The Future of Pain Medicine: An Epilogue
Scott M. Fishman
James P. Rathmell
The creation of this fifth edition of Bonica’s Management of Pain reflects a major collaboration among many of the world’s leading authorities in the basic and clinical sciences. As in prior editions, this text serves as a resource for those who seek to increase their understanding of this aspect of the human condition. However, it also provides an important reference point—an elaboration on how far we have come and how far we have to go in order to prevent, markedly reduce, and perhaps even cure the pervasive problem of pain as a cause of unnecessary suffering, debility, and economic hardship. As in the previous edition, we will again briefly look ahead to where this journey may—and should—lead us before the next edition of this textbook is written and reflect on what has happened since the last edition was published in 2010.
The future is unpredictable; nonetheless, there are many current trends that portend an optimistic course ahead. Foremost is the pivotal recognition that pain is much more than a symptom and that its consequences, in the acute or chronic form, may be devastating at every level of human health. This profound understanding continues to transform the perspective of modern medicine, offering greater possibilities for dealing with the burden of disease than ever before. Soon after publication of the prior edition of this text, the Institute of Medicine (now the National Academy of Medicine) published its landmark report entitled “Relieving Pain in America,” reporting that approximately 100 million Americans suffer with chronic pain. It highlighted that clinicians remain substantially undereducated about pain and ill prepared to respond.1 This education gap has increasingly been seen as a one of the major root causes of the current epidemic of prescription drug abuse, in that US clinicians were advised, if not forced, to recognize pain as a fifth vital sign with woefully inadequate education, science, and clinical resources. Nonetheless, just as pain as the fifth vital sign was a well-intentioned but poorly executed intervention aimed at reversing decades of ignoring pain, the field of pain medicine continues to progress along a notable course. Prior to the first edition of this textbook, there were no pain specialists, pain journals, pain specialty organizations, pain advocacy groups, pain training programs, or laws or regulations specifically addressing the issues involved in delivering pain relief. At the time that the third and most recent edition of this text was written, the number of published reports in the realm of pain within the medical literature was a fraction of those today and there was no pain consortium at the National Institutes of Health (NIH). Clinical training of pain specialists was in its infancy, with minimal guidance from accrediting bodies. Certification of pain specialists through the American Board of Medical Specialties (ABMS) was available only to anesthesiologists, and the immense problem of pain management in primary care had barely been raised.
Ironically, in part due to increased attention related to the opioid crisis in the United States, recent unprecedented events suggest that we are on a trajectory toward improved knowledge about pain and increased commitment to pain relief, particularly care that is not solely focused on opioids. These events include increasing demands for standards for pain-related assessment and safe treatment in all health care facilities as well as mandates for improving education in pain and its management. There is little doubt that the future for pain management is inextricably linked to both science and education. Core competencies for all health professionals have now been established as a tool for educators to guide curriculum and for accreditors to base evaluation of educational institutions. Today, pain has growing representation in the NIH, and professional societies are working diligently to further increase this new commitment. Subspecialty clinical training has become much more integrative and multidisciplinary as a result of groundbreaking revisions to requirements set by the Accreditation Council of Graduate Medical Education (ACGME). Previously, such requirements were predominantly directed by the discipline of anesthesiology but have now been revised through an extraordinary collaboration of multiple disciplines. Subspecialty training for a physician from any primary clinical discipline is now possible in accredited programs that lead to certification as a pain specialist by the ABMS. Similarly, the multidisciplinary field of palliative medicine is designated as a subspecialty that is intertwined within many ABMS primary specialties, a most recent example of medicine’s increasing assimilation of symptom management and quality of life interventions. Although pain medicine has also developed as a broad-based, multidisciplinary subspecialty, its place in the overall structure of the field of medicine as a whole is still in evolution. Reform initiatives are well underway to refine the position of this emerging discipline in effort to advance its research, education, and clinical missions. Great debate remains over whether pain medicine should evolve into a more robust subspecialty that integrates parts of many clinical disciplines or whether it should become a primary specialty in its own right, but little progress has been made toward changing the current training paradigm. How pain medicine is ultimately positioned will greatly impact the field of medicine’s ability to meet its fundamental obligations to mitigate suffering.