The “Decade of Pain Control and Research": Part I
Part I: What Have Been the Greatest Achievements in the Past Ten Years?
In the year 2000, the Joint Commission on Accreditation of Healthcare Organizations released new standards for the assessment and management of pain in the facilities they accredit and certify. C. Richard Chapman, Ph.D., then the President of the American Pain Society, described this as “a giant step…a major leap forward”. A few months later Congress passed and the President signed a law that declared the ten-years beginning January 1, 2001 as the Decade of Pain Control and Research.
Charles E. Argoff, MD:
Charles E. Argoff, MD, is Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in New York. Dr. Argoff received his medical degree from Northwestern University’s Feinberg School of Medicine in Chicago, Illinois. He completed an internship in the Department of Medicine and a residency in the Department of Neurology at the State University of New York in Stony Brook and a fellowship in Developmental and Metabolic Neurology at the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS). (continued below)
"What is your personal evaluation of the achievements in the past ten years as the Decade of Pain Control and Research draws to an end?"
There has been tremendous progress in the past decade in understanding that there is a critical need to do a better job in treating pain. However, this increased awareness has not led to increasingly better outcomes. A great many questions have been raised that still need to be answered in the future. Among them are questions such as what should be the role of interventional treatments in managing chronic pain, how can multimodal therapy help to improve outcomes, what qualifies someone to be considered a pain “specialist”, and what do primary care providers need to know to do a good job treating pain.
The fact is that most pain is treated in the primary care provider’s office. The “good” part of this is that as part of an increased level of awareness, primary care providers have been asked to play an increasingly significant role in the management of chronic pain. This leads to the possibility that primary care providers will work in collaboration with pain specialists. Unfortunately, how it plays out in reality differs from region to region, based on skill sets and availability of pain experts for consultation. What is “not good” is that the people who often have to address this problem often don’t have the appropriate skill set to do the job, and need additional training and education in order to do so.
In some ways, raising awareness of the problem of untreated chronic pain has opened “a can of worms”, and I don’t think the explosion in the number of guidelines on this topic has actually affected the care of the patients in many cases. Some primary care providers do recognize that there are now many choices for pain treatment and procedures that should be followed, but still many patients are not given choices, and compliance to clinical guidelines may be low at the primary care level.
Although there may not have been significant clinical advances in chronic pain management over the last decade, in my opinion, there also have been tremendous advances in the basic sciences that have contributed to our understanding of chronic pain. These would include recognizing how acute pain that is poorly treated often becomes chronic pain, and why chronic pain is so different from acute pain. I believe that due to these advances, chronic pain is now better understood and recognized as a disease or disorder of the nervous system, rather than just a set of symptoms. But we are still challenged with trying to identify what we do know from what we don’t know, so we can select the best treatment that is tailored for the individual patient.
In the previous decades, when the cry arose for the need to treat cancer pain and chronic pain better, we may have underappreciated the complexity of pain, attempted to increase symptomatic treatment, and did not anticipate problems like the ones we are seeing now, like long-term side effects of chronic opioid therapy and the problems associated with aberrant drug-related behavior, especially drug diversion.
Dr. Argoff is a member of the International Association for the Study of Pain, the American Academy of Pain Medicine, and the American Academy of Neurology, among other professional organizations. He serves on the editorial board of the Clinical Journal of Pain and as a reviewer for the Journal of Pain, Brain, JAMA, Archives of Physical Medicine and Rehabilitation, Journal of Musculoskeletal Pain, Journal of Pain and Symptom Management, and the Clinical Journal of Pain. He is Co-Editor of the Neuropathic Pain Section of Pain Medicine.
Dr. Argoff has served as a guest editor for and published articles in the Clinical Journal of Pain and Current Pain and Headache Reports, among other peer-reviewed journals. He has written on many types of pain, including myofascial pain, spinal and radicular pain, and neuropathic pain. He has written on such treatments as topical analgesics, interventional pain management, botulinum toxins, and oral analgesics, and has contributed many book chapters as well. Dr. Argoff had an active role in the development of the diabetic peripheral neuropathic pain guidelines published in Mayo Clinic Proceedings, and he has contributed to other published neuropathic pain treatment guidelines. He is one of the editors of the recently published textbook Raj’s Practical Management of Pain, Fourth Edition. He is the co-author of Defeat Chronic Pain Now, a just published book for people with chronic pain. He has recently published the third edition of Pain Management Secrets.