The patient on this months cover wouldnt need to tell you hes in pain. You expect as much with patients who have Stevens-Johnson syndrome. But, how often do patients walk out your door with pain youre unaware of? What observable symptoms does a patient need to have for you to recognize that he or she is in pain and in need of oral medication or a referral for pain management?

Pain is a silent epidemic in the United States, says Kathryn Weiner, Ph.D., director of the American Academy of Pain Management. And, she says, its under-treatment represents a major problem confronting our modern culture.

Some 25 million Americans suffer from acute pain resulting from surgery or an accident.¹ An additional 50 million Americans live with chronic pain caused by disease, a disorder or an accident. Id call that an epidemic by any standardsand one that certainly deserves more discussion in the medical literature.

To that end, in this months cover story, Understand and Control Your Patients Pain, Sandra Bozich, O.D., explains how oral pain medications work to help alleviate your patients pain, and how and when to prescribe these medications. Paul C. Ajamian, O.D., also tackles pain in this months Comanagement Q+A column, Its Not Such a Pain!

If, as the American Academy of Pain Management contends, pain is not being appropriately addressed, who is dropping the ball? Whose responsibility is it to seek solutions?

Even though oral narcotics are not within an O.D.s scope of practice in all states, it is an O.D.s responsibility to address patients pain and, when needed, to comanage with a physician who can treat it. Whatever your prescribing rights may be, your role in the pain management team is just as critical as any other doctors role.

Because pain is a complex puzzle, no single health-care profession holds the puzzle piece that solves this puzzle; rather, each health-care profession holds a critical piece that contributes to the completion of the puzzle, Dr. Weiner says. And you, doctor, are an important piece of that puzzle.

Additionally, prescribing rights do not make one type of doctor better at evaluating and managing patients pain than another type. Indeed, research shows that all types of doctors underestimate their patients pain and discomfort, Dr. Ajamian points out.

The Chronic Pain in America: Roadblocks to Relief study found that one out of four pain patients have changed doctors at least three times, primarily because these patients still experienced pain.² Other reasons for which patients reported changing doctors: Their pain was not taken seriously, their doctors were unwilling to treat pain aggressively, and their doctors lacked knowledge about how to treat pain.

Whether or not you write the script, your patients will likely judge you based on how you address their pain. And, the first step in managing pain is to diagnose its severity. The only way to do that is to ask, says Bruce Onofrey, R.Ph., O.D. Not every patient with severe pain presents with signs as visible as those presented by the patient on this months cover. Many suffer in silence, others are not heard, some are not believed, and a few are never even asked.

For more information on pain management, go to www.painfoundation.org or www.aapainmanage.org.

We Want to Hear From You Review of Optometry wants to hear from you. Please send letters, case reports or other inspiring accounts of how you"ve taken part in the care of a patient whose life was affected by pain. E-mail ahellem@jobson.com