The prevalence and excessive cost of pain, especially when the pain becomes chronic, remains a major health-care problem in the United States. Currently, a biopsychosocial perspective of pain has been found to be the most heuristic approach to understanding and managing it. Using this perspective, an important advance has been made in the possibility of individually tailoring treatment for each patient, with the result being better outcomes. The author reviews the extant literature demonstrating a robust "psychosocial disability factor" among injured workers that is important not only in pain perception, but also in the subsequent development of chronic pain-related disability. Such results emphasize the importance of taking into account how psychosocial and physical factors are intertwined in a complex way in determining pain symptomatology. On the basis of these findings, a number of surgical pre-screening approaches have been developed and found to be effective for maximizing surgical outcomes as described by Carragee, Epker, and Block in other papers in this special topics series. Recently, several organizations in the U.S. have also developed new standards for the evaluation of pain. For example, the Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that physicians consider pain as a "5th vital sign" in evaluating patients. Such initiatives have created a new mandate to regularly assess and manage all types of pain. The use of opioids, as well as implantable pain-management modalities, are among the options. The author notes that the literature on these modalities focuses on interdisciplinary patient-screening approaches prior to their administration as a way of maximizing treatment outcomes. The papers by Praeger, Jacobs, and Robinson et al. in this special topics series describe the approach to pretreatment assessment for these modalities in detail. Finally, the author presents a stepwise, biopsychosocial approach as the basis for assessment before decisions regarding surgery, opioid maintenance therapy, and implantable pain-management modalities. The author suggests that systematic pretreatment interventions will facilitate a more structured standard of care in the evaluation and treatment of patients with pain and ultimately better outcomes.
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