It's a little sad to have to start on the other side of the Atlantic, but the Europeans have real pain management clinics as departments in most larger hospitals. The idea is to bring together teams of people who specialize in the treatment of pain rather than the underlying cause. This leaves the original department having responsibility for continuing the treatment of the cause, but brings in fresh people to deal with the pain, treating it as if it was a disease in its own right. As a first step, the pain management team reviews the patient's medical records to date. This is not with a view to finding fault with the original treatment, but simply to confirm that everything reasonable has been done to resolve the physical problems. This may involve new tests or merely discussing the case with the original attending doctors. Assuming the pain team agree that nothing further can be done, it comes down to treating the pain itself. This will be through a combination of drugs, physical therapy, cognitive behavioral therapy, and such other treatments as the team shall decide. This can include alternative therapies such as acupuncture. The fact there may not be a complete medical justification for some of these treatments is less relevant when it comes to the treatment of pain.

People react to pain differently. Unlike the treatment of a purely physical condition such as an infection, treating pain involves the mind. Many people react as favorably to a placebo as a conventional drug. So if people are convinced an approach is going to help them deal more effectively with pain, they often feel an improvement in their condition.

Unfortunately, when we come back to our country, we find the term "pain management clinic" often describes a pill mill. Florida is one of the worst affected states. There are several hundred clinics, many of them set up without going through the appropriate zoning or licensing procedures. They exist solely to distribute drugs, usually the most abused, surviving only until law enforcement agents step in and close them down. Indeed, the situation has become so bad in Florida, the government has now imposed a moratorium on all new clinics while new laws are introduced to control the problem. So if you see such a clinic in your neighborhood and there are often queues of people for the dispensary, you will understand the nature of the operation.

Because hospitals have established a hierarchy based on individual specialisms, no one is going to break ranks to introduce a new pain management specialism, particularly if this might find fault with the treatment given by a high status department. So the European approach has made little impact in our hospitals. Although one or two centers of excellence such as the Mayo Clinic have introduced comprehensive rehabilitation centers, there's no immediate prospect of this idea being taken up in the "ordinary" hospital. This leaves us with doctors who rely on Tramadol to give us relief from moderate to severe pain. There's nothing actually wrong with this in the short term. Tramadol is an excellent drug. But the Europeans and the Mayo Clinic aim to wean people off drugs and produce a better quality of life through other techniques.