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.

Terminally Ill Patients
Pain is a common problem among terminally ill patients. Most patients with advanced cancer experience significant pain. Although multiple reports and studies indicate that resources for successful pain management are available for as many as 90% of these patients, many still continue to suffer needlessly. Because of the effect both a terminal illness and marked pain can have on a patient’s life and the prevalence of depression associated with such illness and pain, psychiatrists and other mental health care professionals may be asked to participate in the care of these patients. However, many psychiatrists (even those in consultation-liaison work) may have limited familiarity with end-of-life issues.

The opioid analgesics are considered the mainstay of the treatment of cancer-related pain. But the psychotherapeutic and psychopharmacological techniques used in nonmalignant pain are being incorporated into cancer pain care. Relaxation training and other cognitive-behavioral techniques have been proven effective in cancer and bone marrow transplantation patients. Adjuvants to opioids (such as antidepressants, anticonvulsants, or stimulants) may provide critical assistance in pain and symptom control.

Pain is a common problem among patients with acquired immunodeficiency syndrome (AIDS) and appears to be associated with significant psychological comorbidity. However, because of the severe, often life-threatening physical disorders that these patients have, the pain itself may receive relatively little attention. Literature indicating that pain may inhibit immune function and exacerbate other medical conditions heightens the importance of addressing pain in patients with AIDS and other terminal illnesses.

The inadequate control of pain in terminally ill patients has been in the spotlight recently because of the current debate about physician-assisted suicide. Severe pain can result in suicidal ideation and the patient’s request for physician-assisted suicide. However, surveys of patients consistently show that loss of dignity and independence rank higher than pain as reasons for considering assisted suicide. Determining in individual cases whether the desire to die arises from untreated symptoms, psychopathology, or free choice can be very difficult. Thus, there have been calls for psychiatrists to serve a gatekeeping function for physician-assisted suicide. But in the absence of a clear social consensus about suicide, it is likely a mistake for psychiatry to take on this job. Nevertheless, the important undertreated dimensions of suffering serve as a challenge to psychiatrists to improve their understanding of the psychological and existential issues encountered at the end of life.

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