PAIN MEDICINE NETWORK
Vol. 15, No. 2, Summer 2000

From the Editor in Chief

To Diagnose, Cure, Palliate, Restore Function, and Educate: That Is Our mission
Peter Staats, MD, Editor in Chief, Pain Medicine Network

As a young specialty, Pain Medicine frequently is challenged to justify its existence, to explain what sets the pain physician apart from other physicians. As I see it, our mission is fivefold: to diagnose, cure (when possible), palliate, restore function and educate.

Diagnosing pain
Before anything else, a specific diagnosis must be established. The diagnosis of “chronic pain syndrome” is too simplistic for modern day pain management. We now know that pain is not only transmitted via nociceptors to the spinal cord and up to the brain, but that a vast complexity of pain processing takes place in the periphery, spinal cord, and brain that our expertise better allows us to understand.

The diagnosis begins with a comprehensive medical and psychological evaluation that facilitates our synthesis of complex information. The evaluation can include the use of laboratory tests to confirm our suspicions, the appropriate use of laboratory and electrical diagnostic studies and, of course, diagnostic blocks. Concepts of neuropathic pain, wind-up, tolerance, and viscero-somatic convergence should be second nature to the Pain Medicine physician. More than most other medical specialist, we are tuned in to the psychological amplifiers of pain and are experts at using the available tools to diagnose pain problems. Phillip Lippe, MD, AAPM Executive Medical Director, suggests that we distinguish between two types of pain: “Eudynia,” which refers to acute pain (the type of temporary pain most physicians are familiar with), and “Maldynia,” or chronic pain syndromes characterized by a constellation of behavioral and biologic changes that, as we know, occur in a very complex group of patients. These two terms help physicians in other specialties identify pain and appreciate the complex nature of what we do.

Cure when possible
Contrary to popular opinion, pain physicians do cure patients with chronic pain. Whether the pain stems from an undiagnosed disc problem (curable via surgery or block therapy) or piriformis syndrome (which is possibly responsive to myofascial injections combined with physical therapy), the Pain Medicine physician keeps an armamentarium of pain therapies in his tool box. By focusing on the symptoms, we function much like a general contractor, choosing the appropriate therapy for the right patient at the right time. However, the thoughtful Pain Medicine physician carefully weighs all of the risks before embarking on an irreversible course of treatment. This is where much of the art of medicine lies today.

Managing pain
When a cure for pain is not possible, the Pain Medicine physician is very effective at managing pain. Over the last 15 years or so, our knowledge of therapies known to be effective in decreasing the sensation of pain has increased dramatically. At our disposal are medical therapies that decrease activity in c-fibers, modulate transmission in the spinal cord, improve mood, and alter the perception of pain. We have developed cognitive and behavioral strategies that help patients control their symptoms and use interventional strategies that modulate transmission in the periphery, spinal cord, and brain. New drugs are developed and old drugs given new indications all of the time.

Restore function
It is the rare patient who finds all of his or her pain alleviated by medical and interventional therapies. Much more frequently, patients report a marked decrease in their pain and an improvement in their ability to function. When I assess satisfaction in my clinic, I am frequently amazed by what patients say they are thankful for. Even those with limited improvement in pain scores report a marked improvement in function. When pain scores are not altered but function is improved, satisfaction is unanimously high. Patients want to return to a productive life, play with their grandchildren, help out around the house and, yes, return to work.

Education
Even if every AAPM member worked overtime, he or she still wouldn’t scratch the surface of treating all of the acute and chronic pain conditions in the United States. As Pain Medicine physicians, we must do more than provide outstanding care for patients with pain. We must raise the standard of pain care in our communities, and we must do more to help treat patients on a broader, more global scale. There are many opportunities and avenues that we can follow to achieve these ends. These can be grouped under four areas: research, legislation, education, and, of course, financial contribution.

The next generation
Practitioners can no longer rely on the academic physician to design, implement, and publish the research that will advance our field. Academic physicians are under the same time constraints as the private practitioner. However, without advancing science by doing a few basic research projects, we will have a difficult time calling ourselves a real science, and it is unlikely that insurers will continue to pay for our services. We need broad, outcomes-based research that will advance our knowledge of pain and its treatment. Physicians, patients, and insurers alike must become aware of new advances, and law makers need to be lobbied to assure reimbursement.

What can you do to help? Write an article for your local medical society, teach a class on pain in medical school, give a lecture or two to the primary care physician, speak to the patients in your community, or volunteer to serve on an AAPM committee that advances some aspect of pain care that interests you. This is your mission, should you choose to accept it. I hope you will.

Mark Your Calendar!
American Board of Pain
Medicine Examination
Monday, February 19, 2001
Fontainebleau Hilton Hotel
Miami, FL