Editor's Memo
by Forest A. Tennant, MD, DrPH
 While the “tough case”
is legend to the practicing physician — be it a cancer, kidney, or cardiac patient
— it seems that the whole world, including some physicians, wants to deny that there
are “tough pain cases.” For example, this editor recently heard a physician
— a medical advisor to a New York Stock Exchange Insurance Company — actually
state that no pain patient “could possibly need more than four generic hydrocodone
and two ibuprofen a day.” This severely-misinformed statement was interwoven into his
diatribe against anesthesiologists and their interventions and the “exorbitant”
costs of pain medication. But the tough pain case or ‘outlyer’ does indeed exist
in Everyville, USA. Sometimes it’s the patient who only responds to meperidine, or
requires three kinds of opioids per day, or the patient who needs an IV catheter for
hydromorphone. Some of the ‘outlyers’ need some fairly esoteric, yet effective
pain regimens. So, who is to take these cases that aren’t supposed to exist?
It has become clear that the U.S. must recruit and train generalist physicians to treat
the large number of patients with persistent pain. Epidemiologic studies of the prevalence
of pain in the general population indicate that at least 2 to 5% of the adult population
requires daily opioids for pain control, yet it is estimated that there are probably no
more than about 3,000 physicians in the United States who hold themselves out to be pain
specialists. A recent study in Ohio showed that only about 2% of pain patients are treated
by physicians who classify themselves as pain specialists.
At this time, family practice, preventive medicine, psychiatry, and internal medicine
residencies do not offer fellowships or preceptorships in pain management. Although they
may do so in the future, there will be a lag time of several years before we can count on
formal, post-graduate training to ensure that every community has caring, capable
physicians to treat the persistent pain patient and “tough case.” In the
meantime, generalist physicians will have to be recruited and trained by other means. It
may be difficult, but it’s the right thing to do.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Mar/Apr 2004
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