Editor's Memo
by Forest A. Tennant, MD, DrPH
 Until just lately,
over-zealous bureaucrats and regulators have forced the pain field to focus more on
self-protection than patient protection. Described in this issue is an innovative network
of doctors in San Diego County, “Share the Risk Model” by Shurman et al, which
facilitates referrals, second opinions, and tests for about everything possible just to
prescribe to pain patients a few Vicodin« and avoid prosecution.
Fortunately, the over-zealous prosecutory mood of most government agencies has faded as
our entire country has recognized the conundrum of an affluent population that lives a
long time and receives excellent medical care but leaves a sizeable number of unfortunate
souls alive with severe, chronic pain.
The ground-breaking model known as “Share The Risk” is worth adopting in a
lot of American communities. Perhaps overlooked is that professional risk isn’t just
reduced in this model but pain and medical care are improved. Lost in the battle to allow
physicians to administer and patients to receive pain care is the fact that severe chronic
pain needs the care of more than one physician. Pain patients, particularly those severe
enough to require the regular use of Schedule II opioids are going to require, at a
minimum, a primary care MD along with a pain specialist. One or two other specialists are
likely to be required to tend to such co-morbidities as cardiac, endocrine, immunologic,
and neuropsychiatric complications. As physicians continue to reduce their fear of
prosecution, they will most assuredly begin to observe the degenerative and vegetative
complications of pain, per se. But look out. Families, lawyers, and nay-sayers will want
to blame medication and the doctor rather than the severe hormone, immunologic, and
morphologic changes caused by pain. Not only do we want to recognize and share the care of
these tragic individuals, we must address malpractice risk needs. This journal is aware of
many physicians who have been blamed for dementia, heart attack, or deaths in pain
patients rather than the sad, scientific fact that severe chronic pain may age one
prematurely and shorten a patient’s life—even with aggressive pain treatment.
In this issue of PPM, Dr. Steve Singer addresses a related “Share The Care”
issue in his excellent review on topirimate for migraine prevention. He asks a penetrating
question. Will—or can—the primary care or generalist physician have the time to
learn and treat with a drug such as topirimate that is clearly superior to other
treatments when it admittedly requires more physician time. There’s little question
that many of our best agents, techniques, and modalities require more face-to-face patient
time. And this realization is occurring at a time when the U.S. is entering a period of
considerable doctor shortage.
So how do we share the care? PPM has no magic answers, but we do believe it’s time
to throw away all the old myths and absolutes such as “multi-disciplinary care is a
must,” or “only pain specialists can treat pain.” Simply, each physician in
each town is going to have to look around and assess the resources available. While they
may be ample in San Diego, I suspect that North Dakota may have slimmer
“pickin’s”. But whatever the “pickin’s” happen to be, we can
share the care with the resources available to us to the best of our ability.
—Forest A. Tennant, MD, DrPH
Editor in Chief
— October 2006
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