January/February 2003: Pain, Revisited

Priscilla Scherer


January 15, 2003


Pain is a topic like religion: what reveals the most is not what any one person says, but what you learn from what all people say. --John Barbuto, MD, Sandy, Utah

I wouldn't call it a Pandora's box, or a can of worms, exactly...maybe a festering wound. Whatever it is, I certainly opened it when I wrote about the state of pain management in a column back in November. I asked for opinions and expected to hear from a few more readers than usual but, my goodness, I heard from hundreds of you! Half from frustrated patients in pain, half from frustrated physicians who want to help their patients, and 1 from a doctor who poetically chided me for using my friend's unique experience to support such a call for wide-ranging change in education and practice ("One swallow does not make a summer."). Of course, this last person was right, and yes, my anecdote probably does not apply to the problem of chronic pain management, but if you total all the others who wrote in, it may add up to a significant sample size.

Those pain sufferers who wrote overwhelmingly agreed that most healthcare professionals -- specialists and generalists alike -- are clueless about pain. The physicians and other healthcare professionals who responded were not at all clueless but are stymied by a system that does present a veritable Hydra of obstacles to good management. Plus, pain is itself a many-faceted entity with multiple mechanisms that depends as much on the individual patient as on the neurophysiology underlying it.

I am including a few of these responses here, chosen because of the different viewpoints and aspects of pain and pain management that they present. Then, I invite you to add your thoughts and ideas to a discussion forum on pain management.

Several respondents emphasized the obstacles constructed by managed care providers, but several also discussed the problem of primary care physicians who don't want to deal with patients who require narcotics.

I am an internist with 18 years experience and a strong interest and over 80 hours of CME in pain management. My efforts in pain management have met with tremendous resistance by HMOs. I recently had my contract terminated with one of them. Pain management at the primary level is difficult, isolating, and nasty from a business standpoint. On the other hand, it is very rewarding and satisfying for patient and physician when good results are obtained. -- William Teubl, MD, Rhinebeck, New York

Several Canadian physicians noted that compared with the United States, training and practices in pain management there more closely follow the paradigm proposed by Dr. Rollin Gallagher and mentioned in the November column. However, others noted the multifaceted nature of pain management that, in our society, makes it difficult to manage successfully.

I was trained in a Canadian medical school and am happy to say that we received considerably more training on pain management. Dr. Gallagher's ideas of a community network model with referral to a central pain management center of expertise is also an excellent concept. However, in these days of managed care, and given the number of uninsured patients in our society, I don't think there is any easy answer. Too often, many factors stand in the way of proper pain management. Primary care providers often have not sufficient time to properly assess patients in an office setting. Patients often come to the PCP with an already lengthy history of their painful problem. Poorly educated people do not have the ability to prevent or manage their common (usually musculoskeletal) pain problems, nor to deal well with the ensuing psychosocial issues that arise, such as depression, stress, or inability to work. And waiting times for referrals for pain management are too long in many settings. -- Meg MacDonald, MD, San Jose, California

A number of pain specialists took issue with my characterization of pain management as static, but also agreed that medical training in pain mechanisms, recognition, and management is dismally inadequate.

I disagree that we are where we were decades ago. The science and practice of pain management has progressed a long way. The problem is simple: Medical schools should devote considerably more time providing in-depth training to medical students and residents in pain mechanisms and pain management. The hour of glossed over training is simply ridiculous. Medical schools are simply not interested in teaching about pain even though a major percentage of physician visits are pain related. When I was president of the American Pain Society (1991-1992), we developed a medical school curriculum, but no medical school showed interest in adopting it. Subsequently, we tried to educate the board of medical examiners in several states regarding the importance of pain management. As a result more questions regarding pain were included in the board exams, forcing medical schools to make cursory attempts to teach more about pain. Unfortunately, because "pain does not kill," many prominent administrators and institutions will not devote funds or space to solving the problem. This unbelievable mentality is what prevents patients from receiving the care they need; or, when they do receive it from their primary doctors, why it is ineffective. Your friend's problem was not a failure of the current state of pain management, rather it was a failure of a medical education system unwilling to teach their students the current state of pain management.

-- John L. Reeves II, PhD, Past President, American Pain Society

And this from an anesthesiologist who specializes in pain management:

Our current state of education for the primary care clinician is wholly inadequate. I have the opportunity to teach the introductory lecture to the incoming primary care physicians each year at our teaching hospital. When I asked for a show of hands from those who could recall having received any formal lectures on pain management in medical school, only 3 out of 35 raised their hands. When I asked if anyone could define what addiction was with regard to opiates not a single person could. Our resident physicians still believe that patients with cancer pain, when treated with opiates, are at risk of addiction. Needless to say we have a long way to go before the primary care clinician will be able to effectively manage pain. Until the medical teaching model changes, I do not believe that these attitudes and beliefs about the importance of treating pain will change. -- Bruce Nicholson, MD, Allentown, Pennsylvania

An authority on central pain syndromes suggested that, as with other brain disorders, until we have a way to quantify pain, it can only be approached with suspicion and guesswork.

The problem with pain is that we have no way to measure it or quantify it. Science is about measurement. If imaging scientists would focus on pain as seen on functional MRI or the new gas tensor imaging, it could be done, but no one seems motivated to bother with variables that change the imaging pictures. If pain were acknowledged to be severe, we would do something about it. So without the ability to measure, we are wildly guessing, acting like indifferent callous doctors, and we get burned both ways. The feds have an interest in managing "controlled substances," yet there is little rationality in the way this is administered. As Ron Melzack showed, patients in severe chronic pain do not become "drug addicts." -- Ken McHenry, MD, Provo, Utah

Finally, I'd like to end a little provocatively, with a response that highlights only a few of the difficult nuances of pain assessment and management, from a neurologist who "does a lot of pain work."

If you lump all pain experience into the same pot, then a great deal of pain is already being managed by PCPs. The patients who are referred on to a specialist (by the doctor or by themselves) are those with chronic pain, or poorly explained pain, or pain associated with observed pathology outside of the purview of the PCP. Mundane, routine pain is present in the great majority of all medical care visits. However, it is not a major problem and is not culled out as focus for a pain discussion. In many of these visits the patient does not seek treatment for pain, but if you were to inquire insightfully you would find it was there (maybe very minor, and not a problem the patient wants the doctor to address).

Also, if you are to understand pain you must look beyond humans. Anthropocentric proclivities may lead people to presume we are something entirely different, but this clearly is not true (as genetic comparisons across species clearly reveals). When you look at animals what you must observe is what doesn't happen: chronic pain without clear pathological foundation. And, you must also observe how, for animals, pain is a nociceptive indicator and aid to prevention of further tissue damage (the concept you referenced). Notably, in animals pain is not a metaphor for anguish. Animals don't appear to suffer from chronic pain syndromes. These last sentences are interrelated.

When a baby is born its first activity is to cry: defining "I am here. Take care of me." We then spend the first several years of our lives being dependent. During that time a child cries a lot. The child cries when unhappy, unsupported, in need, or in pain. The behavior is similar while the mechanisms are different. What does the adult do when unhappy, unsupported, in need, or ....?

Pain management, when focused on the difficult cases, is perplexing because very often the patients with the worst claimed pain are the people with the least to see on examination. What are they suffering from?

You can understand pain, if you look broadly enough at the issues. The specifics of pain management vary widely, just as do the dynamics of pain in varying patient situations. Pain is managed in millions of patients a day. Where people focus on the discussion of pain is in that smaller percentage where the issues are not simple. The patient might have a hidden abscess, or there might be something else hidden. -- John P. Barbuto, MD, Sandy, Utah

I hope you'll add your opinion, suggestions, ideas, and experience to this discussion. As with most important dilemmas, a lively exchange of problems, thoughts, and ideas precedes solutions, and perhaps that will be the outcome here. Regretfully, the debate will have to continue without me. This is my final From the Editor column for Medscape, as I move on to new challenges. I leave with many thanks to the fine editorial board and contributors, the outstanding Medscape staff, and to all the members who have made the management of this site so rewarding.

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