The physician treating a patient with chronic pain may be faced with a veritable blizzard of potentially relevant clinical information. Some of these data are critical to the outcome of treatment. How does the physician sort through this information, decide on the most salient facts, and make the most efficient clinical decisions about the process of care? Twenty years ago, the author investigated these questions while practicing and teaching a model integrated family practice and psychiatry training program at the University of Vermont.30,42,46 Physicians may feel like apprentice masters of the physiologic universe as they manage medical crises with well-established medical-surgical interventions that change the course of pathologic physiology or anatomy. Only when patients refused treatment, ignored advice, or reentered the same hospital unit within a relatively short time span did concerns about behavioral factors become more salient in physicians' minds. Although physicians may welcome patients with complex disease processes and disturbed bodily physiology, each one a fascinating application of biomedical diagnostic technology, they also may tend to resent patients with illnesses complicated by psychosocial problems because such patients threaten physicians' almost mythical faith in the biomedical model. The most vexing cases, particularly those with obvious psychiatric comorbidity that would interfere with treatment, are often labeled pejoratively with terms such as crock or turkey. Chronic pain patients, particularly those seeking pain medications are frequent targets of such assignations, as Marbach et al43 have established in their studies of the stigmatization process associated with chronic pain and treatment with analgesics, particularly opioids. Even those not ostensibly seeking medication probably were even if they suppressed the conscious thought because of stigma. In hindsight, the importance of environmental and psychosocial factors seems obvious. The evidence for their influence is irrefutable and is particularly strong in the area of chronic pain. An expert panel of scientists from other fields concluded that the evidence for the effectiveness of behavioral treatments for certain chronic pain disorders was strong, particularly when packaged with other treatments found in multidisciplinary treatment centers.49 If one were to analyze the content of most medical interactions in most pain medicine offices, despite their enormous salience, these factors are still largely ignored. The articles in this issue of the Medical Clinics describe the considerable advances in understanding of the neurophysiology and molecular biology of pain perception and modulation and their clinical correlates in various disorders. The reciprocal effects of environmental events, psychosocial factors, and emotions, as translated through neurophysiologic systems, on pain perception, pain disability, and the cascade of other negative consequences that may ensue from unrelenting nociception have been established as well. The neurophysiology of these processes is also becoming better understood. Considered together in any one patient, this plethora of biopsychosocial factors presents a wide range of assessment and management problems for the clinician and team; in a population for study, these multiple factors present a serious methodologic challenge to the investigator attempting to understand causal relationships in the onset and course of injury and disability. Although most experienced clinicians accept that the clinical course of chronic pain, similar to most chronic illness, may be best understood within the framework of the biopsychosocial model,7,8,22 most have not yet developed a systematic approach to using this information practically and cost-effectively in their daily clinical practice. This article addresses this problem. The first section presents a biopsychosocial model of pain. The second section presents an application of the biopsychosocial approach to the clinical assessment and management of clinical cases with chronic pain.

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