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The victim's primary care physician prescribed a painkiller and a muscle relaxant for a sore and stiff neck. A week later, Jane told her doctor her neck had improved. But she complained of pain in her shoulder and lower back.

In January 2001 she began seeing a new doctor, who ordered an MRI. It revealed mild bone degeneration and an abnormality in a cervical vertebra. Doe started several months of physical therapy.

Nine months post-injury, Doe underwent a 30-day outpatient interdisciplinary pain management program. It included counseling, physical therapy, occupational therapy, osteopathic manipulation, pain self-management and other services. Two years later, in 2003, two independent medical exams could not find a compelling reason for her to remain out of work.

A pain specialist in mid-2003 began to give her injections. Then another specialist concluded that she suffered from "thoracic outlet syndrome." He began treating her with pain medication.

Considering her semiweekly chiropractic visits and weekly psychological visits failed to treat Doe, the victim's medical care could be summarized as a grand flop.

Her workers' comp insurer was paying $10,000 a year in medication costs. She was on an opioid, a barbiturate and an analgesic patch. Yet she complained of constant pain and showed signs of depression.

In early 2004, more than three years after her injury, a new case manager sent Doe to a psychiatrist with a specialty in conservative chronic pain management. The psychiatrist worked with his patient to wean her from narcotics and to get her to comply with a self-directed pain management approach.

Though she has not returned to work, her case was settled late last year. It provides for ongoing medical care, to the tune of about $5,000 a year--a huge drop in yearly medication costs.

Today, the patient takes four medications, none of them opioids, sees a psychologist, receives massage therapy, visits a chiropractor occasionally, and uses a transcutaneous electrical neural stimulation unit. But she stopped seeing the pain specialist who came into the picture in mid-2003, and the thoracic outlet specialist.

So the new team, coming in three years after the injury, helped Doe end her use of opioids, trimmed her list of multiple medical providers, and helped her become with more self-reliant. This case is a success in a world where failure runs rampant. However, Schell said that if her doctors had promoted return to work at the beginning, Doe might be back at work and coping with her pain.

Here's my take on the case. While reviewing Doe's story, it seems pretty clear that the time to address chronic pain is in the first weeks and months of injury. Would you not agree?

PETER ROUSMANIERE, a Vermont-based consultant and writer, is the workers' comp columnist for Risk & Insurance®.

April 15, 2005

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