emotional
distress: severe emotional or mental distress

4.  Pain is difficult to define and describe.
 Essentially, pain is the way your brain
interprets information about a particular
sensation that your body is experiencing.
 Information (or "signals") about this painful
sensation are sent via nerve pathways to
your brain. The way in which your brain
interprets these signals as "pain" can be
affected by many outside factors, some of
which can be controlled by special
techniques.

7.  Back pain accounted for 40 percent of
absences from work, second only to the
common cold. (Katz JN. Lumbar disc
disorders and low-back pain:
socioeconomic factors and consequences.
J Bone Joint Surg. 2006;88A(suppl.
2):21-24.)

8.  Acute pain is of short duration, usually the
result of an injury, surgery or illness. This
type of pain includes acute injuries, post-
operative pain and post-trauma pain.

10.  Chronic pain is an ongoing condition, such
as back and neck pain, headaches, complex
regional pain syndrome Type 1 (reflex
sympathetic dystrophy), neuropathic pain
(nerve injury pain), musculoskeletal
pain, and pain related to illness.

12.  Nocioceptive
 Neuropathic
 Psychogenic
 Idiopathic

13.  Nociceptive pain is caused by stimulation of
peripheral nerve fibers that respond only to
stimuli approaching or exceeding harmful
intensity
 Pain that is associated with tissue injury in
the presence of normal neurological function

15.  Pain that is associated with abnormal
neuronal function in either the central
nervous system or peripheral nervous system

17.  Pain that is associated with emotional
conflict or psychosocial problems (aka
somatoform pain) that are sufficient to allow
the conclusion that they are the main
causative influences. Exclusion of organic
disorders is not sufficient on its own to
warrant the diagnosis.

20.  Pain that is present in the absence of
identifiable physical or psychological
substrate or is considered excessive for the
existing organic process.
 Difficult to explain why there is pain
 It is believed to be of psychological origin but
may involve both cerebral and peripheral
physiological mechanisms.

22.  Chronic pain is widely believed to represent
disease itself. It can be made much worse by
environmental and psychological factors.
Chronic pain persists over a longer period of
time than acute pain and is resistant to most
medical treatments. It can, and often
does, cause severe problems for patients.

24.  Nocioceptive Pain
› Anti-inflammatory agents (nonselective)
› Anti-inflammatory agents (selective)
› Strong non-opiate preparations
› Weak opiate preparations
› Strong opiate preparations

25.  Anti-inflammatory (nonselective)
› Ibuprofen (Motrin)
› Naproxen (Aleve or Naprosyn)
› Etodolac (Lodine)
› Ketoprofen (Orudis)
› Ketorolac (Toradol)

26.  Anti-inflammatory- selective (Cox II inhib)
› Celecoxib ( Celebrex)
› Lumiracoxib (Prexige)
› Parecoxib (Dynastat)
› Etoricoxib (Arcoxia)

27.  Strong non-opiate
› Tramadol
 Weak opiates
› codeine, hydrocodone (Vicodin) – usually in
combination with aspirin or acetaminophen

28.  Strong opiate preparations
› Oxycodone (Oxycontin)
› Morphine sulfate
› Methadone
› Meperidine (Demerol)
› Buprenorphine (Buprenex)
› Fentanyl (Duragesic, Actiq)

29.  Neuropathic pain
› Anticonvulsants
› Tricyclic antidepressants
› Selective serotonin reuptake inhibitors (SSRI)
› Other antidepressants
› Antispasmodic agents
› Other agents

30.  Anticonvulsants
› Gabapentin – Neurontin (drug of choice as are
low side effects)
› Oxcarbazepine (Trileptal)
› Topiramate (Topamax)
› Levetiracetam
› Zonisamide
› Lamotrigine
› Carbamazepine
› Phenytoin (Dilantin)

31.  Tricyclic antidepressants
› Amitriptyline (Elavil)
› Nortriptyline (Pamelor)
› Doxepin (Sinequan)
› Imipramine (Tofranil)
› Desipramine (Norpramin)

32.  SSRI – Selective serotonin reuptake inhibitor
 Generally less effective for the
management of pain, then tricyclic
antidepressants
 Fluoxetine (Prozac)
 Paroxetine (Paxil)
 Sertraline (Zoloft)

33.  Others
› many additional medications have been tried to
varying degrees of success.

35.  In summary, pain is a particularly complex
and challenging issue to deal with.
 Sorting out what is real versus not real is
nearly impossible.
 All pain is real to that individual perceiving
that unpleasant situation.
 Add to this the tangent factors of indemnity
benefits, what is felt is owed, and the rest
makes this a particularly difficult situation
for the workers compensation professional
to deal with.

36.  Several things are essential
A. A comprehensive physical evaluation of the
individual
B. A comprehensive assessment as to identify the type
of pain
C. Development of a treatment plan protocol that is
consistent with national published parameters
(ODG) N v. Y drugs. Past messages from the
Division notes that 48% money spent of meds, were
for drugs listed as “N” drugs.
D. Use of appropriate medications, particularly
sustained release reparations when dealing with
chronic pain
E. Adjunctive medications should be considered at
every level

37. Thank you