It is often the silent patients who suffer the most - those who don't wince, cry or writhe.
For them, debilitating pain is not something to fear; it's a fact of life.
"The quiet ones scare me the most," said Dr. Paul W. Davies, director of the pain management program at Anne Arundel Medical Center. "They've been in pain so long, they've become disassociated with it."
Davies' 6-month-old program is an indicator that the treatment of chronic pain - once limited to a handful of institutions - has become a staple at community hospitals and larger centers as well.
In the past three years, Greater Baltimore Medical Center, University of Maryland Medical Center and St. Joseph Medical Center have also launched pain programs.
According to the American Hospital Association, 42 percent of the country's community hospitals have some type of pain management program, up from fewer than a third in 1998. Two-thirds of Maryland's hospitals offer pain management programs and that number is on the rise, said Nancy Fiedler, senior vice president of the Maryland Hospital Association.
"Thirty years ago, people predicted pain management was a dead end and advised me not to go into it," said Dr. Donlin Long, a neurosurgeon who established one of the first multi-disciplinary pain programs at Johns Hopkins Hospital in 1974.
"It's taken this long to convince people of its importance - it's finally becoming a focus."
Consider the case of Melissa Prentice, a 21-year-old student at the University of Texas who has suffered from chronic back, shoulder and neck pain for years.
She visited Davies' clinic at Anne Arundel at the suggestion of her mother, who lives in Graysonville, after a series of doctors were unable to help her.
"Most of them thought I was just imagining things," she said. "I'd tell them about the pain in my back and they would say nothing could be done, and that maybe I was just depressed."
Davies has treated her with injections, physical therapy and nutritional consultations.
"The injections have really eased my tension and pain, particularly in my neck," said Prentice. "What I have is never going to go away, but the treatments have helped me to get through my days without the pain bothering me."
A poll of 625 Maryland adults by the American Pain Foundation and the Maryland Pain Initiative in 2002 found that 34 percent live with moderate to severe pain. The most common causes were cancer, nerve disorders, serious injury, back problems, migraine headaches and arthritis.
This year, Johns Hopkins Medical School revised its curriculum to include comprehensive pain management instruction. Still, only 3 percent of medical schools in the country offer specialized studies in pain, according to the most recent study by the Association of American Medical Colleges.
Just a byproduct
Doctors such as Long and Davies say growth in the field has been slowed by historical perceptions of pain. Defined by doctors as an unpleasant sensory and emotional experience, pain was traditionally viewed as a byproduct of illness or injury.
It wasn't until the 1960s that the medical community began to study pain as its own condition, one that often remains long after an illness has been treated and afflicts more than 50 million people.
"People are recognizing that just because you're ill, it doesn't mean that you have to be in pain," Davies said.
Like most pain doctors, Davies - who sees five to 15 new patients a day - devotes up to an hour for initial visits. Like Prentice, most of his patients have already seen multiple physicians, none of whom has been able to relieve their suffering.
Davies starts by listening as patients describe the nature of their pain. To help them define it, he asks a series of questions. Does it ache, stab, shoot, gnaw or cramp? Is it constant, or intermittent? Does it get better or worse over time? It is focused, or does it radiate?
Davies also asks patients to rate their pain on a scale of one to 10. One means it's mild. Ten is the kind of pain that makes some patients want to die.
"Ten is the worst pain imaginable," Davies said. "Most of the patients we see are a five or six, and are desperate for relief. Some are so desperate they will ask us to chop their leg off."
Dr. Nelson Hendler, who in 1978 founded the Mensana Clinic, a pain treatment center in Stevenson, is well-versed in patients with the most severe pain - often victims of serious accidents.
"They describe their pain by the effect it's had on their lives," Hendler said. "Some of them get divorced. They can't go to work. They can't sleep. Their lives have been devastated."