The high prevalence rates suggest that any attempt to solve the pain crisis based upon increasing the availability of tertiary

care services is doomed, by weight of numbers, to fail. Thus the only viable solution to the crisis is empowerment of primary care physicians, especially family see more practitioners, who can be taught effective skills in chronic pain management. Inhibitors,research,lifescience,medical The model presented below is based upon empowering primary care physicians with education stressing theoretical knowledge together with practical hands-on clinically oriented learning. The model constitutes a three-tiered pyramid, each tier narrower than the one below, from the lower-tiered primary care physicians who should be trained

as pain trustees, up to the second-tiered secondary care or community consultant physicians, and up to the tertiary center-based specialists in pain medicine ( Figure 1 ). In our model, the vast majority of pain patients should be treated in the primary care setting. Inhibitors,research,lifescience,medical Patients suffering from more complex problems should be referred to secondary, Inhibitors,research,lifescience,medical community-based consultants, probably working within a small multidisciplinary setup. These consultants could either be pain specialist working in the community or primary care physicians who have undergone further training and are pain trustees with an a additional diploma in pain Inhibitors,research,lifescience,medical and musculoskeletal medicine. Finally, the top tier should be populated by specialists in pain medicine who have undergone extensive further training, especially in the utilization of invasive procedures. Only the most complex of cases, and those needing specialized care, should be referred to tertiary pain centers. Figure 1 The Pyramid Model for the Stratification of Chronic Pain Treatment in the Community. The main challenge in realizing this model lies in the training of doctors according to these

tiers, empowering them with knowledge Inhibitors,research,lifescience,medical and skills necessary for the task. There are already a few year-long courses being taught in Israel, most notably in the Rambam School of Pain Medicine in association with the Technion, at Tel Aviv University in association with the family practice association, and at the Beer Sheva School of Medicine. In the following section we will give a detailed description of the necessary training much of the various levels (see Figure 1 and Table 1 ). Table 1 Operative Plan for Implementing the Pyramid Model. PRIMARY CARE PHYSICIANS Patients who suffer chronic pain are primarily seen by family physicians and, to a lesser extent, by orthopedic surgeons, neurologists, rheumatologists, and other specialists. Since most of these physicians have not received sufficient training in the treatment of pain as students and as residents, their knowledge in the field is based primarily on postgraduate education.