Chronic Pain In-Depth Series (Part 1): Wrestling With an Insidious Illness
By PETER ROUSMANIERE, our Vermont-based workers' compensation columnist
On any given day in the United States, about 500,000 injured workers are being treated for chronic pain, experts estimate. Many of these workers have already gone on to the permanent disability ranks.
But the story doesn't quite end there. Every year, in fact, another 50,000 workers are added to the chronic pain patient rolls, according to industry estimates. Chronic pain has become epidemic in the workers' comp arena and a growth industry in the marketplace.
Some clinicians assert that chronic pain has always afflicted workers. It's just that in the past, until the 1990s, many of these cases were dismissed out of hand. Health insurers and doctors, unschooled in diagnosing and treating pain, simply did not recognize when workers were afflicted with it.
Take Dr. Robert Spencer, for instance, an anesthesiologist and pain specialist in Bedford, N.H. When he graduated from Yale Medical School in the mid-1980s, pain management was of marginal interest.
Spencer recalls meeting with the school's former dean and sharing with him his interest in pursuing anesthesia as a specialty. "He said to me, 'What's a guy like you going into anesthesia for?' And when I said to him, 'Pain management,' he said, 'Ahh, OK, now I understand.' "
Spencer, it turned out, was right to follow his instinct as it was during the 1970s and 1980s that the medical community began to think of managing pain as a specialty. Until then, pain was misunderstood and poorly addressed.
Medical interest in pain management grew, with end-of-life services, such as hospices, being among the first to incorporate pain management into care planning. Today many healthcare specialties treat chronic pain, not just physicians of differing disciplines, but nurses, occupational therapists, physical therapists, acupuncturists and psychologists.
The treatment of chronic pain has finally, after many years, found its place as a legitimate discipline.
But care for chronic pain afflicting many injured workers follows a tortured path.
Typically the treatment of chronic pain, at least initially, is limited to drugs, from over-the-counter brands like Tylenol to powerful prescription narcotics like Percocet. The Hartford reports that in pharmacy costs, Oxycontin topped the list. Another pain killer, Neurontin, ranked second.
For the carrier, the doctor and the patient, pill popping can be easier than invasive surgery. But over time, the use and the cost of treating chronic pain with brand-name drugs typically escalates during the course of treatment. Powerful drugs have addictive properties and while some injured workers will eventually leave the chronic pain rolls, thousands more will remain, often for the rest of their lives.
In some cases, prescription narcotic use may dramatically increase, especially if the treatment for pain is back surgery or a related condition. After that, if surgery is successful, drug use may be reduced to a lower level for long-term treatment.
Workers are treated by their primary care physician, usually internists with little in-depth training in chronic pain. The physician will typically prescribe pain killers. If the initial treatment appears to be ineffective in relieving pain, the physician increases dosages or escalates the strength of the medications to more powerful drugs, all of which can have side effects and complications. Perhaps more insidious is that the pain itself can become the injury.
If the pain treatment is unsuccessful, the primary care physician may refer the patient to a pain specialist.
But what specialist? A physiatrist will focus on the patient's recovery of work capacity. Anesthesiologists are inclined to search for pain relief solutions, such as medication, injections and implants. A surgeon will look for disk generation or other flaws crying out for surgery. Psychologists will look to remove the mental barriers to recovery. An alternative medicine specialist will try acupuncture or yoga.
Each clinician brings to a patient assumptions about what chronic pain is and how to control the pain, if not cure it altogether.
For the patient, this is a maze-like situation. For the carriers, this often means reimbursing four or five different specialists who are unlikely to be coordinating any of the patient's treatment.
It would help if specialists followed treatment guidelines and insurance carriers want specialists to adopt such guidelines as they improve care and reduce costs. Dr. Terence Wilson, medical director of Intracorp's disability review services, says he and his colleagues rely on treatment guidelines from many sources, some of which are updated often.
"A common request (for treatment) that we see comes in after a cascade of events, with multiple interventions having been attempted." The typical request is about the appropriateness of medications, with the requesting doctor often seeking advice and approval.
Treatment of chronic pain has strained the workers' comp system. Because chronic pain can be difficult to diagnose and is frequently not listed on the claim as the injury or problem, it can be difficult to determine the size of the problem.
Recent studies show, however, that chronic pain is linked to half or more of the claims that lengthen into permanent disability awards. Many experts estimate that chronic pain accounts for more than half of all claim costs. If not treated successfully, chronic pain can extend medical treatment, reduce or eliminate the ability of the worker to return to work and vastly increase the total cost of the workers' comp injury.
Today there are some effective treatment protocols, depending upon the nature of the diagnosis, which can reduce the impact of the pain if not the pain itself. These options usually involve a combination of treatments including various drug therapies, physical therapy and effective, one-on-one mental health counseling.
PAIN'S MESSENGER MODEL
Claims adjusters, workers' comp managers and medical case managers most often explain that chronic pain amounts to a failure to resolve an injury to a specific part of the body, such as a section of the spine, part of a leg or an articulation. According to this model, pain persists when that part of the body insists in reporting the pain as a message to the brain.
This model assumes that the part of the body injured, a spinal disk, or the wrist, for example, is the origin of pain and sends messages to the brain. If there appears to be nothing wrong with the body part, but the patient continues to complain, the adjuster or case manager may easily infer either that the patient is faking, or has a mental health condition complicating the problems. In this case, the mental health condition is often associated with a pre-existing condition.
This "messenger" model has the virtue of simplicity to recommend it. But research from the 1960s has proven it wrong. More recent studies suggest that chronic pain is likely to be a central nervous system disorder, in which the brain plays a surging, creative role.
Pain perceptions are very malleable. Wounded soldiers have been known to deny any pain from conditions that in peacetime hospitals caused extreme anguish. A recent test of students at the Massachusetts Institute of Technology revealed that when given a placebo in place of what was called a new narcotic drug, many patients reported lower pain experience from electrical shocks. They reported even lower pain when told the new drug was expensive.
Researchers in the 1960s devised a much more elaborate theory of pain. Neurobiology, with complex psychological features, is for many clinicians today the primary battleground for the body's struggle with the pain experience.
The brain forms, according to this theory, opinions about the sensations it receives. It can rewrite messages, sending them back down through the neurological network. Similar patients experiencing the same injury can have starkly different experiences. The brain can assign pain to a body part that is different from the one which had received the injury and it can cause a person to react with alarm to even a zephyr-like touch to the skin.
This "gate control" theory of pain not only helps to explain huge variations in a victim's experience of pain over time, but also opens the way for psychology to play a role in diagnosis and treatment. How you think determines, in part, how you feel, so the theory goes.
Gate control theory after its introduction in the 1960s assumed a dominant influence within the professional corridors of pain management. Yet, 40 years on, the notion that brain and body conspire to create pain experience still baffles people in and outside of the workers' comp system.
And so it is that many injured workers appear to think in ways that clearly influence how they experience pain, yet without showing any clue of willful distortion in their pain reports to doctors, case managers and adjusters.
PAIN's NEURO MODEL
Recent research confirms the gate control theory and pushes ahead to describe an even richer, more dynamic model of pain: neuroplasticity.
According to this model, not only does the brain wire itself in part from experience but the patient can induce her or his brain to rewire itself. Thus, chronic pain can arise from faulty wiring and pain can be dramatically reduced when the wiring is corrected.
One way to describe neuroplasticity is by way of the so-called phantom-limb syndrome originally proposed by a physician attending to wounded soldiers at the Battle of Gettysburg during the Civil War. A patient who has lost a limb may feel pain or an urge to itch or move the amputated limb, even though it is no longer there.
In a more recent case involving a motorcycle accident, the rider suffered severed nerve connections to the left hand. The nerves stretching from the arm to the spinal cord to the brain stopped sending messages about the left hand. Yet the pain from the injury persisted.
V.S. Ramachandran, a researcher at the University of California at Davis, devised the following exercise for this patient in his hypothesis of the neuroplasticity model. The patient placed his right (normal) and left (inert) hands into a box. A mirror lined a middle wall of the box, facing the right hand.
When the patient leaned down to the right, so that his left hand was not visible and looked into the mirror, he saw a mirror image of his right hand where his left hand could be. It looked like his left hand was alert! The constant discomfort he had felt from his left hand disappeared.
The patient practiced looking at his "left hand" in this way for several weeks until he discovered that, whether his hands were in or out of the box, the discomfort disappeared. Through guided practice, the patient induced his brain to change its perceptions.
This is not to say that chronic pain is entirely in the brain. Surgery can work to reduce pain, at least some of the time. So can exercise, weight loss and smoking cessation. But at the very least, a period of counseling, along the lines of cognitive behavioral therapy, should be a staple of every chronic pain treatment, according to some experts.
When different specialists approach the same case, they act as if they are bringing their own deck of cards to a game the rules of which are not consensually respected. If one observes how clinicians act, not what they say, it is evident that many pain specialists ignore or at best grudgingly accept the idea of counseling.
And so, chronic pain treatment continues in its Babel-like condition.
When asked how to ensure that a chronic pain patient is diagnosed and cared for in a balanced way, one of the medical directors of a very large employer sighed, "If I had an answer--Oy! I don't have an answer for that."
"If anything, low back pain appears to be a more complex, variable, mysterious condition than it did 10 years or 15 years ago," says Dr. Geno Martinez, staff physiatrist at Boston's New England Baptist Hospital Spine Center.
In part 2 of our chronic pain series, author Peter Rousmaniere looks at the different strategies that insurers, third-party administrators, managed care and pharmacy benefit managers and employers use to handle treatment, costs and return-to-work issues surrounding the epidemic of chronic pain among injured workers.
October 15, 2008
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