to the editor: An editorial1 on chronic pain management in American Family Physician illustrates many of the reasons that the current management of this heterogeneous disorder is so unsatisfactory. Reflecting the common tendency to think of chronic pain as a single entity requiring a single approach to treatment, the editorial's text begins with an estimate from the National Center for Health Statistics that “32.8 percent of the U.S. general population has persistent or chronic pain symptoms.”1
Such survey data do not provide a precise indication of how many of those persons have trivial discomfort that most people would ignore, how many have moderate pain that can be self-treated adequately with over-the-counter analgesics, how many have pain that can be managed effectively under a physician's care, and how many have truly disabling pain. Surveys of this type do not discriminate adequately between patients with life-threatening diseases (e.g., disseminated cancer), those with benign but painful disorders amenable to objective diagnosis (e.g., postherpetic neuralgia), and those with less tangible conditions such as fibromyalgia. It is difficult to imagine truly effective pain care that ignores this differentiation.
Consistent with established trends in the treatment of pain in the United States, the management section of the Marcus editorial1 focuses primarily on opioid treatment and indications for referral. Psychosocial factors are briefly mentioned but deserve more attention. There is incomplete but increasingly persuasive evidence that renewed attention to human thought and behavior is a key feature in effective management of chronic pain. Almost every issue of Pain features at least one paper supporting the hypothesis that psychosocial factors are important in the genesis and persistence of pain behavior.2,3 Family physicians are trained in the biopsychosocial model of medicine and are a natural choice to lead research in this area.
The current research also sheds light on another urgently needed area of clinical inquiry: the etiology of chronic pain behavior. The poor prognosis for functional improvement once the disorder is firmly established indicates that there needs to be more longitudinal research on ways to prevent chronic pain as well as detect and treat it at earlier stages. Here again, family medicine should be taking the lead.