Editor's Memo
by Forest A. Tennant, MD, DrPH
 Don’t you just love those
“one-wayers” who preach one treatment, one way, for all time. My way or the
hi-way! Absolute is their favorite word. It’s “always,” “will,”
and “never” rather than could be, might, or possibly. In pain treatment, the
“one-wayers” totally ignore the basic physiologic and biochemical underpinnings
of the body, much less acknowledge the frailties and attributes of the mind and spirit,
and fail to recognize (heaven forbid!) patient desire. All told, the one-wayers would
rather leave someone suffering in pain rather than change.
It’s incumbent upon all of us to recognize the one-wayers. You’ll find them
in most hospitals and clinics. They populate heavily, of course, in the insurance industry
and government oversight-agencies. You can usually spot them by their rhetoric. Here are
some tip-offs that may warrant a confirmation test to verify the one-way syndrome:
“invasive procedures are too dangerous;” “opioids cause tolerance and
dependence;” “never use Demerol, Darvon, Benzos, Cox II, etc;” “we
have our standards and quality;” “GP’s and NP’s aren’t
qualified;” “detox must be done;” “electrical medicine, acupuncture,
and nutritional supplements are frauds;” or “too many side-effects.” In
reality, the body has multiple systems which modulate pain control. And, yes, most
treatments have risk and side-effects. But uncontrolled pain, with its devastating,
life-shortening complications on the cardiovascular and neurohormonal systems, may be more
risky. What’s more, practically every pain treatment — including acupuncture and
TENS, as well as opioids and muscle relaxants — will develop tolerance. So what?
Unless you are a “one-wayer,” our pain armamentarium has plenty of therapeutic
agents and modalities to rotate or change to when tolerance develops. In this issue, Drs.
Webster and Fakata introduce Ziconotide for intractable, severe pain. This new therapeutic
agent has already been criticized by some “one-wayers” as having too much risk.
Says who? Risk is a joint decision between patient and physician. Ziconotide has a
previously unappreciated mechanism of action, and it is proving to be a terrific therapy
for many intractable pain patients.
Instead of “one-way”, isn’t it time everyone in the pain field
recognizes that therapeutic modalities and pharmacologic agents are additive and
complement each other. Practitioners who treat asthma, diabetes, hypertension, and
depression recognized, long ago, that double or triple therapy, particularly in
recalcitrant, severe cases, gets the needed result when “one-way” may fail.
How do we know which way to go? Let’s start by asking the patient which way is
working and follow up the inquiry with a physical evaluation. You know…something
un-extraordinary — but often overlooked — like blood pressure, pulse, gait, and
mental alertness!
— Forest A. Tennant, MD, DrPH
Editor in Chief
— May/Jun 2005
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