Chronic Pain, Litigation, and Worker's Comp

There is a fascinating and tricky relationship between chronic pain and legal matters. When we see a patient who has chronic pain from a car accident, for example, one of the biggest predictors of the severity of her symptoms and her response to treatment is whether there is ongoing litigation. In the same way, if an injury is work-related, patients tend to do more poorly. Why is this?

The easy conclusion is that the patient has secondary gain, that they have an incentive to malinger, to play the sick role. And when talking about an accident or injury causing chronic back pain, limiting the ability to work, and dramatically reducing the quality of life, we're looking at hefty sums of money. But I wouldn't accuse a patient of dramatizing symptoms for financial gain. When we look under the surface, subjective feelings, behaviors, motivations, and emotions interact in complex and unpredictable fashions.

I saw a patient recently who lost most of her family in a car accident. Subsequently, she coped by immersing herself in her job. She worked a hundred hours a week, nonstop, because if her mind wasn't occupied with her job, it was occupied with her lost family. She then sustained a work-related injury which became so severe she can no longer work. Now, she sits at home ruminating, drinking, thinking of dying. Her pain is a morass of physical injury, maladaptive behaviors, depression, substance abuse, lack of social support, and inability to cope. Her treatment plan is extremely challenging, one that employs a psychiatrist, counselor, addictionologist, physical therapist, and pain specialist.

Another patient was involved in a car accident when a texting driver hit him from behind. After he was treated for multiple fractures in the emergency department, he started to develop chronic whole body pain. As a result of his injuries, he could no longer work. As he went from surgeon to surgeon, doctor to doctor, he started to accumulate bills he could not pay. His ongoing litigation was going nowhere; two years later and he was still calling his lawyer to move things forward. He began to despair, saying things like "if anything could go wrong, it would happen to me" and "I have nothing to live for now." He could not participate in physical therapy, could not afford a psychologist, and became dependent on opiate medications. Addressing these issues is not easy.

It's helpful for us to note whether an injury is work-related or has pending litigation. This affects the psychological and coping skills of the patient, their expectations of the future, and their ability to move on. We aren't primarily concerned with whether these patients have secondary gain; rather, we need to understand the social context of their pain so that we can address all the contributing factors.