VOLUME 29, NUMBER 26 THURSDAY, APRIL 2, 1998
ReporterQA

Q&A

FletcherJames Fletcher is assistant professor of clinical anesthesiology and medical director of the Comprehensive Pain Treatment Service. Located in the University Physicians Office (UPO) on the South Campus, it is the only multidisciplinary pain clinic between Cleveland and Rochester.

Why do most people come to the Comprehensive Pain Treatment Service?

People are referred to the Comprehensive Pain Treatment Service for management of pain in a specialist environment. They are referred by their primary-care physician, surgeon, internist, chiropractor or, occasionally, directly by themselves. The clinic offers a specialist environment, bringing together staff with a special interest in pain to treat patients from a wide variety of symptom backgrounds. This is possible because all the staff at the pain clinic specialize specifically in pain management, and have access to backup staff outside the clinic who have also demonstrated a successful approach to pain management. Often patients have seen a number of other doctors to have their symptoms, signs and abnormal results of investigations treated, with either no or limited success.

Who are the professionals on your pain-treatment team?

At present the clinic has on a single site one physician, one nurse practitioner and two pain psychologists. The clinic also makes extensive use of physical therapy as part of an interdisciplinary approach to pain management.

What are the most common causes of chronic pain that you see?

Low back pain is the most common cause of referral, this being the single largest cause of lost work days due to disability. Many patients also have myofascial pain-pain in the muscles of the back or shoulders. The clinic also specializes in two other types of pain problem: patients with limb pain who have a condition often referred to as "reflex sympathetic dystrophy," and patients with headaches, who will often benefit from techniques taught by the pain psychologists, in addition to medical management.

What effect does chronic pain tend to have on a person's life?

Chronic pain affects patients in a spectrum of ways. This varies from minor physical dysfunction to gross disruption of personal and family life. Depression is a common accompaniment to chronic pain and probably reflects the continuous assault the brain endures as a result of feeling pain. Anxiety due to loss of work, family or money also affects the chronic-pain patient and needs addressing as part of an interdisciplinary approach.

Do you focus on managing pain, or eliminating it?

We focus both on managing pain and eliminating it. Initially we look for methods of reducing pain. These may involve medication, injection, pain-psychology interventions and physical methods. Often these will bring a patient's pain to a level where they can resume a more normal life and enables them to cope with any remaining pain themselves. Remember that the patient will usually have been extensively investigated for a specific diagnosis and that any appropriate treatment, often surgical, will have already been done.

Is most pain manageable? If not, what are the exceptions?

Most chronic pain syndromes can be managed, although many cannot be completely cured. Patients who are referred early to the clinic have the best chance of returning to a more normal life. Patients who have been in chronic pain for many years are the least able to benefit from treatment. Also patients who actively misuse or abuse alcohol, drugs or tobacco have a very poor chance of improvement.

What treatments-besides drug therapy-do you use to treat pain?

The majority of patients attending the pain clinic undergo a behavioral assessment by one of the pain psychologists. If appropriate, the patient then will begin a behavioral approach to pain management, which may focus on helping the patient understand their pain and the significance it should have in their life, changing behavior patterns that reinforce pain, relaxation methods to reduce pain and biofeedback to enable the patient to control their pain. The patient is treated simultaneously by the medical side of the clinic, which, in addition to medications, may choose to perform injections into painful areas or around nerves supplying, but away from, the painful area. Prescriptions for physical therapy and transcutaneous electrical nerve stimulation may be given. In addition, if an attempt to return the patient to the workforce is appropriate, an assessment of functional capacity may be necessary prior to recommending vocational retraining into a job more suited to the patient's capabilities. For patients with intractable pain problems, we sometimes recommend more interventional treatments, such as spinal-cord stimulation or spinal morphine infusion.

What do you consider the most important change in the treatment of pain in the past decade?

The most important advance over the last decade has been the acceptance of chronic pain as a separate disease, allowing the patient to be believed and not dismissed as "crazy." This has allowed a more objective look at chronic-pain syndromes and has thus facilitated research into many areas, both at the basic-science level and in clinical practice. The understanding (albeit still poor) of the mechanisms of chronic pain have allowed the beginnings of a logical and scientifically based treatment strategy. The next 10 years should be even more exciting!

What's something most people don't know about chronic pain and should?

People need to know that chronic pain is a disease in its own right and that it can usually be managed adequately. They should know that early presentation for appropriate treatment is important. Pain becomes defined as chronic after it has been present for three to six months. This exceeds the time for normal healing to occur and therefore it is unlikely that any physical change is going to occur as a result of the healing process. The patient at this stage probably has the diagnosis of "chronic pain" and needs appropriate treatment for this diagnosis. The longer chronic pain is left untreated, the worse the outcome.

What question do you wish I had asked, and how would you have answered it?

The UPO is closing soon, but the clinic will continue. We probably will move to the city's hospitals. We may also enter a clinic in Amherst later in the year. At present, contact 829-2600 for an appointment.

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