NADE Response on Pain

The National Association of Disability Examiners (NADE) welcomes the opportunity to comment on the Advanced Notice of Proposed Rulemaking (ANPRM). NADE applauds the Social Security Administration’s efforts to adapt program policies to reflective of current evaluation and treatment of pain.

An established impairment that can cause pain and in turn functional limitation is the hallmark of the SSA (Social Security Administration) disability process. Pain as a symptom is difficult to assess due to the very subjective nature of the symptom.

Many decisions focus on chronic pain syndromes and syndromes of central sensitization. These syndromes must have an impairment as a foundation.

The chronology of longitudinal pain care needs to have an integral part in the decision process.  Documented ongoing care for pain management lends consistency to alleged functional limitations relative to the impairment assessed. 

The VAS (visual analog scale) is a well-established tool to assess pain. Utilized in most clinics, EDs and hospital settings. Though still based upon subjective report, a standardization is present in reporting. Subspecialties like Rheumatology have scales that assess disease severity and function. However, these are difficult to use and the non-familiar reviewer may find difficulty in interpreting them. The chosen scale should be easily accessible for use and have facility in assessment.

By nature, acute pain though initially severe, would not last for 12 continuous months. Nociceptive pain by definition does not typically last more than 12 weeks.  Nociceptive pain is present in acute conditions/injuries.  Nociceptive pain is typically short term and does not have extended impact upon an individual’s function.

Chronic pain is reflective of biochemical changes within the brain and nervous system. A 2015 study identified over 50 million individuals living with chronic pain. Annual costs for treatment and lost work near 700 billion dollars per year. Treatments designed to interrupt those pathways often take time for realization of improved perceived pain. The utilization of care modalities including cognitive behavioral therapy (CBT) serve as adjunct to improve outcomes. Depression is also often factorial in chronic pain syndromes affecting the severity, chronicity and long-term functional impact.  Treatment of co-morbid depression is integral in individuals with chronic pain. .

Neuropathic pain is present in multiple chronic conditions (Multiple sclerosis, Diabetes Mellitus for example). Neuropathic pain can occur is response to injury leading to Complex Regional Pain Syndrome (CRPS). Chemotherapy and other toxins often lead to persistent neuropathic pain well after successful treatments have completed.  This type of pain has the potential for the most long-term limitations and needs consideration accordingly.

Treatment of chronic pain has evolved to integrated approaches. Medications, physiotherapy, physical therapy, behavioral therapy, nutrition and naturopathic care together have roles in improving outcomes.

Outcomes ­measured by subjective reports of decreased pain and improved function are crucial. Regardless of which modality prescribed, symptom and functional improvement are the hallmarks to assess successful treatment. In our decision process, improved functionality is key vs. the modalities of care administered to the individual.

Respectfully submitted,

The National Association of Disability Examiners