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Pain Management

By: Board Certified Pain Management Expert

Despite over 30 years of research advancing the field of Pain Management, woefully little of this research has penetrated the accepted norms of medical practice – that is, how the physician who is not a pain specialist deals with patients in pain. Most physicians still do not understand that chronic pain is a disease, not merely the symptom of a disease. This results in frequent and generally avoidable patient suffering across the spectrum in acute care, emergency, inpatient and office medical practice.

The premier lesson from basic science research into pain neurophysiology over the past 25-30 years is that the longer pain goes untreated or undertreated, the more the pain becomes hard-wired into the central nervous system. As example, the failure to refer patients with reflex sympathetic dystrophy in a timely manner means that the opportunity for early, effective intervention will have passed.  In this specific type of case, orthopedic surgeons are the specialists most often confronted with RSD, and are often the least equipped to diagnose RSD and refer patients for aggressive, early treatment. Cost-containment, as well as treatment-delaying tactics of third party payers also often leads to poor outcomes in that treatable acute pain will develop into chronic pain, potentially causing additional and life-changing physical injury.

Medical-Legal Considerations

To date, there have been only a few precedent-setting cases in which truly gross negligence was committed by physicians in ignoring the suffering of terminal cancer patients.  None-the-less, lack of awareness regarding the management of pain is so widespread a phenomenon that it is practically ubiquitous, particularly for those people in chronic severe pain, but also, still for cancer patients to some degree.

As allowable payments for anesthesia, surgery and other fields came under assault in the 1990’s by both government and the private insurance sector, Pain Management became something of a mini-growth industry.  Many physicians who have not completed appropriate post-graduate training in Pain Management began to practice in the field.  Few provided the careful balance of individual bio-psycho-social evaluation and management that the vast majority of chronic pain suffers require.

Poor outcomes are the logical result of pain management treatment by un or undertrained practitioners. The current situation in Pain Management is analogous to that of Cardiology in the 1970’s, where any physician performing invasive cardiology and catheterization could do so without fear of sanction or medico-legal penalty. Unnecessary morbidity and mortality by the unqualified physician eventually lead to the current state, where only Board Certified Cardiologists are permitted credentialing at reputable hospitals. In my opinion, Pain Management needs to go in that direction as a specialty.

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