Vincents pain is persisting long after the resolution of the primary injury and there is nothing in the history suggesting any ongoing complications of the injury which you

may have to rule out). The conventional treatment strategies have obviously failed. Hence, this referral is justified at this point.

Q. How will you assess the suitability of Vincent for the pain management program? Initial screening evaluation consists of medical and psychological evaluation and review of patient's diaries, referral letter, and medical records.

Vincent's clinical examination reveals a long scar on his left shoulder (which looks well healed) and a small patch of skin with sensory loss over the shoulder. There are no signs of complex regional pain syndrome (CRPS). He tells you that the pain is a constant ache with sharp shooting episodes during the night which is "worrying him a lot" and "keeps him awake." The pain score varies from 5 to 8 out of a maximum of 10. He is worried about moving his neck for fear of worsening of the pain. His medications include acetaminophen, codeine, oral morphine, tramadol, and gabapentin. He mentions that he feels sleepy during the day ever since he has started taking gabapentin. His appetite has increased and he has "put on a several pounds." Vincent feels that the medications are harming his creativity.

The pain center psychologist further assesses Vincent. The interview reveals that Vincent is suffering from depression which was present even before the injury. He is upset that the pain is preventing him from going out and painting outdoors. At the end of the evaluation and in consultation with your team, you conclude that Vincent is a suitable candidate for the multidisciplinary pain management program.

Describe your multidisciplinary pain management process for Vincent? The emphasis ofthe strategies would be on physical conditioning, medication management, acquisition of coping and vocational skills, and gaining knowledge about pain and how the body functions. Vincent needs counseling addressing his needs. The most important aim is to change Vincent's pain from uncontrollable to manageable.

It is advisable to have realistic expectations regarding the outcome from the program. Vincent tells you that he is really upset that he cannot use his left hand effectively to paint and he would be happy if he could do so for at least an hour a day.

As a physician, you are responsible for implementation of medication management. How are you going to achieve this?

Pain medications should be given on a contingent basis to uncouple the reinforcement of pain behavior and medication. Patients in the MPC program do not derive adequate pain relief from analgesics. An attempt to taper the pain medications by means of the pain cocktail technique should be made. Instead of multiple opioids, generally a single long-acting medication should be prescribed.

It is worth considering stopping gabapentin altogether. Gabapentin is not currently indicated and furthermore can cause side effects such as increased appetite and disturbed sleep patterns which can further aggravate his symptoms. He might benefit from an addition of an antidepressant to help with depression and pain symptoms.

Vincent undergoes the MPC program whole-heartedly and cooperates with the mul-tidisciplinary team, which includes physical therapists, pain nurses, and vocational counselors. He learns more about his body and the basic mechanism of chronic pain, which helps him to get over the fear of losing his livelihood. He learns to paint with his right hand with the help of the occupational therapist, and at the end of the program he is able to go out into the open and paint landscapes. Though he still has pain, it no longer bothers him. The MPC program has been a great success for him.

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