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August 1997
Volume 61 |
Number 8
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RESIDENTS' REVIEW
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| Pain Medicine
Offers Residents an Expanded Role |
Veronica Mitchell, M.D.
Scott E. Metzger, M.D.
Pain management is one of the most rapidly growing areas within
the medical field. The role of the pain practitioner has been
regarded important since the beginning of Ancient Civilization.
In the year 3000 B.C.E., the pain practitioner was referred to
as the "asu." However, today we can be referred to as
"algologists."
In this span of 5,000 years, we have seen the development of
general and regional anesthesia, cryotherapy, neuromodulatory
techniques and radio-frequency neurolysis for pain management.
Specific milestones in our field include the recognition of chronic
pain as a disease state in the 1800s, the evolution of pain centers
in the 1930s and 1940s, and the emergence of multidisciplinary
pain clinics in the 1970s.
Pain medicine is an exciting and challenging area for residents
and fellows training in anesthesiology. It allows us to use our
clinical skills to diagnose etiologies of pain syndromes and employ
our technical skills to perform diagnostic and therapeutic procedures.
These procedures include nerve blocks and surgical implantation
of spinal cord stimulators and intrathecal blocks and surgical
implantation of spinal cord stimulators and intrathecal pumps.
Pain medicine, like critical care medicine, has expanded our roles
as anesthesiology residents and fellows and broadened our future
practice opportunities.
The explosion of interest in pain medicine has resulted in many
novel research developments. As the pathophysiology of pain mechanisms
are defined, we are able to introduce new medical therapies for
its management. In addition to nonsteroidal anti-inflammatory
medications and opiates, we are now using antidepressants and
antiepileptic drugs for controlling chronic pain. Drugs such as
ketamine and dextromethorphan are also being used as adjuvant
drugs for the treatment of pain. These drugs block the NMDA receptor,
presumably at central receptors, and may be beneficial in treating
certain chronic pain states. This receptor may also play a role
in the development of tolerance to opiates. The discovery of a
neuro-selective calcium channel blocker in the toxin of a snail
is another example of new research avenues in pain medicine. This
"snail juice," known as SNX-111, is currently under
investigation for intrathecal use in treating chronic pain states.
Other exciting advances include the introduction of epiduroscopy
for evaluation of epidural pathology.
There has been a rapid growth in the number of fellowships offered
in pain management. In fact, the number of accredited fellowships
has nearly doubled in the past two years. The American Society
of Regional Anesthesia (ASRA) publishes a list of available fellowships
within the United States. This book contains important information
on the application process, the faculty and special features about
individual programs.
There is great diversity in educational offerings between programs.
A program that offers comprehensive care with attending staff
trained in medical, surgical and psychiatric approaches to pain
management is desirable. The program should have a patient base
that represents a wide variety of disease syndromes in addition
to having resources that allow for training in the most state-of-the-art
procedures. When actually visiting the program site, keep in mind
the importance of a friendly and helpful support staff. Lastly,
a program should offer didactic sessions that cover the topics
contained in the "Core Curriculum for Professional Education
in Pain" as published by the International Association for
the Study of Pain.
Veronica Mitchell, M.D., is a CA-4 Fellow
in pain management at the Johns Hopkins Hospital, Baltimore, Maryland.
Scott E. Metzger, M.D., is a Pain Consultant
at NeuroSpinal Pain
Consultants, P.A., Tinton Falls, New Jersey.
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