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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 eases 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.

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The treatment of chronic pain has finally, after many years, found its place as a legitimate discipline.

MEDICAL TREATMENT

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 mazelike 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 halt' 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 ease 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.

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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 ease manager may easily infer either that the patient is faking, or has a mental health condition complicating the problems. In this ease, 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.

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Summary

* Chronic pain afflicts 500,000 injured workers in the United States.

* Every year another 50,000 workers are added to the chronic pain patient rolls.

* Over the past 50 years, at least two models have been used to explain chronic pain: the messenger model and the neuroplasticity model.

RELATED ARTICLE: A Roster of Chronic Pain Personality Types.

Picture the waiting room of a Main Street pain clinic. The room's lined with patients young and old, some injured from accidents suffered at work, others the victims of stress and tension brought on by activities repeated over years or even decades.

Patients' discomforts, once acute, have mellowed and settled into an endless ebb and flow of throbbing pain, a condition that has become chronic though not necessarily debilitating.

The mood in the waiting room is somber, even resigned. Yet patients, who come from all walks of life, are alert and some are even chatty. Their tales of the causes of their injuries spring from a multitude of causes.

Following certain characteristics, victims of chronic pain can be grouped into different categories. They are:

* The Walking Pharmacy A 35-year-old inventory worker with a shoulder injury, she is taking several pain drugs, one for long-term control, one for breakthrough pain when needed and a drug for anxiety and one for the sleep disorder brought on by her pain killers. She has become an amateur pharmacist, adjusting prescribed medications and over-the-counter drugs to find for herself pain relief with the least side effects. She wants to get back to work.

* The Traveler Without Maps. A 42-year-old parcel delivery driver with diffuse pain arising from a wrist injury, he worries constantly about an unending future of pain, which he fears robs him of not only a decent-paying job but also access to his beloved recreation of lake fishing.

* The Implant Seeker. This 48-year-old's back problems have not been relieved by several back surgeries. The spinal fusion that she hoped would help did little other than put her at risk for the disk spaces above and below the fusion site. An inpatient care nurse, she has studied spinal cord stimulator implants and hopes to get one, at a cost to her workers' comp insurer of upward of $50,000.

* The Minimalist. No aggressive procedures and the least possible drugs for this yoga-practicing believer in acupuncture. She has returned to her call center job but takes frequent breaks during the day and sick time for neck pain. This struggle has been going on for five years.

* The Swinger. This 26-year-old dry wall worker has been taking recreational drugs since the 9th grade. He has convinced his doctor to increase the dosage of Oxycontin; he sells half of his prescription to his friends. Meanwhile he appears crippled from a knee injury.

--Peter Rousmaniere

First in a Three-Part Series

In the United States, about 500,000 injured workers are being treated for chronic pain, workers' comp insurers estimate. Many of these workers, due to the nature of their injuries, have already gone on permanent disability. But the story doesn't quite end there. Every year, in fact, another 5(],000 workers are added to the chronic pain patient rolls, according to insurance industry estimates. Chronic pain has become epidemic in the workers' comp arena, a growth industry in the workers' compensation marketplace.

@ On the Web

The Pain Chronicles: A Three-Part Series

Editor's Note: Treating chronic pain is an expensive proposition for any workers' comp employer and it is getting more expensive as the years go by as more injured workers are diagnosed with the disease. In this three-part series we explore the issue of chronic pain and some of the strategies that the healthcare industry is using to manage this risk.

Oct. 15, 2008

Part 1: An Insidious Illness

In the United States, about 500,000 injured workers are being treated for chronic pain, workers' comp insurers estimate. Many of these workers, due to the nature of their injuries, have already gone on permanent disability. 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 insurance industry estimates. Chronic pain has become epidemic in the workers' comp arena, a growth industry in the workers' compensation marketplace.

Nov. 1, 2008

Part 2: Fighting the Disease

The strategies adopted by insurers, third-party administrators, pharmacy benefits managers and employers in their fight against chronic pain. Pharmacy benefit management (PBM) companies for example, retained by insurers, have introduced automated data screens to detect aberrant prescription behavior. These screens may catch prescribed dosages for narcotic prescriptions well above the norm and doctor shopping by the patient. Some PBMs even receive real time alerts from pharmacies when a claimant presents a prescription for a drug on a watch list, such as Oxycontin.

Dec. 1, 2008

Part 3: Success and Failure

Two case studies in the treatment of chronic pain, a successful treatment and one that ultimately failed, will explain how difficult and expensive it is to treat chronic pain and how much money can be saved when the treatment succeeds. The two cases are meant to offer a cautionary tale in the chronicling of a disease that is costing workers' comp insurers tens of millions of dollars annually, with no clear answer, either from the government or from the private sector, about how to resolve a debilitating and expensive illness.

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PETER ROUSMANIERE is a Vermont-based columnist for Risk & Insurance[R]. He can be reached at riskletters@lrp.com.