Hi, the next part on the social realm is to talk about occupational stress. Secondary gain, disability and chronic pain. Now work stress is a significant problem for many people, and it seems to be increasing. I don't know about you, but, certainly in in my situation, and the people I know, it just seems to be ramping up. As this cartoon illustrates, the headaches started after I took this new job. It's more stressful than I expected. Isn't that true? Stress at work, increasing prevalence of stress, as well as violence in the workplace caused by both employees and employers. Employee related issues include, you know, poor self-esteem, frustration, depression at the job. Any history of abuse or abusing can certainly create significant stress. Missing work due to health problems and a poor match between worker skills and employer needs all creates significant stress. But there're also employer triggered problems too, like for instance communication difficulties, inability to express the needs of the employer verbally, or lacking information about problem workers. Unsuitable workplace practices such as that benefit the employer, but create fear of the employer, like the rigid break times, demanding schedules, bullying, few employee options. And then, an environment sometimes creates significant stress also. For instance, too many employees, limited pace, for people, high noise levels, uncomfortable room temperatures, all can create significant stress. And the consequences of stress at work are, are very high. In a study of chronic pain from the workplace, poor job control, high expectations for return to work, work stressors all predict the onset or persistence of pain. And you can see all the different issues that can occur with, with stress at work, from time management, health problems, having no time, headaches, bills, stress, job, fear, anxiety, late nights. And what seems to happen often, is that when you're under a lot of stress from work, that it always seems to be on your mind. So when you're at work, you're thinking about avoiding work, sleeping, resting, you can't, but then when you go home, all you can think about is work. And so it's constantly on your mind, and being distracted. And then there's the situation of bullying at work, which has been recognized as a significant problem more recently, and it can lead to high stress, pain, avoidance of work and disability. Some examples of this is purposely undermining someone or targeting a person for negative treatment. Manipulation of an individual's reputation, or social exclusion, or creating isolation for an individual. Often there's intimidation, aggressive or obscene language, verbal or online jokes that are obviously offensive to one individual. And intrusion by pestering, spying, and stalking. Unreasonable assignments, to duties which are unfavorable to, for one person. And repeated requests for impossible deadlines or impossible tasks are all examples of bullying and unrealistic expectations of employees. [BLANK_AUDIO]. So this cartoon illustrates when was your last stress test? The doctor asks. Well, I went to work yesterday. Stress is a significant problem and does contribute to chronic pain, as well as significant disability from work too. So fear of pain, avoidance of work, and ultimate disability can result from stress. [COUGH] One study of disability among 177 adults with chronic back pain due to work show that the prevalence of disability was 65%. And the disability was moderate to severe in 80.7%. So most people who have disability complain significantly of pain. And 3 factors predicted disability. 1, stress at work, as we're discussing, but also low efficacy to change the stress. They feel like they're out of control. And of course resulting depression, and pain predicted disability. So the conclusion here is that we need to resolve work stress. We need to treat depression, and improve employee self-efficacy training to really prevent disability. So, here's a study of 16,932 adults with disability to determine what caused it. And you can see, then this is the different conditions that were related to the disability. And you can see painful musculoskeletal conditions, and rheumatic diseases were the number 2 top causes, but also most neck and back pain is musculoskeletal origin too. So, we really have to deal with and understand musculoskeletal pain, because that is the number 1 cause of disability. And there are ways to predict whether a person or employee will have disability in the future. And one study done by Ray Dionne, it's interesting, looked at the SCL-90, and the R for depression and somatization scores, and found that they can predict disability due to chronic pain. And here are the characteristics that they used with regard to that measure. [BLANK_AUDIO]. We also find that war, again, pe, causes significant pain and disability also. So war injuries not only cause us PTSD and chronic pain, but it's one of the most common causes of disability. And recently, 45% of veterans from the Iraq and Afghanistan, are seeking war disability benefits. Huge number. And that compares to veterans of previous wars of 21%. These new veterans have 8 to 14 different ail, ailments that they document. The most common of which is chronic pain and PTSD. Whereas the veterans of previous wars reported only 2 to 3 different ailments. So something has happened between the veterans of previous wars and this war. These most recent wars. The monthly payments for disability, is not high. There's only $127 per month, or 10%, or up to the maximum of $2769 per month. So it's hardly enough to, to live on. So it's it is not a significant motivator necessarily. So the question of secondary gain, which I'll discuss in the next, comes up, and typically it's not as big a issue as you think. But healthcare and disability cost of wars are $600 billion to $800 billion, and it's ongoing. So these are issues that we need to deal with how to prevent PTSD and chronic pain in war veterans. Now, interestingly enough, opioid medications also play a role in disability. Initial opioids with worker injury complicates care, return to work and cost of worker compensation claims. So a study was done of 12,000 worker comp claims in 21 states, and they found that when opioids were used, the claims were 4 times the total cost compared to claims without any prescriptions. Opioids make up 3% cost in shorter term claims, but 20% of costs in longer term claims. And that the medical costs are 60% of the total claims costs and will increase to 70% by 2019. So it's not, disability payments to the employee, but it's instead payments to healthcare providers, to try to reduce the pain. [BLANK_AUDIO]. So let's discuss a little bit about chronic pain and secondary gain. Are people on disability, or receiving workers compensation, is that secondary gain? Is it a big issue? And is it causing the pain to continue? Is there a significant amount of malingering going on among these patients? This is what often happens. Well, the person with the illness benefits from having the illness. That's what secondary gain is. Examples show that for instance, staying home from a work or school that is unpleasant. Financial gain from litigation and disability, less demands at work, less hours, co-worker reactions to pain magnification, fear of re-injury, and avoiding the jo, job, job market are all examples of secondary gain. [BLANK_AUDIO]. So, a study of secondary gains showed that individuals who are not able to work due to disability report more chronic pain than those with the same condition who are employed. So, and then there's also the concept of tertiary gain and chronic pain. Now this is when a person other than the patient stands to gain from the patient's illness. In this case, it may be the family or partner that gains by avoiding dealing with family problems, enabling a conflicting relationship, or financial gain from litigation, disability, and workers compensation. So employers gain, in some situations by using an illness to end employment of a difficult employee, or insurance company pays the patients. [BLANK_AUDIO]. Health providers gain by dependency on medications that fills their schedule. So you give 'em medication, the patients continue to come back, and you're always going to be busy. As well as repeat surgeries to quote, fix the problem, supports surgeons as well as hospitals. So there's a potential for tertiary gain from all parties that are involved in disability. But is secondary gain a significant issue? There's a lot of people more recently talking about that secondary gain is really not secondary gain, but it's truly secondary loss. And they're often confused between each other. So many patients with chronic pain and disability have so many losses in their lives. Rarely do they want to be disabled and not working. [BLANK_AUDIO]. They have a loss of pride, low self esteem, guilt, social stigma associated with disability. They lost their job. Their economic benefit, their security, their tangible achievement, the reward associated with it. They've also often lose meaningful relationships through their work and their family. And they lose the ability to do recreational activities and exercise. They lose respect and attention from health professionals. Is often lost and the community approval is lost also. The communications of distress are now unclear. When they complain of pain, are they faking it? Or is it really a true sincere aggravation of their complaints? And then of course there's negative sanctions from family and social support talking about that disabled worker. So, these are all losses that occur with patients, or people who are on disability. It's not a pleasant situation. So there's also misuse of secondary gain. This is when people are inappropriately accused of secondary gain. There can be many harmful effects if that occurs. So, you could be accused of malingering, drug seeking behavior and result in suspicion. It interferes with treatment and development of empathy for that particular patient, which is critical to enhance the relationship between the provider and the patient to enhance care. It leads often to confusion about the diagnosis or treatment by doctors who are also confused. When their treatment doesn't work, they blame the patient in secondary gain. Patients often try to validate their symptoms by doing surgeries and other treatments over and over again even though without success. People don't think that they have a real problem unless they validate it. And it leads to anger at health providers, family, friends and then blame others for their pain. And it also leads to being dismissed or ignored as a complainer or someone who's a hypochondriac. So these are misuses of the concept of secondary gain. And secondary gain is really a much less of a problem, than had previously developed. In one study of worker's compensation, that was fuh, of 1,068 workers, that were followed over 6 months. They found that 196 workers were receiving work, worker disability compensation. And predictors of high, of, of, receiving work, worker compensation and disability, was the fear of re-injury and avoidance. You know, of the pain. These are significant factors. People did not want, they did want to return to work, but are afraid it would be aggravated again. And there's a lot that can be done to help prod, prevent that. Also a predictor was low recovery expectation from the worker. So you can enhance that significantly also. [BLANK_AUDIO]. So predictors of not returning to work from back pain. are, there are quite a number of 'em. The likelihood of return to work decreases rapidly as the sick leave duration continues. So getting a person back to work quickly is important, and minimizing the fear as I mentioned. So, the risk factors include family and relationship stress. Poor working conditions. Workers who are new to blue collar jobs, or heavy labor jobs that require efforts beyond their physical ability. Low level of job satisfaction. Depression, anxiety, feeling sick all the time. Not well liked by their superiors. And bullying by their superiors. Previous history of compensation and work related sickness payments. Litigation about compensation, and low level of education, language problems or low income. These are all expected to be risk factors, and in general they're pretty obvious, and they do show that they statistically are predictors. So the take home of this section, is really about social protective factors. These, we need to enhance those factors that help us thrive after disability from an illness. So these are some of the factors we, we can really enhance. One is to create so, close social ties to that person who is disabled. And that can be through family, friends and close neighbors. That we need to provide them with ample support services to return to work as quickly as possible. And to reduce the fear and pain as quickly as possible, by providing access to resources, both financial, human and material resources will help the patient focus on recovery. And not create anxiety and depression about insecurity. And then enhancing communication and reducing barriers, it is very important. And lots of barriers, to returning to work. And then reduce competing requirements, including those that make in, involvement and care difficult. Such as having to work, or care for children at the same time. So, all of these are protective factors that can really enhance the ability to return a person in disability and chronic pain back to work as quickly as you can. So thank you very much for your attention.