Pamela Palmer
A great deal of attention is being paid this year to Americans who are turning 60, the first of the baby boomers born between 1946 and 1964. Baby boomers already appear to be setting themselves apart from their parents and grandparents with more active and productive lifestyles in what formerly were termed "the golden years."
Ironically, though, while people are living longer, thanks to the advances made by modern health care, boomers are also now finding truth in the axiom "The mind is willing, but the body is weak." One of the most common reasons is chronic pain, where one out of every five individuals takes a pill daily to relieve acute aches and soreness.
Pamela Palmer, MD, PhD, is the director of UCSF PainCARE - Center for Advanced Research and Education, which was launched in 2004 to build upon the UCSF Pain Management Center's nearly 20 years of success in caring for patients with the worst of the worst types of pain. Palmer believes that all physicians and nurses, particularly those on the front lines of patient care, need to be skilled at assessing pain and determining an appropriate course of action - whether by treating the patient's pain if it's a condition that is manageable at the local clinic setting, or by appropriately referring the patient to a pain specialist when a more advanced level of care is required.
Q: Pain is one of the "common denominators" of life. Back pain, arthritis, headaches - if we aren't in pain ourselves, we all know someone who is. In fact, pain is the number one presenting symptom for most medical conditions. How would you describe pain?
A: For some patients, pain is straightforward. They have arthritis or other conditions that respond well to prescription anti-inflammatories or a combination of medication and physical therapy, and are back to being active relatively quickly after seeing their physicians.
But when pain results from a traumatic event like a car accident, how a patient's body responds to that incident can be more important than the actual trauma. One person may be treated for the acute pain and never have a problem again. Another may develop chronic pain because of neurological processing that results in the central nervous system developing a "memory" of pain. This can also be true for seemingly minor injuries, such as an ankle injury, where a patient's simple sprain turns into the much more difficult condition known as complex regional pain syndrome (also known as reflex sympathetic dystrophy).
Pain is complex and is a combination of anatomic and behavioral processes. When defining pain, one can think of nociception - the perception of pain - plus the level of suffering. The nervous system sends painful signals to the brain, and the patient's brain interprets those signals based on his or her life experience, as well as the actual medical condition itself. It's not just the physiological cause of the pain, but the degree of suffering and the events in the patient's life experience that contribute to that patient's sense of pain that we need to evaluate.
Q: How do you approach treatment of pain?
A: At the Pain Management Center, we see numerous types of pain, including back pain, cancer pain, post-herpetic neuralgia (pain from shingles), complex regional pain syndrome, myofascial pain, neuropathic pain, post-injury or surgical pain, and rheumatologic pain, among others. We perform diagnostic procedures, nerve blocks and other types of injections, implantable therapies and neuroablative procedures, and may also prescribe oral or other medications, or refer patients to our physical therapist, psychologist or biofeedback specialist, if needed.
We take a multidisciplinary approach by treating the whole person. We look at root physiological causes and also look at potential psychological factors because pain can lead to depression, anxiety and family hardship. And these same factors can also cause or worsen pain, or even lengthen the time course of the pain.
So, it's really important to try to determine what pain means to each patient - and in this regard, patience is key. It can take up to six months in chronic pain conditions to fully evaluate what anatomical and behavioral factors play a role in any given patient.
Q: What do you think of the phenomenon of the wave of baby boomers turning 60?
A: It's more than a little scary when you stop to think about it. By 2011, 20 percent of Americans will be over the age of 65. Compare that to the year 1900, when only 4 percent of Americans were over 65. That population has grown to a bigger percentage because we can now treat cancer, diabetes and many other diseases better. But from the musculoskeletal standpoint, we're also now seeing a larger number of elderly patients with degenerative spine and joint disease. In some cases, it's due to genetic predisposition for people who have spinal disease in their 30s and 40s. In others, we're simply outliving our spines and joints - in essence, it's a natural progression.
Fortunately, although we're not yet able to reverse mechanical degeneration, orthopedic procedures such as joint replacement have advanced to such a degree that, with adequate pain management, patients are able to be active and vital well into their 80s and beyond.
But what concerns many of the leading pain management experts worldwide is the sheer volume of patients with pain who will be flooding the health care system in the next 10 to 20 years. Many major medical and nursing schools still don't provide intensive pain management training for their students - particularly those who will become the first point of contact for those patients who say, "I have pain here." And there simply won't be enough pain management specialists to meet this demand if frontline providers refer patients who could be treated in local clinic settings.
We're not ready for the wave, which means we have a potential health care crisis right in front of us.
Q: What are some other pain issues that you see with age?
A: We have published studies showing that there is a difference in tolerance between age groups when using opioids, such as morphine, to treat pain. When taking daily opioids for longstanding chronic pain conditions, older people actually report greater pain relief than younger patients, and yet require lower doses. Unfortunately, because the stigma of addiction remains, older people are still often reluctant to take opioids when they are the population most likely to benefit from their use in the chronic setting.
Educating patients and health care providers about these tolerance differences is one of the things we're doing through UCSF PainCARE and the Pain Management Center. We have a patient education group that meets monthly, and we also provide training programs for health care professionals, including our Challenges of Managing Pain series and our online pain management certificate program.
Q: You're training doctors online?
A: Yes, and nurses, physical therapists, psychologists and other health care providers, as well, through the UCSF
Postgraduate Certificate in Pain Management/Online Program. We're collaborating with the University of Sydney and University of Edinburgh to offer the first truly global system of postgraduate pain management education for all health care practitioners who are involved in assessing, diagnosing or treating patients with pain who realize they need more advanced training to improve their patient care.
The program is delivered entirely online, so it's more convenient for health care providers - who are finding it difficult to leave their busy practices to travel to live conferences - and it's more intensive than these traditional live programs. It's based on the Core Curriculum for Professional Education in Pain developed by the International Association for the Study of Pain, and it takes three consecutive academic quarters to complete. So, participants really develop a solid foundation in the assessment and management of the various types of pain they'll be seeing when the wave of baby boomers hits their front doors.
Q: How do you foresee the future for baby boomers?
A: When we dream of retirement, we think we'll spend our days doing exactly as we please - whether it's gardening or golfing. But as it stands now, growing old is not for the faint of heart. Too many people over the age of 60 have pain and related depression or anxiety that robs them of their quality of life.
Routine things, such as standing and sitting, may prevent them from playing with their grandchildren or even going out to the movies. Even my favorite sport, golf, can worsen low back problems by causing repetitive stress injuries just when retirees finally have enough time to truly enjoy the game. So, at the Pain Management Center, we often ask our older patients, "What is the one thing you can't do anymore, but still wish you could?" We listen, and then we try to help them regain as much ability in that area as we can.
Q: Any last thoughts?
A: I once heard a prominent physician here at UCSF say, "Pain doesn't kill anyone." Many of us, when we hear a statement like that, are concerned - and rightly so - because there is so much more to delivering quality health care than just keeping a patient alive. On the flip side, though, I've heard other health care providers say that no one should ever be in pain. And I'm equally concerned because that statement can lead to unrealistic expectations for patients and their families, and can actually make it harder to help patients with pain.
It's important to help patients understand that pain is a fact of life and that pain management is not a cure. Pain management is just that - managing the patient's pain in a way that reduces suffering to the maximum extent possible, offers hope and ultimately leads to a better quality of life. These are worthy goals for all of us who see, or will be seeing, patients with pain.
