ASK THE EXPERTS
For reprint orders, please contact: [email protected]
What has the establishment of multidisciplinary pain centers done to improve the management of chronic pain conditions? Howard L Fields†: Howard Fields received his MD and
PhD in Neuroscience at Stanford University (CA, USA) in 1965–1966. After Internal Medicine training at Bellevue Hospital in New York, he spent 3 years as a research neurologist at Walter Reed Army Institute of Research (MD, USA). Following clinical training in neurology at the Boston City Hospital Service of Harvard Medical School in 1972, he joined the faculty of the University of California, San Francisco (USA) where he is currently Professor of Neurology, Director of the Wheeler Center for the Neurobiology of Addiction and Principal Investigator at the Ernest Gallo Clinic and Research Center. Fields’ major interests are in nervous system mechanisms of pain and substance abuse, with a focus on how endogenous opioids contribute to these mechanisms. He was a founder of the UCSF Pain Management Center and has made major contributions to understanding and treating neuropathic pain. His group was the first to demonstrate the clinical effectiveness of opioids for neuropathic pain and of topical lidocaine for postherpetic neuralgia. In laboratory studies he discovered and elucidated a pain-modulating neural circuit that is required for opioids to produce analgesia. He also discovered that placebo analgesia is blocked by an opioid antagonist. Recently, his laboratory has discovered nerve cells in the striatum that selectively encode the magnitude of a reward. They have also shown how the neurotransmitter dopamine contributes to motivation and reward-based choice. Fields has received numerous research awards and has given many named lectureships including a Merit Award from the NIH, the Kerr Award of the American Pain Society, the Cotzias Award of the American Academy of Neurology and the RD Adams lecture of the American Neurological Association. He also gave the Beecher Lecture (in anesthesiology) and the Adams Lecture (in neurology) at Harvard. In 1997, he was elected to membership in the Institute of Medicine and in 2010, he was elected to the American Academy of Arts and Sciences. Why is multidisciplinary care particularly appropriate for the management of chronic pain? Although not all patients with conditions that are chronically painful need multidisciplinary care, there are several reasons why a multidisciplinary approach is essential for a large number of patients who have treatment-resistant problems. There is the problem of diagnosis. There are some somatic pain and psychosocial
problems that are not common enough for primary care physicians to make a correct diagnosis. These may include complex regional pain syndrome, myofascial neck and back pain, temporomandibular joint dysfunction, repetitive strain injury, depression, somatization disorders and analgesic abuse. These problems are seen more frequently in pain clinics and so the staff can more accurately diagnose the problems.
News & Views News Journal Watch Ask the Experts Interview
“Bedside teaching is the primary and most effective method to instruct trainees in diagnosis, treatment and effective ways to communicate with patients.”
5858 Horton Street, Suite 200, Emeryville, CA 94608, USA; [email protected]
†
10.2217/PMT.10.9 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(1), 23–24
ISSN 1758-1869
23
NEWS & VIEWS Ask the Experts Pain centers can also provide a variety of treatment modalities designed specifically to the patient’s needs. Treatments might include: somatic and sympathetic nerve blocks, cognitive behavioral treatments, interventional procedures such as spinal stimulation or opioid administration, physical therapy and vocational counseling.
“It is essential that an individualized treatment plan is developed for each patient. Problems arise from unimodal procedurally oriented pain centers that offer primarily expensive care with less emphasis on rehabilitation and chronic care.”
What are the benefits of conducting research, teaching & clinical care at the same multidisciplinary pain center? There are two major benefits to having ongoing research at a multidisciplinary pain center (MPC). The first is that research based on the patient population that is referred to the clinic is inherently translational and relevant to practice. Thus, study physicians, who understand the clinical problem in-depth are involved in study design and can rapidly apply what they learn to their practice. The other major benefit of conducting research and teaching in a MPC is that it reinforces the habit of rigorous clinical thinking and of using an evidence-based approach to providing healthcare. This improves patient outcome and creates an optimal teaching environment. Bedside teaching is the primary and most effective method to instruct trainees in diagnosis, treatment and effective ways to c ommunicate with patients.
Is it possible to manage the wide array of chronic pain conditions at one MPC? Yes; however, it is essential that the staff be truly multidisciplinary, and offer a range of treatment options including psychological services. It is essential that an individualized treatment plan is developed for each patient. Problems arise from unimodal procedurally oriented pain centers that offer primarily expensive care with less emphasis on rehabilitation and chronic care. Is it possible to establish MPCs in developing countries? Yes, but only with a multidisciplinary team. Unfortunately, this can be difficult to organize within a constrained budget. How should the effectiveness of a MPC be monitored & evaluated? It is essential that there be a set of published minimum standards. A standard objective accreditation process is the surest method to assure quality. Financial & competing interests disclosure Howard L Fields has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Laura Dormer, Launch Editor [email protected]
24
Pain Manage. (2011) 1(1)
future science group
For reprint orders, please contact: [email protected]
What has the establishment of multidisciplinary pain centers done to improve the management of chronic pain conditions? Howard L Fields†: Howard Fields received his MD and
PhD in Neuroscience at Stanford University (CA, USA) in 1965–1966. After Internal Medicine training at Bellevue Hospital in New York, he spent 3 years as a research neurologist at Walter Reed Army Institute of Research (MD, USA). Following clinical training in neurology at the Boston City Hospital Service of Harvard Medical School in 1972, he joined the faculty of the University of California, San Francisco (USA) where he is currently Professor of Neurology, Director of the Wheeler Center for the Neurobiology of Addiction and Principal Investigator at the Ernest Gallo Clinic and Research Center. Fields’ major interests are in nervous system mechanisms of pain and substance abuse, with a focus on how endogenous opioids contribute to these mechanisms. He was a founder of the UCSF Pain Management Center and has made major contributions to understanding and treating neuropathic pain. His group was the first to demonstrate the clinical effectiveness of opioids for neuropathic pain and of topical lidocaine for postherpetic neuralgia. In laboratory studies he discovered and elucidated a pain-modulating neural circuit that is required for opioids to produce analgesia. He also discovered that placebo analgesia is blocked by an opioid antagonist. Recently, his laboratory has discovered nerve cells in the striatum that selectively encode the magnitude of a reward. They have also shown how the neurotransmitter dopamine contributes to motivation and reward-based choice. Fields has received numerous research awards and has given many named lectureships including a Merit Award from the NIH, the Kerr Award of the American Pain Society, the Cotzias Award of the American Academy of Neurology and the RD Adams lecture of the American Neurological Association. He also gave the Beecher Lecture (in anesthesiology) and the Adams Lecture (in neurology) at Harvard. In 1997, he was elected to membership in the Institute of Medicine and in 2010, he was elected to the American Academy of Arts and Sciences. Why is multidisciplinary care particularly appropriate for the management of chronic pain? Although not all patients with conditions that are chronically painful need multidisciplinary care, there are several reasons why a multidisciplinary approach is essential for a large number of patients who have treatment-resistant problems. There is the problem of diagnosis. There are some somatic pain and psychosocial
problems that are not common enough for primary care physicians to make a correct diagnosis. These may include complex regional pain syndrome, myofascial neck and back pain, temporomandibular joint dysfunction, repetitive strain injury, depression, somatization disorders and analgesic abuse. These problems are seen more frequently in pain clinics and so the staff can more accurately diagnose the problems.
News & Views News Journal Watch Ask the Experts Interview
“Bedside teaching is the primary and most effective method to instruct trainees in diagnosis, treatment and effective ways to communicate with patients.”
5858 Horton Street, Suite 200, Emeryville, CA 94608, USA; [email protected]
†
10.2217/PMT.10.9 © 2011 Future Medicine Ltd
Pain Manage. (2011) 1(1), 23–24
ISSN 1758-1869
23
NEWS & VIEWS Ask the Experts Pain centers can also provide a variety of treatment modalities designed specifically to the patient’s needs. Treatments might include: somatic and sympathetic nerve blocks, cognitive behavioral treatments, interventional procedures such as spinal stimulation or opioid administration, physical therapy and vocational counseling.
“It is essential that an individualized treatment plan is developed for each patient. Problems arise from unimodal procedurally oriented pain centers that offer primarily expensive care with less emphasis on rehabilitation and chronic care.”
What are the benefits of conducting research, teaching & clinical care at the same multidisciplinary pain center? There are two major benefits to having ongoing research at a multidisciplinary pain center (MPC). The first is that research based on the patient population that is referred to the clinic is inherently translational and relevant to practice. Thus, study physicians, who understand the clinical problem in-depth are involved in study design and can rapidly apply what they learn to their practice. The other major benefit of conducting research and teaching in a MPC is that it reinforces the habit of rigorous clinical thinking and of using an evidence-based approach to providing healthcare. This improves patient outcome and creates an optimal teaching environment. Bedside teaching is the primary and most effective method to instruct trainees in diagnosis, treatment and effective ways to c ommunicate with patients.
Is it possible to manage the wide array of chronic pain conditions at one MPC? Yes; however, it is essential that the staff be truly multidisciplinary, and offer a range of treatment options including psychological services. It is essential that an individualized treatment plan is developed for each patient. Problems arise from unimodal procedurally oriented pain centers that offer primarily expensive care with less emphasis on rehabilitation and chronic care. Is it possible to establish MPCs in developing countries? Yes, but only with a multidisciplinary team. Unfortunately, this can be difficult to organize within a constrained budget. How should the effectiveness of a MPC be monitored & evaluated? It is essential that there be a set of published minimum standards. A standard objective accreditation process is the surest method to assure quality. Financial & competing interests disclosure Howard L Fields has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Laura Dormer, Launch Editor [email protected]
24
Pain Manage. (2011) 1(1)
future science group
