Management of Pain in Special Patient Populations

Patients Involved in Litigation or Workers' Compensation Systems

Acute and chronic pain frequently develop following some form of injury that becomes a focus for compensation or litigation. A concern shared by many health care professionals involved in treating patients experiencing pain is the influence financial factors may have in perpetuating pain and disability. Because pain is a subjective problem and is not always clearly related to the degree of identifiable physical problems, there is a concern when financial compensation is at stake about whether they are actually experiencing pain or are distorting the truth for personal gain. Patients whose pain is associated with psychological factors and in whom no physical pathology can be detected are often the subject of special scrutiny. Despite the fear about possible malingering, there is little to indicate that this is a major problem among patients with pain seeking treatment from responsible health care professionals. The Commission on the Evaluation of Pain (Social Security Administration 1987) reported that malingering was not a significant problem in the Social Security Administration's disability system. Leavitt and Sweet (1986) also found that malingering was considered to be rare among individuals complaining of lower back pain.

The effects of litigation and involvement in the workers' compensation system on pain are the subjects of controversy. Results from studies in which this has been examined have both supported and rejected the view that these factors play a significant role in treatment outcome. In their review, Osterweis et al. (1987) reported that the only consistent finding among pain disorder patients involved in legal and workers' compensation proceedings was that those with chronic pain who were employed at the outset of treatment appeared to do better. Involvement in the legal and workers' compensation systems can place patients in countertherapeutic situations in which they must appear sick to receive medical care and financial assistance. These may promote behavior that can maintain or exacerbate pain. To be eligible for benefits to which they are entitled, patients may be forced into inactive lifestyles that compound their problems and make successful treatment even more difficult. The inactivity may be an actual requirement for compensation for injury, or patients may fear that if they show an ability to function despite their pain, the benefits that they are entitled to and need may be taken away. It is difficult to get well if you must continually prove that you are sick. These patients may receive conflicting advice from physicians, lawyers, family members, and friends regarding what direction to take. Although physicians may feel that they are giving patients the correct or best recommendations and that patients who do not accept the recommendations are being difficult, some evidence indicates that physicians may worsen some pain problems. Physicians who treat chronic pain patients must keep in mind the powerful, and often contradictory, messages given to these patients by our society about the causes of pain and their responsibility for pain.