"The longer you go on with untreated pain, the more perpetuated the pain becomes and the more difficult it will be to treat."(B. ELIOT COLE, MD)
B. Eliot Cole, MD, MPA, is the executive director of the American Society of Pain Educators. He believes that early, multidisciplinary care—a team-based approach utilizing experts and therapies from several disciplines—is the best way to treat chronic pain. He advocates for better pain education among doctors and health-care workers.
Q: Can a family doctor successfully treat chronic pain?
A: The view of most primary care doctors is that they treat all pain as acute pain, no matter how long it goes on. Acute pain should be thought of as ending in 30 days, then its subacute for 30 to 60 days, but after that its chronic pain. The biology of chronic pain is not the biology of acute pain. If you fall and break your wrist, the bones will heal within four to six weeks, but pain may continue. You cant treat that like you would the acute fracture.
Q: Whats wrong with treating chronic pain acutely?
A: The longer you go on with untreated pain, the more perpetuated the pain becomes and the more difficult it will be to treat. So if youre treated in 60 to 180 days, your probability of being pain free goes to nearly zero. But if we can get you in the first 30 to 60 days, you might stay pain-free—from that particular problem—for the rest of your life.
Q: What do you advise a patient to do?
A: Take a little individual responsibility and say to the doctor, "Id like to be referred to a pain specialist, or see an orthopedist." In the case of a fractured wrist, the family doctor will do an excellent job setting it. But once the cast comes off and the bone is healed, if its still hurting, youve got a problem. You may need to go to a hand rehabilitation program, you might need an injection into your neck that sort of resets the switch for your arm, you may need a comprehensive pain management plan ultimately. The sooner you can get to that level of care, the better the result will be.
Q: You advocate comprehensive pain management—a combination of approaches such as drugs, counseling, physical therapy, alternative treatments—all coordinated by a team. How many patients actually get that in the United States?
A: In the past decade, the number of large, multidisciplinary pain clinics has dropped dramatically, from more than 1,000 to fewer than 300 today. Even the federal government only operates one comprehensive pain clinic now, in Florida, through the Department of Veterans Affairs.
Next Page: Can you still find pain specialists?
[ pagebreak ] Q: Can you still find pain specialists?
A: There arent enough—especially if youre living in Middle America, youre really hurting. There are very few pain clinics that you can go to. Its going to take some legwork and maybe four hours of driving [from a small city] to get to some place that might give you the help you need. In a major city, though, you can drive down the road and find a big clinic.
Q: Why the decline in pain clinics?
A: The implosion has been partially because of managed care. We still pay for more nerve blocks and procedures than we do for multidisciplinary care, and yet the only thing that statistically has been shown to make a difference is multidisciplinary care.
Q: Is insurance also a barrier?
A: A lot of employers will shop every two or three years for the lowest priced health care they can buy. This year youre with HMO ABC. Three years from now youre with HMO XYZ. The records dont move seamlessly around with you. The docs at each new place have some suspicion about what was done previously. And everybody knows youre going to move again. So nobody wants to do the job right on their watch.
Q: With all of these obstacles, arent you asking a lot of the patient to say that they must demand complex care for pain?
A: Im not asking for patients to do anything complex other than to take ownership of their problem and say theyre not happy. Its your arm that hurts. At the end of six weeks, if its still hurting, you need to be proactively saying, "I need to move on to the next phase." When the doctor says to just give it time, give it six months, you have to say, "No, no, no."
Q: So even when youre in pain, you have to take charge?
A: I hope patients will just get the point. You dont have to hurt. People suffer a lot more than they need to. And if they took a bit of action and became a so-called bad patient, became a little disruptive, said, "You know, this isnt your arm that hurts, its my arm, and I want referral now, not in six months," things would be better.