Anesthesia: Chronic Pain Management

Chronic Pain Management

Pain—the most common symptom that brings patients to see a physician—is nearly always a mani-festation of a pathological process. This symptom may have a wide variety of causes ranging from rela-tively benign conditions to acute injury, myocardial ischemia, degenerative changes, or malignancy. In most cases, after a diagnosis is made, conservative measures are prescribed and the patient responds successfully. In others, referral to a pain medicine specialist for evaluation and treatment improves out-comes and conserves health care resources. In still other situations, pain persists and patients develop chronic pain, the cause of which remains obscure after preliminary investigations have excluded seri-ous and life-threatening illnesses and, if warranted, surgical intervention has either failed to relieve pain or has produced a new pain syndrome.

The term pain management in a general sense applies to the entire discipline of anesthesiology, but its modern usage more specifically involves management of pain throughout the perioperative period as well as nonsurgical pain in both inpa-tient and outpatient settings. Pain medicine prac-tice may be broadly divided into acute and chronic pain management. The former primarily deals with patients recovering from surgery or with acute medical conditions in a hospital setting, whereas the latter includes diverse groups of patients almost always seen in the outpatient set-ting. Unfortunately, this distinction is artificial and considerable overlap exists; a good example is the patient with cancer who frequently requires short-and long-term pain management in both inpatient and outpatient settings.

The contemporary practice of pain manage-ment is not limited to anesthesiologists but often includes other physicians (physiatrists, surgeons, internists, oncologists, psychiatrists, and neurolo-gists) and nonphysicians (psychologists, physical therapists, acupuncturists, and hypnotists). The most effective approaches are multidisciplinary, in which the patient is evaluated by one or more phy-sicians who conduct an initial examination, make a diagnosis, and formulate a treatment plan, and where subsequent evaluation and use of the services and resources of other health care providers are readily available.

Anesthesiologists trained in pain manage-ment are in a unique position to coordinate multi-disciplinary pain management centers because of their broad training in dealing with a wide variety of patients from surgical, obstetric, pediatric, and medical subspecialties and their expertise in clinical pharmacology and applied neuroanatomy, including the use of peripheral and central nerve blocks.