The alleviation of pain has been central to the humane practice of medicine since its ancient beginnings. How this essential mission has been carried out, however, has evolved exponentially with time, driven by the expansion of medical knowledge, the invention of new treatments, and ongoing changes in the practice of medicine itself. Today, this evolution is unfolding in the United States against the backdrop of radical changes in the way in which healthcare is practiced and financed.
The rapid pace of change in the knowledge and care of pain has motivated this revised and expanded third edition of Principles and Practice of Pain Medicine. Since the previous edition was published in 2004, new treatments and treatment modalities have been created; a major paradigm shift has occurred in the use of opioid analgesics; and substantial progress has been made in how pain is studied, taught, and treated.
What has not changed is the demand for pain relief. If anything, the tide of patients in pain has swelled: the Institute of Medicine (IOM) reported in 2011 that about 100 million American adults suffer from chronic pain, more than those suffering from diabetes, heart disease, and cancer combined.1 The annual direct and indirect cost is estimated to exceed $600 billion annually;1 and these estimates do not include the burdens of acute pain, pain in pediatric populations, cancer-related pain, or pain at the end of life. Opioid analgesics, which have been widely deployed in the past decade against this onslaught of chronic pain, continue to be associated with efficacy data that is weak to inadequate. In addition, these agents have proven to pose substantial risks and to require greater caution than was widely recognized prior to publication of the second edition. Since then, data have convincingly shown a trend toward the excessive prescribing of opioids, as well as the dramatic scope of the U.S. epidemic of prescription drug abuse, which only recently has shown signs of easing.2
Viewing the IOM findings of high prevalence and costs of pain, in the light of both the epidemic of prescription opioid abuse and the fact that the U.S. presently consumes the vast majority of the world supply of prescription opioids, strongly suggests that many patients are being inadequately treated for their pain. It has become clear that inadequate treatment may result from too much as well as too little treatment. We are reminded that the enthusiasm for the benefits of analgesic therapies must be tempered by a clear-eyed appreciation for their risks. This is just one of the important attitudinal shifts that have been reflected in the revisions of this third edition—shifts that may also apply to procedural and psychosocial options for pain management.
Currently, medicine possesses greater knowledge and more tools to manage pain than ever before. Yet the foundational scientific knowledge base for pain is still insufficient to fully support treatment decisions and major health policies. The National Institutes of Health continues to spend a disproportionately small fraction of its budget on pain relative to the substantial burden of pain on patients and society at large. In addition to inadequate funding of research in pain medicine, education about pain and its safe and effective management is astonishingly under-represented in the curricula for most pre-licensure healthcare professional schools, as well as post-graduate and continuing education programs. According to the 2011 IOM report on Pain in America: “Despite the large role that care of patients with pain will play in their daily practice, many health professionals, especially physicians, appear underprepared for and uncomfortable with carrying out this aspect of their work. These professionals need and deserve greater knowledge and skills so they can contribute to the necessary cultural transformation in the perception and treatment of people with pain.” The transformation for pain care envisioned by the IOM will require recognizing pain and its management as a core component of the education for every health professional.
Many of the obstacles that impede progress in addressing pain may be attributed to its omnipresence throughout healthcare, which confounds division into neat partitions and units. The traditional organizations that are intended to support patient care, education, and research are often unable to fully integrate the vast dimensions of pain, too often leading to fragmented organizations and programs. It is no surprise that pain remains poorly integrated within the siloed departmental structure of traditional medicine or the vital institutions that support research and education. These systemic failings mean that clinicians (generalists and specialists), as well as educators, researchers, and students, are too often ill-equipped to effectively deal with the challenge of helping the millions of Americans who have complex, multi-dimensional pain conditions.
In the midst of massive economic uncertainty in U.S. healthcare, it might appear that we simply cannot afford to make such foundational changes. However, evidence of the costs associated with the current epidemic of prescription drug abuse, as well as the substantial costs associated with inadequately treated pain, suggests that we cannot afford not to make these changes. Doing so will require intensified partnerships and integration within our health systems and with the organizations that fund our research, accredit our schools for health professionals, and license and certify our clinicians and healthcare facilities.
It could be easy to despair in the face of these challenges. Yet the years since the previous edition of Principles and Practice have also witnessed many hopeful changes. Science continues its steep growth in knowledge of pain, and pain management is increasingly recognized as integral to healthcare. Both of these perspectives drive the advancement of treatment forward. Recent thoughtful policy and regulatory changes raise hope that we are in the process of reversing our excessive reliance on opioids for chronic pain, which may stem the current epidemic of prescription opioid abuse and overdose. Substantial efforts at the federal level are currently underway, holding the promise of an integrated national strategy for pain care, research, and education.
The third edition of this textbook represents over two decades of sustained commitment to interdisciplinary pain education by many thought leaders including Dr Bajwa, Dr Wootton, and Dr Warfield. With its many revisions and updates, this volume presents a review of current perspectives that will be invaluable to specialists and generalists across many health professions. The principles and practice of pain medicine will continue to evolve, of course, but the authors of future editions may look back on this edition as reflecting an important time in medical history. Perhaps they will see that we were at a tipping point beyond which pain care would be solidly founded on quality evidence, comprehensive education, and integration throughout healthcare.
Chief, Division of Pain Medicine
Professor and Vice Chair for Pain Medicine & Faculty Development
Department of Anesthesiology
University of California, Davis Health System