Beyond the Needle

(Jacobson, Chabal) Associate Professor of Anesthesiology.(Mariano) Assistant Professor of Psychiatry and Behavioral Sciences.(Chaney) Associate Professor of Psychiatry and Behavioral Sciences.Received from the Anesthesiology and Mental Health Departments, VA Puget Sound Health Care System, Seattle Division and the University of Washington, Seattle, Washington. Submitted for publication February 11, 1997. Accepted for publication June 3, 1997.Address reprint requests to Dr. Jacobson: Anesthesiology Service (112A), VA Puget Sound Health Care System, Seattle Division, 1660 South Columbian Way, Seattle, Washington 98108–1597. Address electronic mail to: louisj@u.washington.edu.Chronic pain is a major health care and social problem. [1–3] Involvement in pain management represents an opportunity for practitioners of anesthesiology to expand services beyond the operating room. Pain management is already an integral and important component of anesthesia practice, and the specialty of anesthesiology is committed to its management. [4–6] Anesthesiologists occupy prominent positions as practitioners, educators, researchers, and administrators. Anesthesia residency programs are required to provide education and training in pain management, and numerous pain fellowship programs are organized under the auspices of Departments of Anesthesiology. Pain is a recognized subspecialty of the American Board of Anesthesiology, and extensive efforts are expended in education and certification in pain. Pain is comprehensively discussed in the standard anesthesiology textbooks. [7–9] Our major purpose of this article is to suggest that added opportunities exist for anesthesiologists in chronic non-malignant pain management. Further progress requires that anesthesiologists learn new conceptual models of chronic pain, acquire non-traditional skills, and become comfortable in different professional roles.Anesthesiologists' skills in regional anesthesia contributed to advances in management and secured for them an important role in chronic pain management. Unfortunately, many chronic pain patients are inappropriate candidates for such treatments. Much of the confusion surrounding their treatment with nerve blocks results from anesthesiologists extrapolating from their management methods for acute and cancer pain, where pain relief is the goal, to chronic non-malignant pain where long-term pain relief is usually an unrealistic goal. [10–14] Anesthesiologists for many years have recognized that nerve blocks are contraindicated in the two large subgroups of patients most debilitated by chronic pain: patients with no identifiable organic abnormality and patients whose disability appears to be grossly excessive given the known physical problems. [1,15–17] Many patients not appropriate for nerve blocks and who require chronic pain treatment have no access to multidisciplinary pain centers because of their geographic location, financial factors, and the application of stringent selection criteria. [18] Consequently, they represent a population with an unmet need. Therefore, their contributions notwithstanding, anesthesiologists could expand their horizons beyond nerve blocks.This article reviews the development of pain management as a specialty in anesthesiology. It summarizes the challenges chronic pain patients present to anesthesiologists whose primary mode of helping is to perform procedures. It describes an expanded role for anesthesiologists, either directing or participating, on multidisciplinary teams. Regional anesthesia, although important, is only one of the tools anesthesiologists bring to comprehensive pain management. Regional anesthesia requires judicious application in an appropriate context to be of maximum benefit to patients.The task for anesthesiologists seeking to serve patients for whom traditional procedurally based treatments are ineffective is not to become more expert in the newest intervention or state-of-the-art technology, but rather to acquire the skills necessary to function effectively in the role of educator and motivator (physician-healer). [19–23] The challenge for anesthesiologists is to create an expanded role that uses the full complement of their expertise and skills and that simultaneously provides services within a model that recognizes the complexity of chronic pain. For patients in whom conventional procedurally based treatments are ineffective and in those who have not found success at traditional pain clinics, the authors advocate a self-care rehabilitation approach that underscores patients' active responsibility to manage their lives despite pain. In this biopsychosocial model, pain is considered to be simultaneously physical and psychological and the emphasis is on pain as a life structuring process rather than solely a biological process.The challenge is how best to train anesthesiologists in biopsychosocial chronic pain management to complement their regional anesthesia skills. With long-term chronic pain management as the goal, education of anesthesiologists should include psychosocial aspects. Anesthesiologists need not reject interventions such as nerve blocks but rather use them as an adjunct to a broad-based biopsychosocial approach.The anesthesiologist, as a member of a multidisciplinary team, helps to facilitate patient functioning and emphasizes the active role of the patient and broadens management goals beyond often unattainable pain relief. Anesthesiologists become long-term providers for patients with chronic pain, functioning primarily as educators and motivators. A codisciplinary structure is described that uses a simultaneous interview technique and accommodates the integrated management of chronic pain through a biopsychosocial approach. These concepts are illustrated with descriptions of the multidisciplinary pain program developed at the Seattle Division of the Veterans Affairs Puget Sound Health Care System (VAPSHCS) to treat this difficult and challenging patient population.The introduction of cocaine as a topical local anesthetic in 1884 and its rapid adoption for use by injection resulted in surgeons developing regional anesthetic techniques. [24,25] Anesthesiologists subsequently became proficient in providing regional anesthesia for surgical procedures. The application of nerve blocks for pain management [26,27] provided the historical template on which the current involvement of anesthesiologists has evolved. [28,29] In 1936, Rovenstine established a nerve block service in the Department of Anesthesiology at Bellevue Hospital in New York. [30,31] By the 1950s, many anesthesiology-based pain relief clinics, using nerve blocks as the primary treatment or diagnostic method, were established in the United States and in the United Kingdom. [28,29,32–34]It was recognized that many patients with chronic pain fared poorly despite nerve block therapy alone. [15] This observation led to a closer examination of the nature of chronic pain [15,35] and the suggestion that physicians treat such patients in conjunction with input from other disciplines. With the development of a coordinated multidisciplinary program in the early 1960s, Bonica formalized the notion that complex pain problems could be managed most effectively with a team approach. [36] The emphasis was on diagnosis and management, with each member contributing specialized knowledge and skills to the common goal of making a correct diagnosis and developing the most effective therapy. Anesthesiologists, with their unique nerve block skills, were integral team members whose clinical role remained largely technical and firmly linked to a biomedical model of pain.In 1977, Engel [37] proposed an alternative view of medicine, the biopsychosocial model, which subsequently was adapted to chronic pain. [38] From this perspective, chronic non-malignant pain is conceptualized as the result of complex and inseparable interactions involving biological, psychological, social, and cultural factors. [39,40] The focus shifted from pain as a biological process to the analysis of pain as experienced by the patient and communicated to others. Professionals involved in chronic non-malignant pain management now have a theoretical template from which to explore the nature of the pain experience [40] to provide better pain management. Biomedical interventional techniques are considered to be of limited use because it is recognized that chronic pain is rarely caused by nociception alone. [16,17]Carron's [16] statement that “minimal pathology with maximum dysfunction remains the enigma of chronic pain” succinctly epitomizes the dilemma of the anesthesiologist who uses a biomedical approach. From the biomedical perspective, the patient is expected to adopt a passive role while submitting to the expert recommendations of the physician. [41,42] Pain is viewed as the result of a disease or injury, and it is assumed that identification of its nociceptive origin enables appropriate intervention. Both parties assume that the physician will use the full range of technical skills, expertise, and resources in search of a physical cause and cure of the patient's pain. Cure or symptom relief is the desired outcome. When such efforts fail to either identify a cause or to provide adequate relief, the patient is referred to the next physician, and the process begins again. Sternbach describes this process as a “pain game” and notes that the fundamental challenge in chronic pain is to modify this process. [43] We prefer the term treatment imperative because it emphasizes the interpersonal and social pressures physicians experience in their efforts to help patients.Although Carron's opinion that “anesthesiologists who use blocks as their primary or sole modality of therapy should not be treating patients with chronic pain” seems radical, it may be relevant for patients who lack organic abnormality or whose disability is excessive. Such management is likely doomed to failure if one is judging success with regard to long-term outcomes. [15] Biomedical pain practitioners should be encouraged to restrict their interventions to those patients who present with high levels of psychosocial functioning and clear organic etiologies indisputably amenable to nerve block therapy. Such restraints would severely limit the practice of anesthesiologists interested in chronic pain unless they adopted an expanded role of educator and motivator.The etiology of back pain is unclear in more than 80% of patients presenting to family practitioners. [3] By the time patients are referred to a pain specialist, they have usually had many somatic treatments that have failed to provide long-term benefit, and the relationship between manageable organic abnormality and observed disability is unclear. This “referral filter effect” concentrates cases of unclear etiology and overwhelming psychosocial dysfunction in specialty pain clinics. [44] Chronic pain patients exhibit a complex melange of features, characterized by depression, conflict with the medical and legal systems, emotional issues, family dysfunction, and substance abuse problems. As a consequence, care-seeking is an integral aspect of the pain experience, and excessive health care use ensues. [44,45]Chronic pain patients are enigmatic if their caregivers' ideas and treatments are limited to a biomedical approach, and as a consequence, caregivers are unable to offer rational management based on objective information. The biopsychosocial model regards nociception as inextricably embedded within a complex web of physical, psychological (cognitive, emotional, and behavioral), and sociocultural factors. [37,38,41,46] Rather than being puzzled by such patients, the biopsychosocial anesthesiologist accepts the limitations of biomedical explanations and interventions with regard to chronic pain and seeks to help by other means. A multidimensional perspective [41,47] on pain is acknowledged by the International Association for the Study of Pain (IASP), which defines pain as simultaneously a physical and psychological experience. [48] It is pivotal to note that objective findings of tissue damage are not required for a report of pain to be considered real. As such, there is no need for reported pain and disability to relate linearly to objective physiological findings.Functional disability is an important aspect of the chronic pain experience. In patients suffering with chronic non-malignant pain, there often is little correlation between the reported pain, physical findings, results of diagnostic tests, and observed disability. [49–51] The anesthesiologist working with chronic pain patients is encouraged to recognize that disability is not solely a function of injury, but that it also incorporates the domains of attitude and lifestyle.Chronic pain accounts for a disproportionately large amount of medical care use, although these patients often do not have objectively confirmed signs to match their symptoms, which would justify high levels of medical intervention. [52] Severity of disease is not linearly related to health care use [44] as illustrated by patients with chronic low back pain using more health care resources than patients with multiple sclerosis. [45] In chronically ill populations, psychosocial factors predict health care use better than the number or severity of physical symptoms. [44,45] Recognizing these factors avoids unnecessary tests and referrals. It is important to appreciate these aspects in the current healthcare environment, which places a premium on minimizing health care costs.The primary role of the biopsychosocial anesthesiologist is as a physician-educator, not as a technical expert. The challenge for anesthesiologists is how best to complement their regional anesthesia skills to render more comprehensive pain management services. They need not reject nerve blocks and precise, sophisticated technologies, [10–12] but rather use their technical expertise within a broad-based biopsychosocial approach. Unless judiciously delivered in an appropriate biopsychosocial context, nerve blocks are interventions that might help patients feel better in the short term, but they do not address the fundamental problem of being overwhelmed by the psychosocial consequences of chronic pain in the long term. Anesthesiologists are urged to not limit their concerns solely to biological issues and to expand their skills beyond traditional biomedical methods.The biopsychosocial model [37,38] considers chronic pain as an illness rather than as a disease. [53–55] Shifting from a biomedical to a biopsychosocial approach has profound ramifications for the anesthesiologist. A major impediment to its unconditional acceptance by anesthesiologists is the misconception that a biopsychosocial model is antagonistic toward biomedical approaches and that biopsychosocial and biomedical approaches are mutually exclusive. Biomedical ideas and methods are actually subsumed under a biopsychosocial mantle. The biopsychosocial model is inclusive and fully accommodates all biomedical aspects, placing them in a broad context and providing guidance in the advisability and timing of their use. The major difference with the biomedical approach is in the wider scope of inquiry and intervention in the biopsychosocial model. In this model, biological factors are only one of many complex influences on pain.The challenge for anesthesiologists is how to contribute more than biological and technical expertise toward the care of chronic pain patients. Anesthesiologists working with “enigmatic” patients should learn to value the caring and healing aspects of medicine, [19–22,56–58] at least equally to the science and technology to develop the skills necessary to help such patients. Effective management requires interventions at complex social and interpersonal levels and at molecular and cellular levels. Sir William Osler's observation of a century ago that “it is more important to know what sort of person has a disease than to know what disease a person has” remains relevant currently for chronic pain patients.In a biopsychosocial framework, anesthesiologists are encouraged to function as physician-healers [19–23](educators and motivators) and not solely as nerve block technicians. [15] A physician-healer [19] is a skilled clinician, educator, motivator, and patient advocate with good judgment. Regardless of whether sophisticated invasive technology, physical rehabilitation, or cognitive-behavioral approaches are used, the physician-healer recognizes that the significant issues are more about caring and healing than the specific tools and interventions. A technician views the tool as the primary intervention. Managing disease is technologic and procedural (biomedical), whereas caring for patients with a chronic illness, such as chronic pain, involves interpersonal, motivational, [23] and educational [47] processes. The fundamental intervention is effective communication with language as the primary therapy, not nerve blocks or medications. A caring interaction is paramount, [56–58] and continuity of care supersedes intensity of management. Patient and provider beliefs, [59,60] expectations, and the quality of their interactions are more important than specific management. [61]The chronic pain syndrome is characterized by a severely dysfunctional lifestyle centered around avoiding or reducing pain. [41] Multidisciplinary management is recommended because it provides benefit through increased function, reduced health care use, and vocational rehabilitation. [62–67] A self-care (self-management) practice style achieves good long-term outcomes at lower cost and with greater patient satisfaction than when a traditional biomedical approach is used. [42] Self-care emphasizes patient responsibility for addressing life problems other than pain. It minimizes the role of biomedical interventions and redefines management in terms of rehabilitative, rather than curative, goals. [41,46] Patient outcomes depend more on better coping than better medical intervention. The focus of biopsychosocial management is not to reduce pain but to redefine the problem, thereby leading to the goals of decreased disability [68] and increased ability (improved overall quality of life, increased function, and decreased suffering). [41,46,69] Immediate pain relief is not the goal in the long-term management of chronic non-malignant pain. Without knowledge or insight into the goals of chronic pain management, physicians opt for medical tests and management in unproductive efforts to control disabling or persistent pain. [3]It is crucial to recognize that the risks of nerve blocks are not confined to the physical complications of the procedure. Such treatment reinforces patient beliefs in an underlying abnormality best managed by biomedical procedures. Further, it maintains expectations that the patient should be the passive recipient of treatment rather than an active participant in the process, and it fosters the illusion that the primary problem in the patient's life is pain. 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