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The Merriam-Webster Dictionary defines epidemic as "affecting or tending to affect an atypically large number of individuals within a population, community or region at the same time."

An August 2003 survey by The Florida Pain Initiative (FPI), an organization consisting of a broad spectrum of healthcare professionals, confirmed that Florida has a pain epidemic, with four out of five Florida households containing at least one member who experienced at least monthly pain.

The impact of the study showed that Floridians are substantially more likely to suffer from chronic pain or recurrent pain than the national average, with 75 percent of respondents saying they suffer pain on at least a monthly basis, compared to 57 percent of Americans in survey results released by Research America! in September 2003.

One might theorize that these numbers are a result of Florida's sizable senior population; however, FPI's survey found that individuals reporting chronic or recurrent pain were distributed across all age groups, with respondents between the ages of 30 and 49 representing the largest percentage of sufferers.

In addition to their physical trauma and emotional frustration, an April 2005 telephone poll by ABC News, USA Today, and Stanford University Medical Center added that two-thirds of those surveyed reported interference with mood, activities, sleep, ability to work or enjoyment of life.

Despite the inestimable human suffering and the societal costs of over $100 billion annually in lost productivity and medical care, chronic pain seems to continually abound. With its statistics so blatantly demanding attention, it begs the question, "Why … why does this epidemic continue to be under-treated?

Several reasons emerge:

· Many primary care physicians (PCPs) lack the knowledge required to accurately assess symptoms and to diagnose the myriad of maladies that cause chronic pain, in order to properly treat it.

· Often, insurance company restrictions on physicians' time spent with patients limits the time necessary to pursue productive questioning regarding pain symptoms, and places additional time constraints on the physician when the patient presents with comorbidity.

· Sometimes, PCPs delay in referring patients to specialists, which may negatively impact the outcome of the subsequent treatment.

· Some PCPs are unaware of newer technologies, or are unwilling to try alternative or complementary treatments that may be helpful.

· Reluctance of physicians to prescribe opioids for fear of legal ramifications, of having their licenses revoked, or of patient dependence.

The first step in pain management is proper assessment and accurate identification of the source of the presenting symptoms.

"We've got, literally, an epidemic of unrelieved pain and … there are a lot of people who aren't getting adequate relief," says June Dahl, PhD, Professor of Pharmacology at the University of Wisconsin School of Medicine and Public Health. "The approach to assessment still is based on asking the patient and believing the patient's report. We don't have any device — a pain monitor or something of that sort — that permits a clinician to measure the pain with an instrument." Her recommendation: Ask and believe the patient's report.

Experts who treat chronic pain say a valid assessment of the patient's pain condition should include the following:

Initiation — when did the pain start? Did it coincide with the occurrence of a physical injury or emotional trauma?

Location — is it localized or widespread?

Duration — how long does it last? Is it episodic?

Sensation — what does it feel like? Is it burning, stabbing, buzzing, radiating?

Intensity — how would the patient rate it on a scale of 1 to 10?

Association — when does it hurt? Are there any particular activities or movements that worsen or lessen the pain?

Action — has the patient taken any action to relieve the pain? If so, did it work?

Based on the patient's responses to these questions, the PCP should be able to determine the next step — whether it is imaging, medication, non-pharmacological treatment or referral.

Acute pain should not be readily dismissed. Dahl says, "It has been established in several studies that unrelieved acute pain is a risk factor for the development of chronic pain problems… because the nervous system is not static, it's dynamic, and it undergoes changes when it is constantly bombarded with noxious stimuli." Effective treatment of acute pain assists in the prevention of chronic pain.

Frequently, diagnoses are missed because the PCP is unfamiliar with the symptoms of some illnesses. Consequently, the physician may label the pain as idiopathic or attribute the pain to being "in the patient's head" because he or she is unable to identify the source.

Kathryn Padgett, PhD, Co-founder and Executive Director of The American Academy of Pain Management says, "I think a lot of times, things like Complex Regional Pain Syndrome (CRPS) get missed by primary care doctors because they're not as conversant with that sort of malady."

CRPS, also known as Reflex Sympathetic Dystrophy (RSD) and as Causalgia, is a malfunction of part of the nervous system. Nerves misfire, sending constant pain signals to the brain. CRPS develops in response to an event the body regards as traumatic, such as an accident, a medical procedure, or even a minor injury such as a sprain or fall.

According to the Reflex Sympathetic Dystrophy Syndrome Association, CRPS/RSD may follow 5 percent of all injuries. Early and accurate diagnosis and appropriate treatment are key to recovery; yet, patients typically report seeing an average of five physicians before being accurately diagnosed.

One identifying characteristic of CRPS/RSD is that the pain is disproportionate — more severe than expected — for the type of injury incurred. Other symptoms include persistent moderate-to-severe pain, swelling, abnormal skin color changes, skin temperature, sweating, limited range of movement, and movement disorders; and the illness is two to three times more prevalent in females than males. Some treatments are medication, physical therapy, psychological support, sympathetic nerve blocks, and, possibly sympathectomy or dorsal column stimulator.

This raises the question, "When should a PCP refer, and to whom?"

The resounding response from specialists interviewed as to when to refer was unanimous — as soon as possible. If the PCP is unable to identify the pain, then refer the patient to a pain specialist immediately. If the PCP is able to make a reasonable preliminary diagnosis, and the pain does not respond to the first course of treatment, refer the patient to the appropriate specialist or team of specialists. Time is of the essence.

Gary Sladek, MD, an Orlando-based Rheumatologist in private practice says, "If there's any suspicion that it's Rheumatoid Arthritis, those are people that we want to see as soon as possible because earlier treatment definitely improves long-term outcome. Especially with these newer agents that are out there, we can pretty much stop the disease in most people."

Sladek says the second most common source of chronic pain he sees in patients is fibromyalgia — another difficult-to-diagnose illness often missed by PCPs. "Fibromyalgia is still basically a diagnosis of exclusion, where you do certain blood tests to rule out hypothyroidism, lupus, and other maybe systemic diseases like polymyositis." Polymyositis is a disease of muscle featuring inflammation of the muscle fibers, and the cause is unknown.

Sladek's approach to treating rheumatic diseases is primarily pharmacologic. For Rheumatoid Arthritis, he uses drugs like Methotrexate, an antimetabolite, which are highly effective in suppressing inflammation. In basic situations, the pain may respond to simple analgesics like ibuprofen, and nonsteroidal anti-inflammatory drugs, such as Celebrex. If unsuccessful, alternatives include antidepressants, which can affect pain thresholds and pain pathways; and anti-seizure drugs, such as Neurontin, which seem to help with neuropathic pain; then, ultimately, more potent pain medicines, such as hydrocodone and OxyContin.

For low back pain, Sladek advocates physical therapy. Other non-pharmacologic therapies for generalized chronic pain that Sladek recommends as worth looking into are acupuncture, mind-body techniques and biofeedback. "Lately," he says, "there've been some reports of yoga in fibromyalgia being quite helpful."

This leads us to the second part of the question — to whom does a PCP refer?

Dahl, the professor of pharmacology notes, "The best success comes when you use a multidisciplinary approach, when you have people from different disciplines with different knowledge and skills bringing what they know to bear on a particular patient's problems."

Padgett adamantly shares that position, "If they have an interdisciplinary treatment team anywhere close to them — that is the gold standard … because the interdisciplinary clinics tend to look at the person's main complaint in multiple layers … where they're looking at the emotional, psychological, … physical, … behavioral issues, cultural issues. They look at the person as a whole person. They even look at the horrific economic issues that often come with being in chronic pain … If that's unavailable, try and find a pain specialist."

Ideally, a complete interdisciplinary team trained in pain management may include:

· A physician (neurologist, physiatrist, or anesthesiologist with expertise in pain management)

· Registered nurse

· Psychiatrist or psychologist

· Physical therapist

· Occupational therapist

· Biofeedback therapist

· Family counselor

· Massage therapist

· Other trained pain management personnel, such as providers of alternative and complementary medicine (acupuncturists, herbalists).

"It takes a lot of different viewpoints and various healing therapeutics to join together to help an individual," says Padgett.

Because the PCP is usually the first doctor to see the patient, it is essential that he or she recognizes that persistent pain may affect every moment and aspect of the patient's life until the source of that pain is identified and either the sources, or the pain symptoms, are properly treated. It is critical to note that chronic pain is frequently accompanied by depression, anxiety, and often the ultimate escape from mind-bending persistent pain — suicide.

"Regardless of [the source of chronic pain], there is a process that one goes through when you realize that your life has been changed by this pain … The level of pain that you experience defines the boundaries of your life ... What happens is your world narrows down to your pain, and nothing more than that." says Padgett. "It changes how you interact with the world. So that's why it's so important for us to validate people who have pain, and to say we need to figure out what's causing it, and then figure out what to do with it … We may or may not be able to cure it, but we can sure as heck help you manage it."

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