SUMMARY

Because of the prevalence of pain and the professional's desire to manage patients with pain more effectively, there are ever-expanding opportunities and demands for patient evaluation and treatment in many medical specialties. Anesthesiologists have guided the evolution of the subspecialty of pain management for years and have elucidated the rationale for the administration of both analgesic and adjunctive drugs, as well as an expanding array of interventional therapies. They have also taught that options for treatment beyond these modalities are equally important. ^[30] As the treatment of patients with neuropathic pain is clearly the practice of pain medicine, all health care professionals must acknowledge the need for a treatment program—one that incorporates a number of therapeutic modalities used concurrently, considers all of the contributors to the "pain" revealed in the systematic evaluation of the patient, and fosters routine follow-up so that the treatment plan can be modified to include only those therapies that are making an obvious and positive contribution to the patient's quality of life. The ultimate goal of the program of treatment is to help the patient achieve a more productive and satisfactory lifestyle. The pain management physician must be a clinician who can integrate proven new advances in evaluation and treatment from scientific research and clinical investigation into his/her practice and yet be able to set aside those therapies and techniques, no matter how lucrative, for which evidence of benefit is lacking.

Blumenthal and colleagues studied residents completing their training in eight medical specialties.^[146] Although most felt prepared to manage the common conditions they would ordinarily encounter in practice, "opportunities for improvement" (in the thoroughness of training) were evident. More than 10% of anesthesiology residents felt uncertain about the management of chronic pain—and this is in the only specialty that has pain management as a mandatory inclusion in the curriculum. Thus, the future is filled with abundant opportunities for graduate and post-graduate continuing education for all specialties. Perhaps pain center services will be expanded, as suggested by Burton and Boedeker. ^[147] In a military system faced with shrinking resources but an expanding patient base, the wonders of telemedicine are being used to make service available to many more patients than could visit a pain management center, and this is being done in a convenient, economic, and efficient manner.

Nielson and Mior proposed a theme that makes great sense—why not work more diligently to prevent chronic pain?^[148] They recommended that (1) workplace studies should be done to create effective injury-reduction strategies, similar to the concept of preemptive analgesia, which advocates treating inflammatory pain before it begins; (2) findings from scientific research about neurophysiologic mechanisms for pain and how rapidly the CNS becomes "hard-wired" toward pain perpetuation should be elucidated and treatment directed at minimizing such changes; and (3) attention should be given to the delayed progression in the resolution of acute pain and the initiation of secondary prevention strategies aimed at identifying risk factors for patients developing neuropathic pain and reducing the likelihood of recurrent pain.

These authors noted that the contemporary biopsychosocial model of pain management fosters multidisciplinary input. They pointed out that this is particularly true of the psychosocial influences on complaints of "pain" that complicate its presentation, treatment, and resolution, and that more can be done to assess and address these factors and earlier so in most patients. Finally, these authors introduced the idea of tertiary prevention, which is related to minimizing the impact of established illness on the patient's life, thus decreasing the pain, the suffering, and the disability in patients with clearly established neuropathic pain. They summarized by stating that "it is particularly important to provide the right intervention, at the right time, for the right patient."^[148] If we are to make headway in reducing the number of patients so adversely affected by neuropathic pain, this seems to be a worthy recommendation.