This chapter is divided in two main sections. The first section addresses the future of pain medicine, and the second tackles the newest trends in pain treatment. The overarching principle guiding the authors of this chapter is the delivery of the highest quality of pain care in a manner that is most consistent with empiric medical evidence. Although the comprehensive treatment of pain has long been a goal of the profession, the practice of pain medicine has become laden with divisions, sub-sub-specialization that has resulted in a field with an unclear core mission. It is also challenged by the definitions imposed by nonpain clinicians. The future of the field of pain medicine relies on greater rigor in at least three domains: (1) defining the medical specialty of pain medicine, (2) educating future pain medicine clinicians, and (3) advancing the basic, clinical, and translational sciences related to the etiology and treatment of pain.
As in this textbook, the practice of pain medicine is often divided into acute, recurrent, and chronic pain medicine (or management). The historical application of this terminology has equated brief episodes of pain (e.g., post-surgical pain) with being an “acute” pain, recurrent, episodic acute pain (e.g., migraine, sickle cell disease), and most other pain conditions with “chronic” pain (associated with persistent cancer and noncancer-related painful disorders). This subtyping by duration is no longer helpful when it is applied to the current, complex, and highly specialized health care environment. For instance, the outpatient pain clinician manages the pain of patients who have recent injuries, thereby fitting the definition of acute pain, not just persistent pain. The hospital “acute” pain service often takes care of patients with persistent pain conditions. As acute, recurrent acute, and chronic (persistent) pain patients are seen in the inpatient and outpatient settings and the employed treatment modalities differ among the populations, the more appropriate distinction may be between the treatment of hospitalized patients with pain and that for nonhospitalized patients with pain.
Recent History of Outpatient Pain Medicine
In the late 1960s, an anesthesiologist, John J. Bonica, founded the first multidisciplinary clinic for the treatment of patients with chronic pain. The practice approached pain from biologic models involving neurologists, internists, orthopedists, and neurosurgeons. After much frustration in treating patients debilitated by their persistent pain, Dr. Bonica, at the urging of the behavioral scientist Wilbert E. Fordyce, adopted the biopsychosocial model of the treatment of pain. The behavioral psychology approach of not rewarding pain behaviors (and, in some instances, ignoring the verbal pain complaints and related behaviors such as moaning and facial grimaces) but focusing on rehabilitation and increased function of the patient was integrated into a multidisciplinary pain clinic. Throughout the 1970s, this clinic and others that incorporated the principles used in the original pain clinic were very successful in treating patients with persistent pain. In the early 1980s, the neurosurgeon John Loeser took over Bonica’s pain clinic and credited the interactions between the providers as the reason why patients did so well.
It would be a logical extension to believe that this model would be adopted by pain treatment facilities throughout the United States because of the revolutionary success the multidisciplinary pain clinic had in treating this challenging patient population. The reality was, unfortunately, far from that assumption. Currently, in the United States, there are relatively few truly multidisciplinary pain clinics that involve management of pain in patients in the inpatient and outpatient settings. The architecture and economics of medicine have been redirected in a way that undermines this successful treatment model. The changes that occurred include the increasing cost of health insurance, the shifting of health insurance costs from employers to employees, and the decreasing coverage of a number of health and mental health care services. These changes have negatively impacted the practice of multidisciplinary pain medicine. The health care economic bottom line meant that physicians had to practice reimbursable medicine for pain treatment clinics to remain viable. The paradox is that there is more evidence supporting the clinical effectiveness and cost-effectiveness of multidisciplinary rehabilitation than any traditional medical or surgical treatment for patients with problems of persistent pain.
This economic shift promoted the unidisciplinary model of pain care in the 1990s, in which physicians focused on the treatment algorithm most closely associated with their medical training and specialty. Anesthesiologists focused on interventional analgesic procedures, and opioid and nonopioid adjuvant medications to treat pain reports, taking the biologic approach to pain care. Physiatrists (physical medicine and rehabilitation) focused on musculoskeletal exams, electrodiagnostic tests, and medical management of pain with opioids. Psychiatrists focused on the medical management of pain, the treatment of addiction disorders resulting from the treatment of pain with opioids and benzodiazepines, and the treatment of psychiatric comorbidities. Psychologists continued to follow behaviorist or cognitive-behaviorist approaches in concert with group therapy to teach pain patients coping skills to live with their chronic daily pain in those institutions where financial support existed, but often as adjuncts to biologically based treatments rather than as components of an integrated approach that had been shown to be effective.
In the late 1990s and 2000s, the continued contraction of medical and health care services covered by government and private insurance and a shift in emphasis even further from the integrated, rehabilitation approach to procedures performed have changed the pain medicine landscape again. Across the United States, anesthesiologists further specialized in interventional pain medicine procedures (transforaminal epidural steroid injections, facet joint interventions, radiofrequency procedures, spinal cord stimulation, and intrathecal pump therapy) with a more modest medical management clinic where opioid and nonopioid medications were recommended to others to prescribe. Physiatrists began performing interventional pain therapies copying the anesthesiologist’s interventional model. Psychiatrists, neurologists, and neurosurgeons reduced or eliminated their pain management practices. Pain psychologists became fewer and fewer, and those who remained focused on pain research and small clinical practices. This less integrated, silo approach that focused on interventional therapies has provided good (though not ideal) care to some patients because of the advancement in some of the pain procedures employed, such as spinal cord stimulation. However, this fundamental conflict has left few options for the significant set of patients with pain that is not amenable to these therapies.
Where to go from here?
In going forward, it is essential to reduce the confused terminology and purpose:
- 1.
Pain is a distinct disease entity when it is no longer associated with an ongoing injury or the immediate repercussions of the injury.
- 2.
The treatment of pain with medications, procedural or surgical therapies, and psychological and physical rehabilitation are all components of the integrated practice of pain medicine.
- 3.
The goal of pain treatment is not simply to relieve pain but to return the patient to satisfactory physical and psychological function.
- 4.
Clinicians with appropriate medical, psychological, or rehabilitative (e.g., physical therapy, social work) training, certification, and credentialing practice within the field of pain medicine. The use of the descriptor “pain management” for the field has led to an overly broad definition of who is able to safely provide these complex pain services and should therefore be retired as a descriptor of the practice.
Where to go from here?
In going forward, it is essential to reduce the confused terminology and purpose:
- 1.
Pain is a distinct disease entity when it is no longer associated with an ongoing injury or the immediate repercussions of the injury.
- 2.
The treatment of pain with medications, procedural or surgical therapies, and psychological and physical rehabilitation are all components of the integrated practice of pain medicine.
- 3.
The goal of pain treatment is not simply to relieve pain but to return the patient to satisfactory physical and psychological function.
- 4.
Clinicians with appropriate medical, psychological, or rehabilitative (e.g., physical therapy, social work) training, certification, and credentialing practice within the field of pain medicine. The use of the descriptor “pain management” for the field has led to an overly broad definition of who is able to safely provide these complex pain services and should therefore be retired as a descriptor of the practice.
Pain Medicine Education of Physicians
Comprehensive and multidisciplinary education of future pain medicine physicians is paramount to the optimal care of patients. Unfortunately, the training of physicians in pain treatment traditionally had a narrow focus on pharmacological or interventional management, with little more than passing reference to the psychological and physical rehabilitative components of pain treatment. This deficit was recognized on a national level, and in 2007 the Accreditation Council for Graduate Medical Education (ACGME) redefined the pain medicine fellowships by setting new standards for achieving the goal of comprehensive pain training. The four medical specialty boards (Anesthesiology, PM&R, Neurology, Psychiatry) administering pain medicine board examinations agreed to a single ACGME-approved pain medicine training fellowship curricula and a single pain medicine subspecialty board examination. In a post-2007 pain medicine fellowship, trainees are required to have training in pain medicine from the medical, rehabilitative, and psychological perspectives. This change in education and certification has been a step in the right direction and has been responsible for the closure of “pain” fellowships that had a predominant or exclusive focus on interventional training. Unfortunately, this unidisciplinary approach to training continues in some of those closed programs as non-ACGME-approved “Interventional Spine” fellowships. This shift has been a disservice to those who train in these programs for numerous reasons including the inability to take the pain medicine board exams as well as to the patients who believe they are receiving care from a comprehensively trained pain physician. Even with these exceptions, the changes made by the ACGME in 2007 have been a good step toward the patient-centered model of multidisciplinary pain medicine developed by John Bonica. However, it is only a single piece of the puzzle.
Additional changes include a future match program for pain medicine fellowship positions that has been approved by the Association of Pain Program Directors. The match should provide a better opportunity for applicants to get their desired training program. For pain medicine clinicians, patient simulation will be included in future maintenance of certification accreditation (MOCA) requirements. Although simulation training is now offered in regular anesthesiology recertification testing and has been proven to be successful, it is new in pain medicine. The American Society of Anesthesiologists Committee on Simulation has already approved simulation centers and aims to establish testing centers in different regions in the country. The curriculum and case scenarios for simulation in pain medicine have been aptly described by Brenner and colleagues.
Future of Pain Medicine
The appropriate changes in pain medicine education have not been accompanied by reform of the reimbursement methodologies. Our insurance system is still heavily biased toward remunerating for procedures and not for clinician decision making. It is also biased toward reports of pain relief and not toward the increased functionality of pain patients. The face of pain medicine will likely change to more of a patient-centered model of reimbursement. We have seen the beginnings of this shift, in which Medicare has begun to associate payment to physicians and hospitals with quality metrics (e.g., refusing to pay for readmission resulting from iatrogenic infections). The future of pain medicine will progress to paying for therapeutic approaches that have successfully returned patients to function and a resumption of their activities of daily living. Based on the positive historical experience of the Bonica-style pain programs, the multidisciplinary model with inpatient and outpatient treatment might be the best goal. The challenge of revisiting this model is the costs associated with these programs in light of low levels of reimbursement for these services. The questions that remain include, can the cost-efficiencies of modern medicine be applied to the old model of comprehensive pain medicine, and will the insurance companies recognize its long-term cost savings and pay for the services in order to make the old model fiscally viable? With respect to chronic low back pain, the answer may be yes.
The manner of education and the modalities used in pain medicine will continue to change, as previously addressed, and the manner in which research or lack thereof influences our practice will become foremost concerns. Physician experience and medical teaching are becoming less and less acceptable rationales for the treatments pain physicians employ. The challenge is that a substantial number of treatments have few rigorous data to support their use. And unfortunately, even when evidence exists, it is often ignored. One of the most common procedures in pain medicine, the epidural steroid injection for back and extremity pain, has been shown to have no benefit for axial low back pain, minimal benefit for back pain associated with spinal stenosis, and moderate short-term benefit for extremity pain related to disk herniation. Yet a subset of physicians continue to perform steroid injections for low back pain and promise long-term benefit for radicular symptoms in spite of studies that showed its short-term efficacy. The medicinal treatment of radicular symptoms is managed as though they are the same as neuropathic pain of disparate etiology including diabetic and postherpetic neuralgia, yet evidence of the efficacy of the most commonly used medications is minimal. These are only two examples of misguided therapies. The challenge will be to produce evidence of effectiveness and safety for medications and procedures that are etiology specific, cost-effective, and widely applicable.
Pharmacological Management of Chronic Pain
This section deals with topics that were not discussed or emphasized in the previous chapters on pharmacological management. The management of cancer pain will probably remain as it has been (i.e., opioid as the mainstay of treatment in combination with other medications including the anticonvulsants). It is in the area of chronic noncancer pain (e.g., osteoarthritis, diabetic painful neuropathy) where drugs that are effective with minimal side effects are being constantly sought. Guidelines from groups of well-respected experts have been proposed in the management of neuropathic pain. These include the European Federation of Neurological Sciences (EFNS), the International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG), and the Canadian Pain Society. The guidelines recommended the anticonvulsants, serotonin and norepinephrine reuptake inhibitors (SNRIs), and antidepressants as the first-line treatments for neuropathic pain. More recent data, coupled with the SNRIs reduced side effects, made the EFNS and the IASP NeuPSIG recommend these as the first-line drugs. These guidelines continue to evolve based on the results of randomized controlled studies.
Pregabalin, with its linear pharmacokinetics, quicker analgesic onset than gabapentin, and efficacy with lower doses, will continue to be used. Although pregabalin and gabapentin are well known, lacosamide has been shown to be effective in diabetic painful neuropathy (DPN). Its clinical use in DPN is awaiting approval from the United States Food and Drug Administration (FDA).
The SNRIs are definite improvements over the tricyclic antidepressants, particularly in their side effect profiles. Milnacipran lacks anticholinergic, antihistaminic, and alpha-adrenergic receptor blocking activity; is weakly protein bound; and has no effect on the P450 system, resulting in fewer drug interactions. Randomized controlled studies in fibromyalgia showed positive results with improvements in fatigue, physical conditioning, and discomfort.
A combination of drugs with different mechanisms of action maybe more effective than any drug alone. Randomized controlled studies showed beneficial effects when drugs with different mechanisms of action are combined. The combination of gabapentin and morphine in patients with postherpetic neuralgia (PHN) and DPN resulted in less pain, lower doses, and fewer side effects from the drugs. The same salutary effects were noted with the combination of gabapentin and nortriptyline, gabapentin and lidocaine plaster for PHN/DPN, and gabapentin and oxycodone in DPN. For neuropathic cancer pain, a combination of opioid and gabapentin was noted to be more effective than opioid monotherapy. However, not all drug combinations showed positive results. No beneficial effects were noted when pregabalin and oxycodone were combined in the treatment of PHN or DPN or with morphine and nortriptyline for lumbosacral radiculitis. Whether the lack of additive effects with the combinations was due to the dosages used (the doses of pregabalin in the study by Zin and colleagues were up to 600 mg/day, whereas the oxycodone dose was 10 mg/day) or to inappropriate drugs being used (radiculitis may not respond to antidepressants) is not known. More studies are needed to determine which drug combinations work best in which chronic pain syndrome. Moreover, in addition to concerns about the side effects of individual medications, with drug combinations there is the added concern about potential drug-drug interactions among some of the medications most frequently combined (such as opioids that also have serotonergic effects, e.g., tramadol and tapentadol, and selective serotonin reuptake inhibitors [SSRIs] and SNRIs where serotonin syndromes may be created by the combination).
For neuropathic pain, clinicians are using nonsteroidal anti-inflammatory drugs (NSAIDs). Although animal models showed the efficacy of NSAIDs for neuropathic pain treatment, clinical studies showed some efficacy, no efficacy, or inconclusive results. The unequivocal results call for randomized studies on the role of NSAIDs in neuropathic pain. However, there are significant concerns about NSAIDs because of their gastrointestinal and renal toxicities, and there are concerns about the cardiac effects of the newer cyclooxygenase-2 inhibitor (COX2) drugs.
It is important to note that regardless of the medication used to control pain, the actual benefits, while statistically significant, are modest, with fewer than 35% of patients obtaining at least a 50% reduction in pain. Moreover, the effects of even the most recently developed medications have shown that they do little to improve physical functioning.
Intravenous Infusions and Topical Analgesics
Intravenous infusions, especially ketamine, are being used more frequently and studies have shown their efficacy. Unfortunately, these publications were either case series or retrospective studies or consisted of patients with different pain syndromes. It is in the treatment of complex regional pain syndromes that controlled studies showed the efficacy of ketamine infusions. Randomized controlled studies are welcome. These studies should involve specific pain syndromes (e.g., spinal cord injuries) and the doses and duration of infusions sought, especially as there may be hepatotoxicity from the infusion; the mechanism of hepatic injury should also be investigated.
The high-dose capsaicin patch is an improvement over the low-dose patch and needs to be applied only every 3 months. The patch has been shown to be effective in the treatment of PHN, DPN, and human immunodeficiency virus (HIV) neuropathy. However, it is expensive and its application is painful even when a local anesthetic cream is pre-applied. Topical clonidine gel was noted to be effective in DPN patients with functional (and possibly sensitized) nociceptors in the affected skin. The use of topical doxepin or topical doxepin and capsaicin was noted to be superior to placebo in treating neuropathic pain. A randomized study showed topical ketamine, amitriptyline, or a combination to be effective for patients with neuropathic pain. Open-label studies on topical amitriptyline and ketamine for neuropathic pain showed encouraging results. The same results were noted with topical ketamine for PHN. More controlled studies are required, especially in view of the advantages of drugs applied topically or as patches in patients who cannot tolerate oral medications.
Prescription Patterns of Pain Medicine Physicians
It is gratifying to note that the prescription patterns of pain physicians reflect evidence-based treatments. Most ask for opioid agreements, electrocardiograms (ECGs) are ordered when methadone is prescribed, the maximum dose of acetaminophen is decreased in moderate alcohol drinkers, opioids are prescribed for cancer pain, and the majority follow the guidelines recommended by the EFNS and the IASP’s NeuPSIG (i.e., anticonvulsants and SNRIs followed by drug combinations). However, several gaps in knowledge were also identified, including the prescription of codeine for patients who have difficulty metabolizing codeine to its active morphine metabolite (i.e., Caucasians, Asians, and pediatric populations). Although only a small percentage responded that they prescribe carisoprodol, this drug is metabolized to meprobamate, which causes dependence and has been shown to be no more effective than placebo. It would be interesting to know the prescription patterns of primary care physicians who take care of most pain problems.
Although opioids are the most commonly prescribed medication for pain, prescriptions for chronic, noncancer pain patients are more controversial. This class of medication may have significant and unintended effects on immune and hormonal function and there is some evidence of the paradoxical effect of opioid-induced hyperalgesia. There are also growing concerns about the misuse and abuse of these drugs. Moreover, opioids appear to have little effect on improving physical functioning. Finally, there is no long-term evidence of the analgesic benefits of opioids.
Interventional Pain Procedures
Disk Herniation, Spinal Stenosis, and Inflammatory Markers
Disk herniation results in the release of phospholipase A2 (PLA2), resulting in the production of prostaglandins. Increased levels of inflammatory cytokines interleukin (IL)-6 and IL-8 were noted in disk materials taken from patients with known disk disease. Cytokines such as IL-1 and IL-6 and tumor necrosis factor alpha (TNF-α) have been strongly linked to radicular pain. IL-1 beta, IL-6, and TNF-α have been noted to increase the discharge rates and mechanosensitivity of the dorsal root ganglion and peripheral receptive fields in rats. Disks express TNF-α, which causes morphologic and functional changes when applied to spinal nerve roots. Levels of IL-6 in the cerebrospinal fluid (CSF) of patients with radicular pain from spinal stenosis correlated with the degree of spinal stenosis.
These studies led investigators to inject TNF-α inhibitors into the epidural space of patients with a herniated disk or spinal stenosis. Studies of epidural etanercept or tocilizumab, a TNF-α inhibitor and an anti-IL6 receptor antibody, respectively, showed some efficacy. The epidural injection of etanercept has been shown to have salutary effects, in terms of pain and numbness, in patients with a herniated disk or spinal stenosis. The epidural injection of tocilizumab decreased low back pain and numbness in patients with spinal stenosis. The follow-ups in these studies were for 1 month or 6 months. These beneficial results should be contrasted with the findings that intravenous infliximab had similar efficacy as placebo in relieving lumbar radicular pain from a herniated disk. More studies are needed in this area, especially to evaluate the risks involved; patients on TNF-α inhibitors are prone to infection.
Epidural Steroid Injections
CNS Injuries After Transforaminal Epidural Steroid Injections
Epidural steroid injections (ESIs) are given to patients to relieve low back and radicular pain. It has been postulated that inflammatory changes in the nerve root cause the pain, and nerve root edema has been demonstrated on computed tomography (CT) scans of patients with herniated disks. The rationale for ESIs includes their anti-inflammatory effect and a specific anti-nociceptive effect. The results of studies on epidural steroids were not uniform. Overall, the studies showed short-term relief.
There have been reports of central nervous system (CNS) injuries, including spinal (paraplegia) and brain (brainstem hemorrhage and cerebellar infarct) events. These unfortunate events are probably secondary to arterial injury (trauma or spasm) or embolism of the particulate steroid. The ascending and deep cervical arteries have been shown to send medullary branches to the anterior spinal artery; these two arteries anastomose with the vertebral artery and are very close to the superior articular process, a landmark in transforaminal epidural steroid injections. Intravascular injection of the contrast into the radicular artery accompanying the nerve root has been demonstrated. Injection of the particulate steroid into the anterior spinal artery (through the medullary branches or the radicular artery) or into the vertebral artery (through the ascending and deep cervical arteries) is possible.
Particulate steroids cause more problems than nonparticulate steroids. The CNS injuries reported with nonparticulate injectates were temporary, compared to permanent injuries with the particulate injectates. Animal studies support the catastrophic lesions/events associated with particulate steroids in comparison to nonparticulate injectates. Animals injected with the particulate steroid became unconscious and required ventilator support or showed cerebral hemorrhage. In contrast, the animals injected with dexamethasone, a nonparticulate steroid, had no evidence of injury and had full recovery.
The reported cases of CNS injuries led a Working Group of Experts and the FDA Safe Use Initiative to formulate recommendations on the prevention of these injuries. The recommendations will probably include knowledge of the anatomy, use of live fluoroscopy or digital subtraction technology (DST), ability to correctly interpret the images, use of nonparticulate steroids in cervical transforaminal injections, and others. Obviously, particulate steroids are acceptable in interlaminar injections. These recommendations will come out in late 2013 or early 2014.
Compounding Steroids
Some physicians use compounded depot steroids for epidural injections to avoid the vehicles and preservatives in the depot steroid and for reasons of price. Avoidance of the preservatives is unnecessary, as the studies on the neurolytic lesions caused by these preservatives used concentrations that were 8- to 10-fold higher than the concentrations of these preservatives in the depot steroids. A case report of flaccid paralysis occurred after an unintentional subarachnoid injection of 40 mL of 0.9% NaCl that contained 1.5% benzyl alcohol. In addition to the lower concentrations of the preservatives in the commercially available steroids, the steroid is diluted with 1 to 3 mL of saline or local anesthetic, further decreasing the concentrations of the preservatives.
An outbreak of fungal meningitis occurred after an epidural injection of compounded methylprednisolone. The episode was traced to contaminated steroid produced by the New England Compounding Company, exposing the lax regulations that oversee compounding companies. Clinicians will continue to use compounded medications because of the lack of availability of other medications (e.g., oral ketamine, intrathecal pump drugs) or because of their lower cost. Pain medicine interventional physicians can assure themselves of a safe product by purchasing compounded drugs from companies accredited by the Pharmacy Compounding Accreditation Board. A list of accredited companies is available on the agency’s website ( www.pcab.org ). There are now bills pending in Congress mandating supervision of compounding companies by the FDA instead of the state where they are located.
Other Interventional Procedures
Minimally invasive lumbar decompression (MILD) procedures for symptomatic central lumbar canal stenosis have been described, wherein the hypertrophied ligamentum flavum is thinned percutaneously. An initial review of the safety of MILD showed no incidents of dural puncture, nerve injury, hematoma, or blood transfusion. A 1-year follow-up of results showed a decrease in pain scores and improvements in the Oswestry Disability Index, Zurich Claudication Questionnaire, and SF-12 Health Survey. There were no major device-related or procedure-related complications. These great results were questioned by a single-center experience of complications including nondecompression of supposedly decompressed levels, persistent neurogenic complications, cerebrospinal fluid (CSF) leak, and transected nerve roots. Obviously, more prospective studies are required to determine the long-term efficacy and complications associated with this procedure.
For intrathecal pain management, an interdisciplinary panel of experts published recommendations that included the proper methods of trialing for long-term intrathecal drug delivery; an update of the algorithms for the rational use of intrathecal medications for the treatment of neuropathic and nociceptive pain; guidance on the how to minimize the risk of respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error; and instruction on the prevention, diagnosis, and management of intrathecal granulomas. No new pharmacological developments are anticipated in the near future.
Psychological Treatment of Patients Experiencing Pain
Research performed since the 1990s confirms that psychology-based pain treatments (e.g., cognitive-behavior therapy, relaxation, positive reinforcement of activity, exposure to activities avoided, realistic goal setting) are more effective than no treatment, standard care, and treatment conditions that control for the effects of time, therapist attention, and treatment outcome expectancies (such as pain education or relaxation training only). However, despite the fact that different treatments are often based on different theoretic perspectives, most psychological treatments result in similar outcomes, and not one of them completely eliminates pain for the majority of patients. However, this is not unique to psychological treatment. Of all treatment modalities, the pharmacological and nonpharmacological, the best evidence for pain reduction averages approximately 30% to 40% in approximately half of treated patients, and this does not always occur with concurrent improvement in physical and emotional function. Thus, none of the most commonly prescribed treatment regimens, by themselves, are sufficient to eliminate pain and to have a major impact on physical and emotional functioning in the majority of patients with persistent pain. This is hardly surprising given the complexity of pain and the myriad of psychological, contextual, historical, and genetic along with neurophysiologic factors involved. In the absence of a cure, there is a need to maximize symptom relief so that patients are able to lead the highest quality of life possible.
Although psychological factors have been demonstrated consistently to play an important role in one’s perception and response to acute and postsurgical pain, the greatest emphasis of psychological treatments has been to help patients manage, cope with, and adapt to the presence of persistent pain and its associated symptoms. Consequently, rarely are psychological treatments applied in the absence of medical and pharmacological treatments for patients with chronic pain.
We anticipate several trends and directions for the application of psychological treatments and psychological principles in the management of patients with persistent pain in the future, specifically (1) combination treatments, (2) matching of treatment components to specific patient characteristics, (3) development and use of maintenance-enhancing strategies based on psychological principles and technological advances, and (4) availability of psychologists and reimbursement. We outline these approaches in the following sections.
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