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May 1996
Volume 60 |
Number 5
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| The Anesthesiologist's
Expanding Role in Pain Management |
Jessie A. Leak, M.D.
Pain management practitioners have the unique opportunity to
access perhaps the largest patient population of any physician.
Pain, both acute and chronic, is the most common symptom that
stimulates us to seek medical attention. As a symptom, it crosses
all demographic, socioeconomic and cultural lines. It encompasses
not only the extremes of age but can start acutely and persist
for infinite periods of time, both remitting and unremitting,
treated and untreated, uniquely circumstantial to almost any patient.
Because the costs, both real and perceived, in terms of suffering,
disability and lost days of work have threatened an already critically
overburdened system, the practice of acute and chronic pain management
has filled a crucial void. Anesthesiologists have risen to this
challenge and continue to be instrumental in establishing guidelines
and practice parameters for the specialty.
Medical Decision-Making Outside the O.R.
While other physicians are trained in pain management, the majority
of multidisciplinary pain management centers have anesthesiologists
as directors or as the "triage" physician. In essence
then, anesthesiologists not only have moved out of the operating
room into a unique and evolving arena, but they are now integrating
heretofore unfamiliar practice patterns into crucial medical decision-making.
Areas such as physical therapy and rehabilitation, neurology,
and psychiatric and psychological therapies integrated into behavior
modification programs, drug rehabilitation, surgical intervention,
occupational therapy and vocational rehabilitation have become
vital in assessing and treating an enormous variety of pain conditions.
Acute and potentially time-limited pain with an established cause
and effect (i.e., perioperative or secondary to injury) tends
to receive a great deal of attention from most physicians, while
chronic pain patients can overburden the medical system as their
symptoms worsen without apparent nociceptive stimulus. Today,
as referring physicians become more savvy as well as consumer
cost-conscious, patients are slowly receiving earlier referrals
to pain management centers. There is emerging recognition that
chronic pain is not just acute pain that has "gone on too
long."
Acute pain is a symptom that most practitioners are extremely
comfortable recognizing and treating. As a natural outgrowth of
the anesthesiologist's skills and presence in the operating room
and intensive care unit, acute pain services are growing increasingly
formalized and accessible even in smaller hospitals. Decreased
lengths of stay and increased patient satisfaction have made pain
practitioners valuable allies in the management of acute perioperative
and nonsurgical pain.
It is likely, however, that the continued reticence of many physicians
to acknowledge chronic pain as a real entity that merits individual
evaluation in a specialized center lies in the neurological training
that we all received as medical students. We were taught that
a continued nociceptive stimulus to the peripheral or central
nervous system causes a neuropathophysiologic aberration that
may cause pain. When the stimulus stops, the pain should cease.
When the patient continues to present with "pain out of proportion
to physical findings," a perception problem between the patient,
the patient's pain and the physician can become a deterrent to
treating and/or rehabilitating the patient.
More than any other factor, anesthesiologists have learned to
reorient thought processes that once led us to examine closely
only time-relevant objective data, now incorporating more information
about the patient's cognitive and emotional status. Perhaps, it
is this ability that sets this type of practitioner apart from
the technician who performs pain blocks. This is not to say, however,
that these procedures are not an integral part of many treatment
plans and that one's ability to perform such blocks is nonessential.
The natural extension of our technical abilities outside the operating
room added to the recognition of the "continued nociceptive
stimulus" as something less objective (i.e., psychosomatic)
also gives added dimension to our traditional role as anesthesiologist.
The ability to define, understand and implement total treatment
plans for chronic pain make this specialty essential in today's
managed care environment.
The Anesthesiologist as Physiatrist, Psychiatrist -- Even Surgeon
The anesthesiologist's role in this context might arguably be
extended to include that of a neuropsychiatrist, physiatrist,
rehabilitation practitioner, hospice administrator and, in some
instances, surgeon. An integrated multidisciplinary pain management
center should have, at a minimum, the capability to perform pain
management, physical therapy and psychology evaluations as part
of the initial intake process.
As implied above, many but not all chronic pain patients have
continued pain despite traditional interventions. These treatments
frequently have included medications such as narcotics and antidepressants,
other physical therapy regimens and surgery for the pain problem.
It is not infrequent that a pain management center is the "last
stop" for these unfortunate patients. To simply reintroduce
these previous treatments implies sure failure; therefore, close
attention to the psychosocial aspects of the patient's milieu
becomes paramount in defining how to maximize and facilitate the
patient's re-entry into his or her home and/or work environment.
Clearly, the perception of pain and its role for the patient in
determining level of dysfunction vary widely. It is estimated
that between 53 percent and 70 percent of all women initially
evaluated in a chronic pain management setting have a previous
history of physical or sexual abuse or molestation. Workplace
injury and possible financial or other secondary gain incentives
for not returning to work must be carefully evaluated. Pre-existing
and current underlying helplessness or depression may potentiate
and exaggerate otherwise minor complaints of pain.
Pain may become an overriding focus for susceptible individuals
wishing to withdraw from dealing with other painful issues. The
issue of intercurrent and perhaps inappropriate use of chronic
narcotics must be considered. Loss of the patient's vocational
ability as well as any other recent losses (e.g., a spouse or
other loved one) are also factors that may alter pain perception.
These cognitive issues can be objectively measured in part with
such tools as the Beck Depression Inventory and the McGill Pain
Questionnaire; however, it is essential to integrate these findings
with a complete history and physical examination.
Not all patients who are referred to chronic pain management centers
have pre-existing psychosocial issues that predispose them to
incurring these conditions. This is not to say that many patients
do not later develop adjustment disorders resultant from their
underlying pain condition that may, in part, inhibit return to
their desired level of function. A small subset of patients appears
to possess adequate coping skills to exempt them from the above
issues.
Once the appropriate initial assessments have been performed,
the development of a treatment plan with the necessary specialist(s)
becomes important. This may include but is not limited to further
tests (e.g., magnetic resonance imaging, bone scan, electromyography,
etc.), physical therapy regimen, biofeedback, group therapy, behavior
modification programs, vocational rehabilitation, drug rehabilitation,
diagnostic or therapeutic pain block(s), intravenous drug testing
such as phentolamine or lidocaine, surgical implantation of a
narcotic or other drug pump, or a spinal cord stimulator. The
ability to determine the optimal treatment regimen is as important
as the skills needed to facilitate the plan.
The traditional role of the anesthesiologist in managing pain
was to perform pain blocks. This is still a mainstay of acute
and chronic pain management. Perioperative pain management, particularly
for the treatment of time-limited pain such as in total knee replacement,
is now a standard of care in indicated patients. Cancer patients
with malignant pain are a second subset of patients for whom a
continuing noxious nociceptive stimulus mandates careful assessment
for blocking these pain pathways, either pharmacologically or
with pain blocks.
The pain practitioner's role as a surgeon in the operating room
is only recently a familiar one. From scheduling of procedures
to requests for anesthesia coverage to actually performing surgical
procedures with or without surgeon backup, the anesthesiologist
is now on the other side of the "ether screen" and may
be regarded as being in an adversarial relationship in an unfamiliar
operating room. Appropriate patient selection, particularly when
considering spinal cord stimulation or narcotic pump implantation,
is essential.
Perhaps the most important and most difficult programs to set
up, administer and facilitate are those that teach patients behavior
modification. Many programs mandate completion of drug rehabilitation
prior to entry. Desired outcomes do not necessarily include lessening
of pain but rather a reorientation or alteration of pain perception
to regain function and increase the quality of life. Some programs
may include group therapy, vocational counseling, physical therapy,
interactive guided imagery, biofeedback, short-term couples or
family counseling, occupational therapy or any combination of
the above. Many pain management programs suggest that candidates
for spinal cord stimulation complete some form of behavior modification
as a means of maximizing surgical outcomes.
Blending Traditional and Expanded Roles
The traditional role of the anesthesiologist as a physician in
the operating room has clearly changed. The specialty of pain
management has grown exponentially in recent years in large measure
because of the recognition that multiple factors contribute to
and potentiate chronic pain.
Anesthesiologists' primary charge of eliminating pain has simply
been taken one step further with full integration of psychosocial
issues in facilitating the elimination of aberrant nociceptive
stimuli where possible and in aiding in the alteration of pain
perception through behavior modification. This expanded role for
anesthesiologists is likely to grow as patients age and try to
adapt to an increasingly complex and stressful environment.
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