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Anesthesiology:
doi: 10.1097/ALN.0b013e3182039f87
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Pain Medicine: Repairing a Fractured Dream

Ballantyne, Jane C. M.D., F.R.C.A.

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IN 2000, John D. Loeser (Seattle, Washington) wrote the following:
Will pain specialists disappear? This is not a trivial question when one is addressing members of a pain association. However, from the perspective of a nation's health care delivery system, the advent or demise of pain specialists is not likely to be noticed. This is especially true in the United States, where most physicians who specialize in pain are anesthesiologists, who will just retreat to the operating room if pain medicine disappears.1
More recently, in an editorial accompanying one of many epidemiologic studies that are revealing how dismal the real outcomes of chronic pain treatments are, particularly opioid-based treatments,2–7 Katz wrote the following:
Referral to pain clinics is particularly helpful when patients have pain that could be alleviated by a nerve block. These patients are, however, the minority. Sending patients to a pain specialist to help with outpatient opioid medication can ease the burden of the primary care physician, and many clinics have interdisciplinary staff to help manage underlying mental health and substance use problems. However, such referrals undermine the relationship between patients and their primary care physicians and suggest that the pain, which is very much a global problem, is in some way separable from physical and mental health. Furthermore, from a practical point of view, pain clinics might not be an option for uninsured low income patients.8
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Are We Losing Ground?

Not long ago, pain management consisted of opioids combined with compassionate care, applied successfully and almost exclusively to the treatment of acute and cancer pain. There were no sophisticated pain interventions; pain was not a disease, a specialty, a journal, or a clinic. Pain research and pain clinics burgeoned in the second half of the twentieth century.9 Chronic pain became not a common burden of humankind but a condition that nobody should have to suffer, to any degree.10 When attempts were made to translate the undoubted gains made in the treatment of acute and end-of-life pain to chronic pain, trouble began. After 20 yr of practicing pain medicine in the United States, I believe I see more suffering now than I ever saw when all physicians did was aggressively treat pain at its worst and most distressing. In the case of chronic pain, we fail patients because we prom-ise more than we can give.5,11,12* For many patients with severe pain at the end of life or related to trauma and surgery, we have lost our greatest weapon (i.e., opioids), at least for patients treated for a long time who become refractory to treatment.13–15
The state of long-term opioid treatment should be considered first. We see a picture of increasing use despite lack of evidence for effectiveness.16 When it is not working, we have been taught to increase the dose until it is, although experience suggests that if it is not working, it is not going to work. Worse still, high doses are associated with toxicity and the refractoriness that may eventually make it impossible to treat pain effectively.17 We are providing a treatment that for many patients is not improving their pain but is compromising their lives and futures. However, even this ignores the bigger societal problem of rampant prescription opioid abuse that affects all strata of society, from teenagers popping “oxys” to the poor and disadvantaged, who see duping their physicians into prescribing opioids as a way to pay for their groceries. Both abuse and death rates associated with prescription opioids have increased alarmingly and in direct correlation with increased prescribing for chronic pain.18,19 That is not to say that there are not some patients whose lives can be improved by opioid treatment; it is to say that current indiscriminate prescribing must be reexamined. Who taught us to do all this? In large part, it has been the drug companies that have for years picked the message and the messengers while sponsoring much of the postgraduate education and all the major pain meetings.20,21
Henry Beecher, M.D., Patrick Wall, D.M., F.R.S., and Ronald Melzack, O.C., O.Q., F.R.C.S., were pioneers of the concept that pain does not simply occur along a line-labeled system, as depicted in the famous Descartes drawing of the boy with his foot in the flame, but is instead a plastic phenomenon that changes according to circumstance. More profound, and more important, Beecher also observed that drug effects and pain are altered according to context.
Quantitative study of the psychologic effects of drugs is an urgent need; such work is properly a part of pharmacology. The possibility of accurate quantitative work in this field has been demonstrated; but even so, accomplishments to date constitute no more than a beginning in what promises to be a great development in pharmacology.22
Beecher recognized, as long ago as the 1940s, that drugs can have different effects in the same patient in different circumstances. The context in which opioids are given, for example, can markedly alter tolerance to their effects.23,24 Attention to the behavioral aspects of pain may even, in some patients, obviate the need for drugs; at the same time, drugs may become ineffective when the powerful placebo is lost.25 Another great pioneer of our field, John Bonica, M.D., whom many consider the founder of modern pain medicine, also recognized that drugs and injections alone do not work for chronic pain; they must be combined with physical and particularly behavioral approaches. So what happened to the multidisciplinary model that Bonica espoused and all of Beecher's work suggested? It became unsupportable because of a failure to recognize that the less glamorous and more ponderous aspects of clinical care are actually worth paying for because they work, even if not with dramatic immediate effects.26–28 The value of the model is still recognized, as suggested by this segment from the American Society of Anesthesiologists Web site:
Frequently the anesthesiologist heads a team of other specialists and doctors who work together to help you manage your pain. The anesthesiologist or other pain medicine doctors (such as neurologists, oncologists, orthopedists, physiatrists, and psychiatrists) and nonphysician specialists (such as nurses, nurse practitioners, physician assistants, physical or rehabilitation therapists and psychologists) all work together to evaluate your condition. Then this ‘team’ of specialists will develop a treatment plan designed just for you.
In reality, how often does such an ideal setup exist? How many multidisciplinary pain centers have had to be closed, and how many academic pain programs have had to focus on interventional approaches to the near exclusion of all else to meet the production metrics expected by their hospitals and bean counters? The model for economic survival is not the model for good care.29,30 In many senses, we are trapped: choosing production-line medicine because we no longer get paid for thoughtful interactions, overusing procedures because they are instantly satisfying and heavily reimbursed, and towing the corporate line (overtly or subliminally) because industry supports our educational and research efforts. But if we, or at least our leaders, do not rise above all of this, then we certainly will lose ground.
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How Can We Turn Things Around?

Table 1
Table 1
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We are anesthesiologists, and anesthesiologists remain the dominant specialists in pain medicine (table 1). Beecher and Bonica were both anesthesiologists; their ideals are as relevant today as they ever were and should be guiding us now and in the future. We have come so far. Unraveling the basic mechanisms of pain, even to the molecular level, has opened up both real and potential possibilities in terms of novel therapeutic interventions. Advances in imaging have allowed us to better understand central neural function and pain mechanisms (research)31 and to perfect regional techniques as never before (clinical practice). Advances in genetics and pharmacogenetics are beginning to shed light on which patients are at risk for chronic pain, addiction, and hyperalgesia; and which drugs are suitable for which patients. We are on the brink of being able to tailor treatments much more precisely.32 Computer- and Internet-based programs are opening up new possibilities in terms of outcomes research, overcoming the limitations of randomized trials, and truly understanding in large populations what our treatments are doing. Computer-based clinician and patient-centered tools can aid practice, especially within the constraints of “high-efficiency” health care.33–35 What should our leaders be doing then? We must revive the multidisciplinary model. We should encourage the government and other noncorporate entities to fund our research so that we are not overreliant on corporate sponsorship. We also should lobby for a fee schedule that produces a better match between reimbursement and proven outcomes.
This is not intended as a message of gloom and doom. Rather, it is intended to help end the complacency and self-satisfaction that has brought us to where we are now (i.e., experiencing growing doubts that pain specialists have the means to alleviate chronic pain).8 Interventions alone will never be enough. As for patients taking opioids, we cannot simply refuse to prescribe or shuttle these patients through high-production clinics. We were at best complacent and at worst active in creating the opioid problem that we see today; it is up to us to help turn it around. Our clinics should help the clinicians in primary care (the primary prescribers) select the right patients for long-term opioid therapy and should be able to offer exactly the type of ideal care outlined by the American Society of Anesthesiologists itself to those (hopefully few) patients who need opioids and specialty care. We must perform the outcomes research coupled with the basic science that will allow us to identify who is helped and by what means and which patients will be better off with nonmedical approaches. I would like to be able to hold my head high and say that what I am doing, and what my specialty is doing, is helping to relieve the burden of chronic pain. And what better time than now to take stock and begin to turn things around, when it is becoming increasingly clear that if we do not lead the pain field in the right direction, others will do it for us.8,36‡§
Jane C. Ballantyne, M.D., F.R.C.A.
Penn Pain Medicine Center, Philadelphia, Pennsylvania. jane.ballantyne@uphs.upenn.edu
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† The management of pain. 1995–2009 American Society of Anesthesiologists. Available at: http://www/asahq.org/patientEducation/managepain.htm. Accessed September 23, 2010, but now defunct. Cited Here...
‡ REMS and Opioid Analgesics Webinar. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM163668.pdf. Accessed October 10, 2010. Cited Here...
§ Hannenberg, A. Letters – The Doctors, the Nurses and the Anesthesia – New York Times. Available at: http://www.nytimes.com/2010/09/12/opinion/l12anesthesia.html?_r=2&pagewanted=print. Accessed October 10, 2010. Cited Here...

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