Michael’s life was not supposed to end up like this. After graduating from high school, he joined the local construction union eventually becoming a union steward. His coworkers and employer respected him. He was skilled, knowledgeable, and exceedingly careful in how he performed his job. His salary was good and, combined with his wife’s income as a nursing assistant, they could afford a nice home and savings to send their children to college.

All these dreams came to an end when a scaffold Michael was standing on at a construction site collapsed. Michael came tumbling down and found himself on the ground, having trouble getting up. A sharp searing pain began in his back, shooting into his right buttock and coworkers had to help him get up. Though Michael suspected he was not “okay,” his first response to the accident was to make sure coworkers were unhurt and to report the incident and injuries to his employer. He brushed his own pain aside—at first.

When Michael got home, his back was stiff and he was limping because of his difficulty in putting weight on his right leg. The next day, his whole body was tight and sore and he even had difficulty getting out of his bed. Still, Michael drove his truck to work and tried to resume his duties until his supervisor, noting his clear pain and distress, suggested Michael leave work and go to a local occupational injury clinic.

At the clinic, Michael was relieved to hear the X-rays showed nothing broken and his intense pain was “muscle strain.” He was given medications, including Vicodin and told he would get better in a few weeks. When Michael questioned being given an opioid, having read about their dangers, he was assured it was an appropriate medication for what had happened to him.

After 3 weeks off from work, Michael was no better and was actually getting worse. His lower back pain was becoming more intense and shooting into his right buttock and calf. His toes were tingling. “Rest” from work had not helped at all. He described his pain like “a poker being driven from my back into my toes,” a common metaphor pain patients use.

At his follow-up visit at the occupational injury clinic, a physician ordered an MRI scan of the injured area. Now Michael was told he had a “herniated disk and a pinched nerve”—a condition he had heard of in coworkers. The problem was—most of those workers had not returned to work after surgery for those conditions so Michael became concerned. Luckily, the clinic physician said Michael only needed a cortisone injection, not surgery.

Most clinicians who work with chronic pain patients can guess what happened next. After three epidurals, a week apart, there was no improvement in Michael’s pain. In fact, after the second epidural, Michael’s back pain increased and he developed headaches, which he never had previously. Although, Workers’ Compensation insurance paid the medical bills and a small portion of Michael’s salary, he was feeling the economic “hit” from the accident and subsequent disability. At his request, clinic doctor cleared him to return to light duty at work but to Michael’s disappointment, his employer said none was available.

Six weeks after the scaffold collapsed, Michael’s entire lifestyle had changed. Instead of rising at 5 AM, he lay in bed till until at least 9 o’clock, sometimes later. Sleep had become fitful and erratic. He no longer watched what he ate and “consoled” himself with pints of ice cream. Michael no longer played with his children or went out with the family. He was becoming irritable. His family, after showing sympathy for him at first and helping him with services and his responsibilities, now gave him wide berth. Michael felt isolated and misunderstood. He missed work and his coworkers with whom who he used to socialize after work.

On Michael’s next visit to the occupational injury clinic, he got a big surprise. A surgeon told him, on the basis of his MRI, he needed surgery to remove the “protruding” disk. Heartened that perhaps they were going to get to the bottom of his pain, Michael scheduled the surgery. Even though the surgery was supposed to be for “disk removal,” Michael was asked to sign a consent form for a fusion surgery if the surgeon decided it was needed during the procedure.

Sure enough, when Michael woke up after surgery, he was told the level below the removed disk had been “worn down” and a fusion was installed replete with plates, screws, and artificial bone. The procedure was not only a lot more complicated than he had expected, it was a lot more expensive and his healing time would be greatly elongated.

Now, Michael was put on oxycodone and told to take one to two tablets as needed. Not a “pill person,” Michael nevertheless took four to six pills daily for the pain which was extreme. After 4 weeks, when he was released to begin physical therapy, such as riding a stationary bicycle, Michael was shocked and dismayed to find his pain dramatically worsened. What was going on? Michael’s low back pain had expanded to his entire back. Toileting and lying in bed were difficult. He began to sleep in a recliner chair away from his wife.

After 6 weeks of continued pain, Michael’s OxyContin was bumped up to 10 mg BID. At first, the dose increase helped him participate in his daily physical therapy—which is widely seen as the only defensible use of non-short-term opioids in chronic pain. But soon his back and leg pain increased with a concomitant constant tingling and the sensation of “bugs crawling” on his leg.

What was the response of the clinic’s staff to Michael’s continued pain? His OxyContin dose was increased to 20 mg BID and he was told to take his Percocet prescription 4–6 day if needed as well. There was more confusion for Michael, too: he was assured that, on the basis of X-rays, his surgery was healing well. Two months after his disk surgery which had turned into a fusion, Michael’s surgeon assured him there was no anatomical reason for his pain and referred him to a well-known pain clinic.

At the pain clinic, Michael’s pain was attributed to “scar tissue built up” and he was given a series of epidurals and facet injections which provided very short-term relief. Because the relief was only short-lived, Michael was advised to undergo two sets of ablations, or nerve burns, on either side of his body, which paradoxically produced a constant burning sensation. Amazingly, Michael’s OxyContin was now increased to 40 mg TID as surgery, injections and ablation had failed in rapid succession.