It is our contention that chronic pain must be treated as a presenting disease. Too often patients suffer because the search for the underlying condition and its definitive treatment is conducted without providing adequate pain relief. Although in acutely painful conditions, it may be important not to mask the pain while making the diagnosis, there is no advantage to doing this with chronically painful illnesses. It is important to understand the underlying physical alterations so that the type of pain can be understood and treated, but treatment of the pain itself is essential to prevent or decrease further wind-up pain and needless suffering. While all treatment comes with a price to pay, it must be understood that there are no "bad" classes of medication, invasive treatments or surgeries. It also should be understood that even the best treatment is harmful if it is the wrong treatment. Painful disorders need to be understood and the most appropriate therapeutics need to be brought to bear in their treatment. Doctors need to not only understand the underlying illness, but the best way to treat the pain that accompanies it. What works for rheumatoid arthritis will not work for a herniated lumbar disc. Treatment needs to be tailored to the illness, the individual and the social circumstances. Without this approach, even the finest surgery will be doomed to fail, because the pain will persist. When pain persists it is important for patients to be sent to a pain specialist to assess the reason for that persistence. The pain specialist should work with the referring physician to come up with the most effective treatment plan and, with the patient as the central member of the treatment team, they should embark upon the most likely course of successful care. There will often be false paths and missteps, but thoroughness, diligence and teamwork will usually help resolve even the most difficult and complicated cases. Treating chronic pain is a case of limiting the amount of pain and improving on the patient's function. With many chronically painful condition the pain cannot be eliminated, but it can most often be controlled and made far more tolerable. The patient cannot afford to be passive in this treatment, as every improvement is based upon the experience of the patient. It also does not work for the physician to take the attitude that they know more about the patient's pain than the patient. While knowledge of the causes and treatment of chronic pain may be the physician's art and science, the actual experience of the painful condition is in the patient's court. Every individual experiences pain in a different way and no physician can legitimately tell a patient what he or she should be feeling Once a treatment plan is established, constant refinement and adjustment must occur. This should be accomplished at each follow-up visit and must take into account, not only improvement or lack of improvement, but also changes in activity level, psychological state, and social circumstances.
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