Chronic Pain In-Depth Series (Part 3): Two Journeys, Two Outcomes
By PETER ROUSMANIERE, an expert on the workers' compensation industry
Diverting his eyes while nervously massaging his left forearm, Jason looks defeated. A 55-year-old man of medium build, his last job, six years ago, was as a midlevel manager in an employee assistance program vendor. The job paid $55,000 a year, enough to live on comfortably in rural Massachusetts.
Today, he lives alone in the town of Southbridge, in the western part of the state, coping on less than $22,000 a year.
He has not worked since August 2002, when a counseling client, fired after a urine test uncovered heroin in his system, threw Jason against a table and onto the floor of the lobby of his office. Jason recalls the brutal assault, including the subsequent arrival of the police. But his memory of the six years that followed is at best scattershot.
Jason (not his real name) is not unlike tens of thousands of chronic pain patients burrowed into the workers' comp system today. They suffer from irregular sleep patterns, drowsiness, imbalance, slurring, and slow reaction times. Many suffer from depression. Worse yet, these victims don't respond well to treatment.
Following the assault, Jason drove himself to an occupational medicine center and filed a workers' comp claim. His employer's carrier, AIM Mutual, quickly accepted the workers' comp claim.
Jason, initially treated for anxiety and acute pain, remembers who treated him but can't remember exactly when. Within months, he descended into depression and suffered from persistent pain in his neck and left shoulder. He speaks of constant headaches and a problem with his left ear.
Jason's case is ironic, perhaps cruelly so: he was trained to respond to help others in time of need. He even supervised the delivery of counseling services in the immediate aftermath of the Sept. 11, 2001, attacks on the World Trade Center.
Now, many years later, he finds himself on the receiving end of a critical incident, not having been properly debriefed after the assault in Southbridge. Debriefing is widely considered a valuable counseling intervention for people to get over a traumatic event.
Nor did he attend a course in multidisciplinary care, which is the gold standard for cases such as his. All he got was five years of talking to a shrink every two weeks, at a minimum of $101.50 per session, the Massachusetts state fee schedule, paid for by AIM Mutual.
Following the accident, the case manager hired by AIM Mutual to follow Jason, referred him to a licensed social worker, who recommended that Jason be admitted for surgery at Boston's New England Baptist Hospital.
Despite going under the knife, the operation failed to relieve Jason's searing neck pain. Jason says he can't sleep properly, and can only walk moderate distances. He says he is intolerant of most medications, but he takes Demerol, a narcotic pain killer, and several times a day puts on Lidoerm patches to control pain flare ups.
From August 2002 to August 2005, Jason lived on total temporary disability checks issued by the carrier. Then, his insurer scaled back its payments, shifting him to partial temporary disability. Those benefits are set to expire next year. Late in 2005, Jason hired an attorney to help him restore full disability benefits.
By then the Social Security disability system had accepted his claim for a permanent disability award. But an independent medical examiner appointed by a workers' comp judge recommended that he be awarded partial permanent benefits on the grounds that he is partially permanently disabled.
Jason, a former Marine and community college graduate, has no clear expectations of working again.
His life was not always this complicated, nor this painful.
"I wanted to get well," he says. "I wanted my life back, to do the things I used to do." Jason was used to living a vigorous life, kayaking frigid New England rivers, climbing the highest peaks of the Berkshires, and rounding New Hampshire hairpins on his antique Harley Davidson motorcycle.
Once the temporary benefits expire next year, Jason will likely either go on permanent partial or permanent total disability unless the case is settled.
Jason says that at the urging of a judge a settlement with AIM Mutual was discussed in 2007, five years after the injury.
"Early, effective, medical and behavioral intervention could make such a difference in their outcomes," says Channing Migner, Jason's Worcester, Mass.,-based attorney. Migner believes AIM has abandoned Jason with respect to guiding treatment and that his client's management of care "has largely been on his own."
Jason, says Migner, is an example of an injured worker who was never enrolled in an adequate pain program.
ABE: A SUCCESS STORY
Injured in the back, Abe, a 34-year-old police officer at the time of his injury in November 2007, was ordered not to return to work by his primary care physician. Partly as a result, his recovery stalled and his case deteriorated into a case of chronic pain. So there he was, 5'11", 185 pounds, fit as an ox, and all he had to show for it was a nagging pain running up and down his spine. For Abe, life wasn't what it used to be.
"His pain was a constant, nagging, shooting, sharp ache aggravated by overuse and lying down at night," says Josh Dion, the nurse practitioner at the Integrative Pain Center in Bedford, N.H., a multidisciplinary treatment center specializing in chronic pain.
The clinic often receives workers' comp cases after the patient has gone through other parts of the medical system. Abe ended up at Integrative after several visits to primary care physicians, dozens of injections and hours of physical therapy. Still, nothing was able to cure his pain.
Abe was injured taking an agility test. Now largely recovered, he is a success story, one that doesn't come often in the world of chronic pain rehabilitation.
"This was a relatively good case because we got him early in his chronic pain," says Dion. After several tests, Abe went into physical conditioning treatment. An injection to unblock a nerve also allowed him to move freely, says Dion.
After 41 sessions of physical therapy, says Dion, Abe showed important gains. He went back to work as a police officer, and his insurer even paid for an elliptical training station at home so that he could continue to exercise.
Dion estimates that if the center sees a patient within a year of the onset of the pain, the treatment team can get 60 percent of the patients back to work within two months. In addition, the lives of the remaining 40 percent can be greatly improved, Dion estimates. Since opening its doors in mid-2007, several hundred patients have been treated at the clinic.
Most patients will gain some relief from chronic pain at a multidisciplinary clinic like Integrative, and as a result such clinics give insurance carriers more confidence in the medication plans followed by patients. So here's where the multidisciplinary clinics provide value, according to the executives with Integrative: it's now far easier for carriers to set aside reserves knowing these claims will likely not deteriorate into long, costly ordeals, says Dion.
Providing multidisciplinary, coordinated care, contrary to much that has been done in field of treating chronic pain, may sound easy. It's not. "The real trick is to try to triage and get the appropriate people into the appropriate office at the appropriate time," says Robert Spencer, an anesthesiologist and member of the team at Integrative.
If you are a patient of the center and seeing one of the clinicians for the first time, you will literally walk through what looks like a physical therapy clinic, with dozens of patients spending hours exercising by themselves, or with the help of machines. For the first-time visitor to the clinic, the conclusion is sudden and immediate: exercise will be a major part of a patient's care.
There's literature that supports the idea that exercise is highly beneficial to reducing pain, and there is a common sense element to it. Every injection, every counseling session, every surgical procedure, every pill is enhanced by physical exercise.
Many pain specialists, whether anesthesiologists or surgeons, don't build enough exercise into their chronic pain rehabilitation programs, according to some experts. But integrating counseling and coaching is needed too, according to Tom Callahan, a founder of Integrative, if the treatment of chronic pain patients is going to be given a chance to succeed
"Coaching involves motivational issues, support, and creating expectations, not long-term talk therapy," says Callahan.
"We get approval from the insurers for the initial consult to see the patient," he also says." When they agree to the initial consult, we propose to the payer that we develop a treatment plan, if appropriate."
First, physical therapy, which includes strength-building exercises. Then would come the psychologist whose care is focused on pain behavior and addiction issues. The interventionist comes next, followed by injections and stimulators implanted into the spinal cord. The physiatrist comes last.
In some cases the treatment of chronic pain boils down to managing the long-term opioid program, and many of Integrative's patients already are on long-term opioid medication. The risk of drug dependence, however, is high and Dion spends a lot of time assessing the medication, seeing if the patient can ultimately get off opioids.
Unfortunately, clinicians and adjusters who work with chronic pain patients on opioids say such patients have low probabilities of returning to work.
December 1, 2008
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