1. CHAPTER
1 The History of
Pain Medicine
Winston C. V. Parris and Benjamin Johnson
History is a distillation of rumor. sequences of smoking, the trauma associated with
THOMAS CARLYLE (1795-1881) automobile accidents, the pathology caused by drug
abuse and drug misuse, and the proliferation of viral
The management of pain, like the management of illnesses (e.g., acquired immunodeficiency syndrome)
disease, is as old as mankind. In the view of Chris- have all contributed further pain and suffering to our
tians, the fall of Adam and Eve in the Garden of Eden lot. Therefore any review of history and politics, eco-
produced for man (and woman) a long life of suffer- nomics, and social interrelationships of the world is
ing disease and pain. This one act allegedly set the inevitably a review of the history of pain. This chapter
stage for several disease concepts, including the expe- focuses on some of the major historical events that
rience of pain in labor and delivery; the concept that have influenced pain, its development, and its man-
hard work is painful; the notion that blood, sweat, agement and highlights the important phases that
and tears are needed to produce fruit; the introduc- led to the current conceptualization of pain and its
tion of pain and disease to human existence; the treatment as an independent specialty in modern
establishment of the fact that hell and its fires are medicine.
painful; and the expectation that heaven is pure,
delightful, spiritually pleasing, and, of course, pain- PAIN AND RELIGION
free. In these concepts, pain is viewed as a negative
experience and one that is associated with disease, The early concept of pain as a form of punishment
morbidity, and the dying process. Most diseases, from supreme spiritual beings for sin and evil activity
including infections, plagues, metabolic disorders is as old as mankind.1 In the book of Genesis, God
(e.g., diabetes mellitus), endocrine disorders, hyper- told Eve that following her fall from grace, she would
tension, and cancer, of course, afflict mankind spon- endure pain during childbirth: “I will greatly multi-
taneously and usually cause significant pain, without ply your pain in childbearing; in pain you shall bring
any wrongdoing, negligence, or irresponsibility on forth children, yet your desire shall be for your
the part of the afflicted person. husband and he shall rule over you” (Genesis 3:16).
As we consider the historical perspective, humans This condemnation led early Christians to accept
have deliberately and knowingly inflicted on one pain as a normal consequence of Eve’s action and to
another many experiences associated with pain— view this consequence as being directly transferred
from the earliest wars to the more recent irrational to them. Thus any attempt to decrease the pain asso-
shooting incidents in the Arkansas and Oregon public ciated with labor and delivery was treated by early
school systems, from the scourging of Jesus to the Christians with disdain and disapproval. It was not
contemporary strife in the Middle East, the Rwandan until 1847, when Queen Victoria was administered
genocide, the Irish “religious” fratricide, and the con- chloroform by James Simpson2 for the delivery of her
flicts in Bosnia and the Balkans. All wars, including eighth child, Prince Leopold, that contemporary
the great wars, World War I and World War II, the Christians, and in particular Protestants, accepted
American Civil War, the Korean War, and the the notion that it was not heretical to promote pain-
Vietnam War, have all been associated with untold less childbirth as part of the obstetric process.
pain, suffering, and death. From the Old Testament, Job has been praised for
Although we as human beings have not learned his endurance of pain and suffering. Yet, Job’s friends
from these painful episodes and continue to inflict wondered whether these tribulations were an indica-
pain on others, the advances and increasing sophis- tion that he had committed some great sin for which
tication of the 21st century have brought about new God was punishing him. Their justification for
concepts of disease and the painful states that dis- this assumption was based in the book of Proverbs,
eases produce. The social illnesses—veneral diseases, which suggested that “no harm befalls the righteous”
the pulmonary, cardiovascular, and neoplastic con- (Proverbs 12:21). Notwithstanding, Job was consid-
3

2. 4 General Considerations
ered a faithful servant by God and was not guilty of from Georgia into Texas. Although surgical anesthe-
any wrongdoing. In fact, he was described as a man sia was well developed by the late 19th century, reli-
who was “blameless and upright” and one who feared gious controversy over its use required Pope Pius XII
God and turned away from evil.3 to give his approval before anesthesia could be exten-
In the 5th century, St. Augustine wrote that “all sively used for surgical procedures.6 Pope Pius XII
diseases of Christians are to be ascribed to demons; wrote, “The patient, desirous of avoiding or relieving
chiefly do they torment the fresh baptized, yea, even pain, may without any disquietude of conscience,
the guiltless newborn infant,” implying that not use the means discovered by science which in them-
even innocent infants escaped the work of demons. selves are not immoral.”
Today, major typhoons, hurricanes, fires, earth-
quakes, volcanoes, tsunamis, floods, droughts, and PAIN AND THE ANCIENT CULTURES
fires destroy hundreds, and at times thousands, of
innocent, defenseless people. One ponders the ratio- Disease, pain, and death have always been consid-
nale of such pain and suffering endured by otherwise ered undesirable. The principles on which medicine
good people while seemingly ruthless and evil persons was founded were based on measures to overcome
apparently triumph and prosper in an atmosphere of human suffering from disease. Thus pain was usually
luxury and comfort. thought of as either emanating from an injury or
This paradox can be discouraging at times but is originating from the dysfunction of an internal organ
usually upheld by firm Christian belief. In the 1st or system. Traditionally, pain after physical injury
century, many people who belonged to the Catholic (e.g., a gunshot wound or spear injury) was not con-
Church were rebuked and suffered ruthless persecu- sidered problematic, since as soon as the offending
tion, including death, because of their belief in Jesus injurious agent was removed or once the conse-
as the Messiah. Some who were subsequently de- quences of the offending injury were corrected, the
scribed as martyrs endured their suffering with the patient either recovered rapidly or, on occasion,
belief that they did it for the love of Christ, and they died.7 On the other hand, pain from disease (e.g., the
felt that their suffering identified them with Christ’s pain of an inflamed gallbladder or ruptured appen-
suffering on the cross during his crucifixion.4 This dix) was regarded with more mystique, and treat-
may be the earliest example of the value of psycho- ment was usually tinged with superstitious tradition.
therapy as an important modality in managing pain. The tribal concept of pain came from the belief that
Thus many present-day cancer patients with strong it resulted from an “intrusion” from outside the
Christian beliefs view their pain and suffering as part body. These “intruders” were thought to be evil
of their journey toward eternal salvation. This spirits sent by the gods as a form of punishment. It
concept has led to several scientifically conducted was in this setting that the role of medicine men and
and government-sponsored studies evaluating inter- shamans flourished, because these were the persons
cessory prayer as an effective modality for controlling assigned to treat the pain syndromes associated with
cancer pain. internal disease. Because it was thought that spirits
To fully appreciate the historical significance of entered the body by different avenues, the rational
pain, it is important to reflect on the origins of the approach to therapy was aimed at blocking the par-
“pain patient.” The word pain comes from the Latin ticular pathway chosen by the spirit.
word poena, which means “punishment.” The word In Egypt, the left nostril was considered the specific
patient is derived from the Latin word patior, meaning site where disease entered. This belief was confirmed
“to endure suffering or pain.” Thus it is not too out- by the Papyri of Ebers and Berlin,8 which stated that
rageous to appreciate that, in ancient days, persons the treatment of headache involved expulsion of the
who experienced pain were interpreted to have offending spirit by sneezing, sweating, vomiting, uri-
received punishment in the form of suffering that nation, and even trephination. In New Guinea, it was
was either dispensed by the gods or offered up to believed that evil spirits entered via a spear or an
appease the gods for transgressions.5 arrow that then produced spontaneous pain.7 Thus
As epidural anesthesia has developed and the tech- it was common for the shaman to occasionally purge
niques have been refined so that mortality and the evil spirit from a painful offending wound and
morbidity are negligible, childbirth and delivery are neutralize it with his special powers or his special
increasingly considered relatively painless in most medicines. Egyptians treated some forms of pain by
developed societies. Unfortunately, in many coun- placing an electric fish from the Nile over the wounds
tries neither the personnel nor the technology is in order to control the pain.9 The resulting electrical
available and resources to provide such personnel stimulation that produced pain relief actually works
and technology are inadequate, making childbirth a by a mechanism similar to transcutaneous electrical
primitively painful and at times disastrous event. The nerve stimulation, which is frequently used today to
history of anesthesia is full of instances wherein treat pain.
attempts to relieve pain were initially met with resis- The Papyrus of Ebers, an ancient Egyptian manu-
tance and at times violence. In the mid-19th century, script, contains a wide variety of pharmacologic
Crawford Long of Georgia attempted to develop and information and describes many techniques and
provide anesthesia, but contemporary Christians of recipes, some of which still have validity.8 The Papyri
that state considered him a heretic for his scholarly describe the use of opium for the treatment of pain
activity. As a result, he literally had to flee for his life in children. Other concoctions for treating pediatric

3. The History of Pain Medicine 5
pain have included wearing amulets filled with a While these advances were taking place, there were
dead man’s tooth (Omnibonus Ferraruis, 1577) as a simultaneous advances in the development of thera-
treatment for teething pain. Although early docu- peutic modalities, including the use of drugs (e.g.,
ments specifically address the management of pain opium) as well as heat, cold, massage, trephining,
in children, it is unfortunate that even today the and exercise to treat painful illnesses. These develop-
treatment of pediatric pain is far from optimal. This ments brought about the establishment of the prin-
glaring deficiency was highlighted in 1977 by Eland, ciples of surgery for treating disease. Electricity was
who demonstrated that in a population of children first used by the Greeks of that era as they exploited
4 to 8 years of age, only 50% received analgesics for the power of the electrogenic torpedo fish (Scribonius
postoperative pain.3 The results are even more unsat- longus) to treat the pain of arthritis and headache.
isfactory for the treatment of chronic pain and cancer Electrostatic generators were used in the late Middle
pain in children. It is unfortunate that the observa- Ages, as was the Leyden jar; these developments
tions of earlier scholars have been ignored. Two erro- resulted in the reemergence of electrotherapy as a
neous assumptions—that (1) children are less sensitive modality for managing medical problems, including
to pain and (2) the central nervous system is rela- pain. There was a relative standstill in the develop-
tively undeveloped in neonates—are partially respon- ment of electrotherapy as a medical modality until
sible for this deficiency. the invention of the electric battery in the 19th
Early Native Americans believed that pain was century. Then several attempts were made to revive
experienced in the heart, whereas the Chinese identi- its use as an effective medical modality, but these
fied multiple points in the body where pain might concepts did not catch on and were largely used
originate or might be self-perpetuating.10 Conse- only by charlatans and obscure scientists and prac-
quently, attempts were made to drain the body of titioners. Throughout the Middle Ages and the
these “pain points” by inserting needles, a concept Renaissance, debate raged regarding the origin and
that may have given birth to the principles of acu- processing center of pain. Fortunes fluctuated be-
puncture therapy, which is well over 2000 years tween proponents of the brain theory and pro-
old.11 ponents of the heart theory, depending on which
The ancient Greeks were the first to consider pain theory was favored.
to be a sensory function that might be derived from Heart theory proponents appeared to prosper when
peripheral stimulation.12 In particular, Aristotle William Harvey, recognized for his discovery of the
believed that pain was a central sensation arriving circulation, supported the heart as the focus for pain
from some form of stimulation of the flesh, while sensation. Descartes disagreed vehemently with the
Plato hypothesized that the brain was the destination Harvey hypothesis, and his description of pain con-
of all peripheral stimulation.1 Aristotle advanced the duction from peripheral damage through nerves to
notion that the heart was the originating source or the brain led to the first plausible pain theory, that
processing center for pain. He based his hypothesis is, the specificity theory.16 It is interesting to note that
on the concept that an excess of vital heat was con- the specificity theory followed Descartes’ description
ducted by the blood to the heart where pain was by some 2 centuries. Several other theories followed
modulated and perceived. Because of his great repu- the specificity theory and contributed to the founda-
tation, many Greek philosophers followed Aristotle tion for understanding pain and pain mechanisms.
and embraced the notion that the heart was the
center for pain processing.13 Another Greek philoso- PAIN AND PAIN THEORIES
pher, Stratton, and other distinguished Egyptians,
including Herophilus and Eistratus, disagreed with The specificity theory, originally proposed by Des-
Aristotle and proposed the concept that the brain cartes, was formally revised by Schiff based on animal
was the site of pain perception as suggested by Plato. research. The fundamental tenet of the theory was
Their theories were reinforced by actual anatomic that each sensory modality, including pain, was
studies showing the connections of the peripheral transmitted along an independent pathway. By
and central nervous systems.14 examining the effect of incisions in the spinal cord,
Notwithstanding, controversies between the oppos- Schiff16 demonstrated that touch and pain were inde-
ing theories of the brain and the heart as the center pendent sensations. Furthermore, he demonstrated
for pain continued, and it was not until 400 years that sectioning of the spinal cord deferentially
later that the Roman philosopher Galen rejuvenated resulted in the loss of one modality without affect-
the works of the Egyptians Herophilus and Eistratus, ing the other. Further work along the same lines by
and greatly reemphasized the model of the central Bliz,17 Goldscheider,18 and von Frey19 contributed to
nervous system. Although Galen’s work was compel- the concept that separate and distinct receptors
ling, he received little recognition for it until the existed for the modalities of pain, touch, warmth,
20th century. and cold.
Toward the period of the Roman Empire, steady During the 18th and 19th centuries, new inven-
progress was made in understanding pain as a sensa- tions, new theories, and new thinking emerged. This
tion similar to other sensations in the body. Develop- period was known as the Scientific Revolution, and
ments made in anatomy, and to a lesser extent several important inventions took place, including
physiology, helped establish that the brain, not the the discovery of the analgesic properties of nitrous
heart, was the center for the processing of pain.15 oxide, followed by the discovery of the local anes-

4. 6 General Considerations
thetic agents (e.g., cocaine). The study of anatomy Dryden once wrote, “For all the happiness mankind
was also developing rapidly as an important branch can gain is not in pleasure, but in rest from pain.”
of science and medicine; most notable was the dis- Thus many fatal nonpainful diseases are not as feared
covery of the anatomic division of the spinal cord as relatively trivial painful ones.
into sensory (dorsal) and motor (ventral) divisions. Throughout the ages, physicians and healers have
In 1840, Mueller proposed that, based on anatomic focused their attention on managing pain. Thus in
studies, there was a straight-through system of spe- managing cancer, an important measure of success-
cific nerve energies in which specific energy from a ful treatment is the success with which any associ-
given sensation was transmitted along sensory nerves ated pain is managed. Although many technologic
to the brain.20 Mueller’s theories led Darwin to advances have been made in medicine, it is only
propose the intensive theory of pain,21 which main- within the past 10 to 20 years that significant strides
tained that the sensation of pain was not a separate have been made to deal with chronic pain as a disease
modality but instead resulted from a sensory over- entity per se—one requiring specialized study, spe-
load of sufficient intensity for any modality. This cialized evaluation, and specialized therapeutic inter-
theory was modified by Erb22 and then expanded by ventions. As better techniques and more effective
Goldscheider18 to encompass the roles of both stimu- methods for evaluation and treatment of pain, espe-
lus intensity and central summation of stimuli. cially chronic pain, are developed, the management
Although the intensive theory was persuasive, the of this disease will be considered more complete and
controversy continued, with the result that by the an important supplement to the great strides made
mid-20th century, the specificity theory was univer- in other areas of chronic disease management.
sally accepted as the more plausible theory of pain.
With this official blessing (although it was not PAIN IN THE 20TH CENTURY
unanimous) of the contemporary scientific commu-
nity, strategies for pain therapy began to focus on General anesthesia was formally discovered by
identifying and interrupting pain pathways. This William Morton in 1846; in 1847, Simpson used
tendency was both a blessing and a curse. It was a chloroform to provide anesthesia for labor and deliv-
blessing in that it led many researchers to explore ery.9 Around the same time, the needle and the
surgical techniques that might interrupt pain path- syringe were invented. Many local anesthetic agents
ways and consequently relieve pain, but it was a were also discovered in that era. In 1888, Corning
curse in that it blind-sided the medical community described the use of a local anesthetic, cocaine, for
for more that half a century into believing that pain the treatment of nerve pain. Techniques for local and
pathways and their interruption were the total answer regional anesthesia for both surgery and pain disor-
to the pain puzzle. This trend was begun in the late ders proliferated rapidly.
19th century by Letievant, who first described spe- In 1907, Schlosser reported significant relief of
cific neurectomy techniques for treating neuralgic neuralgic pain for long periods with alcohol injection
pain.23 Afterward, various surgical interventions for of damaged and painful nerves. Reports of similar
chronic pain were developed and used, including treatment came from the management of pain result-
rhizotomy, cordotomy, leucotomy, tractotomy, my- ing from tuberculous and neoplastic invasion.25 In
elotomy, and several other operative procedures 1926 and 1928, Swetlow and White, respectively,
designed to interrupt the central nervous system and reported on the use of alcohol injections into tho-
consequently reduce pain.24 Most of these techniques racic sympathetic ganglia to treat chronic angina. In
were abysmal failures that not only did not relieve 1931, Dogliotti described the use of alcohol injected
pain but also on occasion produced much more pain into the cervical subarachnoid space to treat pain
than was previously present. A major consequence associated with cancer.26
lingers today—the notion that pain can be “fixed” One consequence of war has been the develop-
by a surgical procedure or other modality. ment of new techniques and procedures to manage
injuries. In World War I (1914-1918), numerous inju-
PAIN AND DISEASE ries were associated with trauma (e.g., dismember-
ment, peripheral vascular insufficiency, and frostbite).
The cardinal features of disease as recognized by early In World War II (1939-1946), not only peripheral
philosophers included calor, rubor, tumor, and dolor; vascular injuries but also phantom limb phenomena,
the English translation is heat, redness, swelling, and causalgias, and many sympathetically mediated pain
pain. One of the important highlights in the history syndromes occurred. Leriche developed the tech-
of pain medicine was the realization that even though nique of sympathetic neural blockade with procaine
heat, redness, and swelling may disappear, pain can to treat the causalgic injuries of war.27 John Bonica,
continue long after and be unresponsive on occasion himself an army surgeon during World War II, rec-
to different therapeutic modalities. When pain con- ognized the gross inadequacy of managing war inju-
tinues long after the natural pathogenetic course of ries and other painful states of veterans with the
disease has ended, a chronic pain syndrome develops existing unidisciplinary approaches.28 This led him
with characteristic clinical features, including depres- to propose the concept of a multidisciplinary, multi-
sion, dependency, disability, disuse, drug misuse, modal management for chronic pain. Bonica also
drug abuse, and, of course, “doctor shopping.” John highlighted the fact that pain of all kinds was being

5. The History of Pain Medicine 7
undertreated; his work has borne fruit, in that he is on the theory but also to the maturity of pain medi-
universally considered the “father of pain,” and he cine as a science.30 As a consequence, the American
was the catalyst for the formation of many estab- Pain Society, the American Academy of Pain Medicine,
lished national and international pain organizations. the IASP, and the World Institute of Pain (WIP) flour-
The clinic he developed at the University of Wash- ish today as serious and responsible organizations
ington in Seattle remains a model for the multidisci- dealing with various aspects of pain medicine, includ-
plinary management of chronic pain. As a result of ing education, science, certification, and credential-
his work, the American Pain Society and the Interna- ing of members of the specialty of pain medicine.
tional Association for the Study of Pain (IASP) have
been formed, are still active, and continue to lead in PAIN AND THE IMPACT OF PSYCHOLOGY
pain research and pain management. Bonica’s lasting
legacy is the historic volume The Management of Pain, The history of pain medicine would be incomplete
published in 1953. without acknowledging the noteworthy contribu-
Anesthesia as a specialty developed but was still tions of psychologists. Their influential research and
associated with significant mortality and morbidity. clinical activities have been an integral part of a revo-
Anesthesia departments were considered divisions of lution in the conceptualization of the pain experi-
surgery, not reaching full autonomy until after World ence.31 For example, in the early 20th century, the
War II. Because of morbidity associated with general role of the cerebral cortex in the perception of pain
anesthesia and because several new local anesthetics was controversial, due to a lack of understanding of
were being discovered, regional anesthesia and its neuroanatomic pathways and the neurophysiologic
associated techniques began to flourish in the United mechanisms involved in pain perception.32,33 This
States. Bonica also played a major role in advancing controversy largely ended with the introduction of
the use of epidural anesthesia to manage the pain the gate control theory by Wall and Melzack in
associated with labor and delivery. Regional anesthe- 1965.29 The gate control theory has stood the test of
sia suffered a significant setback in the United time, in that subsequent research using modern
Kingdom with the negative publicity surrounding brain imaging techniques such as PET, fMRI, and
the 1954 cases of Wooley and Roe, who suffered SPECT has also described the activation of mul-
serious and irreversible neurologic damage after tiple cortical and subcortical sites of activity in the
spinal anesthesia. It took 3 more decades to fully brain during pain perception. Further elaboration of
overcome that setback and to see regional anesthesia the psychological aspects of the pain experience
widely accepted as safe and effective in the United includes the three psychological dimensions of pain:
Kingdom. Several persons contributing significantly sensory-discriminative, motivational-affective, and
to the development of regional anesthesia are cognitive-evaluative.34
Corning, Quincke-August Bier, Pitkin, Etherington- Psychological researchers have greatly advanced
Wilson, Barker, and Adriani. the field of pain medicine by reconceptualizing both
As recent society has developed and as science has the etiology of the pain experience and the treatment
prospered, the general public has come to consider strategy. Early pain researchers conceptualized the
pain to be unsatisfactory and unacceptable. As a pain experience as a product of either somatic pathol-
result, demands have been made that resulted in the ogy or psychological factors. However, psychological
development of labor and delivery anesthesia ser- researchers have convincingly challenged this mis-
vices, acute pain services, and, more recently, chronic conception by presenting research that illustrates the
pain clinics. Bonica’s vision was not only the devel- complex interaction between biomedical and psy-
opment of those clinics but also the founding and chosocial factors.35-37
maintenance of national and international pain This biopsychosiocial approach to the pain experi-
organizations to promote research and scientific ence encourages the realization that pain is a complex
understanding of pain medicine. As a result, a tre- perceptual experience modulated by a wide range of
mendous amount of research continues, almost qua- biopsychosocial factors, including emotions, social
drupling each year. and environmental contexts, and cultural back-
An outstanding contribution in the field of research ground, as well as beliefs, attitudes, and expectations.
was the development and publication of the gate As the acutely painful experience transitions into a
control theory by Melzack and Wall in 1965.29 This chronic phenomenon, these biopsychosocial abnor-
theory, built on the preexisting and prevalent specific- malities develop permanency. Thus, chronic pain
ity and intensive theories, provided a sound scientific affects all facets of a person’s functional universe, at
basis for understanding pain mechanisms and for great expense to the individual and society. Conse-
developing other concepts on which sound hypothe- quently, logic dictates that this multimodal etiology
ses could be developed. The gate control theory of pain requires a multimodal therapeutic strategy
emphasizes the importance of both of ascending and for opti-mal cost-effective treatment outcomes.38,39
descending modulation systems and laid down a solid Additional contributions from the field of psychol-
framework for the management of different pain syn- ogy include therapeutic behavioral modification
dromes. The gate control theory almost single-hand- techniques for the management of pain. Such tech-
edly legitimized pain as a scientific discipline, leading niques as cognitive behavioral intervention, guided
not only to many other research endeavors building imagery, biofeedback, and autogenic training are the

6. 8 General Considerations
direct results of using the concepts presented in the chronic pain assessment and management especially
gate control theory. In addition, neuromodulatory in developing countries. Cancer pain awareness and
therapeutic modalities such as transcutaneous elec- its management have been noteworthy contributions
trical nerve stimulation (TENS), peripheral nerve of the IASP.
stimulation, spinal cord stimulation, and deep brain Special interest groups (SIGs) within the IASP have
stimulation are also logical offspring of the concepts successfully promoted research, understanding, edu-
presented in the gate control theory. cation, and enhanced pain management of the par-
The evaluation of candidates for interventional ticular special interest. Areas of interest include pain
medical procedures is another valuable historical in children, neuropathic pain, herbal medicine, and
contribution from the field of psychology. Not only neuropathic pain, among others. The IASP also pro-
is the psychologist’s expertise in the identification of motes and administers Chronic Pain Fellowship pro-
appropriate patients valuable for the success of thera- grams for deserving candidates all over the world.
peutic procedural interventions in the management
of pain, but his or her expertise is helpful in identify- The American Pain Society
ing patients who are not appropriate candidates for
procedural interventions. Thus, psychologists have Spurred by a burgeoning public interest in pain man-
contributed positively toward the cost-effectiveness agement and research as well as the formation of the
and usefulness of diagnostic and therapeutic pain Eastern and Western USA Chapters of the IASP, the
medicine. American Pain Society (APS) was formed in 1977 as
a result of a meeting of the Ad Hoc Advisory Com-
PAIN AND PAIN INSTITUTIONS mittee on the Formation of a National Pain Organiza-
tion. The need for a national organization of pain
The International Association for the Study of Pain professionals was realized as growth of the IASP con-
tinued. The APS became the first national chapter of
The IASP is the largest multidisciplinary international the IASP, and has constituent regional and state
association in the field of pain. Founded in 1973 chapters. The APS has its own journal, The Journal of
by John J. Bonica, MD, the IASP is a nonprofit Pain, and holds national meetings. Its main function
professional organization dedicated to furthering is to carry out the mission of the IASP on a national
research on pain and improving the care of patients level.
experiencing pain. Membership is open to scientists,
physicians, dentists, psychologists, nurses, physical Commission on the Accreditation of
therapists, and other health professionals actively Rehabilitation Facilities
engaged in pain, and to those who have special inter-
est in the diagnosis and treatment of pain. The IASP As pain clinics developed, it became clear that there
has members in more than 100 national chapters. was a need for credentialing, not only of pain centers
The goals and objectives of IASP are to foster and and pain clinics, but also of pain clinicians. In 1983,
encourage research of pain mechanisms and pain the Commission on Accreditation of Rehabilitation
syndromes, and to help improve the management of Facilities (CARF) was the first to offer a system of
patients with acute and chronic pain by bringing accreditation for pain clinics and pain treatment
together scientists, physicians, and other health pro- centers. The CARF model was based on the rehabilita-
fessionals of various disciplines and backgrounds tion system, and it quickly became clear that the
who have interest in pain research and management. orientation of CARF would be physical and psycho-
The goals of the IASP also include mandates to social rehabilitation of patients suffering pain in con-
promote education and training in the field of pain, trast to modality treatment to reduce pain sensation.
as well as to promote and facilitate the dissemination CARF standards mandated that multidisciplinary
of new information in the field of pain. One of the pain management programs offer medical, psycho-
instruments of dissemination is sponsorship of the logic, and physical therapy modalities for pain man-
journal Pain. In addition, the IASP promotes and agement. Pain clinicians were not accredited by
sponsors a highly successful triennial World Con- CARF, and it quickly became apparent that one could
gress as well as other meetings. IASP encourages the have an accredited pain center without having
development of national chapters for the national accredited pain clinicians. The CARF model gained
implementation of the international mission of the modest acceptance among insurance carriers and
IASP. The IASP also encourages the adoption of a third-party payers, primarily because of its emphasis
uniform classification, nomenclature, and definition on accountability and program evaluation. Its major
regarding pain and pain syndromes. The develop- goals included such objective measures as increased
ment of a uniform records system in regard to infor- physical function, reduced medication intake, and
mation relating to pain mechanisms, syndromes, and return-to-work issues.
management is also a stated goal of the IASP, and
education of the general public to the results and The American Academy of Pain Medicine
implications of current pain research is another
mission of the IASP. As CARF gained prominence, many pain clinicians
The IASP has partnered with the World Health realized that neither CARF nor the APS completely
Organization (WHO) in providing guidelines for met their practice and professional needs. Further-

7. The History of Pain Medicine 9
more, it became obvious that there was a major defi- for eligible physicians. Among the many criteria,
ciency in evaluating the competence of pain the minimum criterion is that candidates be ABMS
physicians, in that there were no uniform standards board-certified in their primary specialty.
for training and credentialing of these pain clini- 3. The establishment of The Clinical Journal of Pain,
cians. Thus in 1983, at a meeting of the APS in which initially served as the official journal of
Washington, DC, a group of physicians (of whom AAPM and has now been replaced with the journal
chapter author Winston Parris was privileged to be a Pain Medicine.
member) formed the American Academy of Algology Additional goals include an attempt to establish
(the term algology is derived from the word algos uniform practice parameters and outcome measures
[Greek for “pain”], and logos [Greek for “study”]). The for different pain modalities.
name was changed 2 years later to the American
Academy of Pain Medicine (AAPM), a name that is The American Board of Pain Medicine
more acceptable in mainstream medicine.
This academy was formed to meet the needs and The ABPM is the examination division of the AAPM,
aspirations of pain physicians in the United States. Its which serves the public by improving the quality of
major focus was to address the specific concerns of pain medicine through certification of pain special-
pain physicians and to enhance, authenticate, develop, ists. It evaluates candidates who voluntarily appear
and lead to the credentialing of pain medicine special- for examination after a credentialing process and cer-
ists. As a medical specialty society, the academy is tifies them as diplomates in pain medicine if they suc-
involved in education, training, advocacy, and cessfully pass the examination process. This mission
research in the specialty of pain medicine. The prac- serves the public by helping ensure that the physi-
tice of pain medicine is multidisciplinary in approach, cians passing the examination have an approved
incorporating modalities from various specialties to level of expertise and currency of knowledge in pain
ensure the comprehensive evaluation and treatment medicine. More than 2000 physicians have become
of the pain patient. AAPM represents the diverse scope diplomates of the ABPM.
of the field through membership from a variety of
origins, including such specialties as anesthesiology, The American Society of Regional Anesthesia
internal medicine, neurology, neurologic surgery, and Pain Medicine
orthopedic surgery, physiatry, and psychiatry. The
goals of the AAPM include the promotion of quality The American Society of Regional Anesthesia (ASRA)
care of both patients experiencing pain as a symptom is the preeminent society on regional anesthesia. The
of a disease and patients with the primary disease of society is based in the United States; other societies
pain through research, education, and advocacy, and on regional anesthesia are based in Europe, Asia, and
the advancement of the specialty of pain medicine. Latin America. Cognizant of the fact that anesthe-
As we enter the managed care era, it is clear that siologists comprise the majority of pain medicine
issues such as reimbursement, contract negotiations, practitioners and interventional pain physicians and
fee scheduling, practice management, mergers, acqui- perform translational and clinical research, the ASRA
sitions, and other business-related matters are becom- started another annual meeting dealing exclusively
ing increasingly important to pain practitioners. The with pain medicine. The annual meeting of the ASRA
political and business arms of the American Academy that deals with regional anesthesia is held in the
of Pain Medicine are becoming instrumental in spring, whereas their annual meeting on pain medi-
helping guide physicians through the murky waters cine is held in the fall. To better fulfill its mission,
of managed care and pain medicine. the ASRA has changed its name to the American
In an attempt to provide creditable credentialing Society of Regional Anesthesia and Pain Medicine
in pain medicine, the AAPM sponsored the American and the name of their highly cited journal, Regional
College of Pain Medicine (ACPM), which organized, Anesthesia, to Regional Anesthesia and Pain Medicine.
developed, and administered the first credentialing The journal is the official publication of the
examination in 1992. Successful candidates received American, European, Asian and Oceanic, and Latin
the Fellowship of the American College of Pain Medi- American Societies of Regional Anesthesia.
cine. In the process of attempting to receive recogni-
tion of the American Board of Medical Specialties The American Society of Interventional
(ABMS), the name was changed on the recommenda- Pain Physicians
tion of the ABMS to the American Board of Pain
Medicine (ABPM). The American Society of Interventional Pain Physi-
Since the development of AAPM, most of the orga- cians (ASIPP) is a national organization representing
nization’s goals have been met: the interests of interventional pain physicians in the
1. The successful lobbying for a seat for pain medicine United States. The society was founded in 1998 by
in the House of Delegates of the American Medical Dr. Laxmaiah Manchikanti and associates for the
Association (AMA). purpose of improving the delivery of interventional
2. The successful establishment of a credentialing pain management services to patients across the
body, the American Board of Pain Medicine United States, whether in hospitals, ambulatory sur-
(formerly the American College of Pain Medicine), gical centers, or medical offices. The ASIPP has an
which offers annual credentialing examinations active political action committee, which has been

8. 10 General Considerations
instrumental in achieving numerous legislative vic- ship and an online University of Integrated Studies
tories benefiting its constituents and their patients. that offers graduate-level online courses for health
The goals of the ASIPP include the preservation practitioners. In addition, there are various levels of
of insurance coverage, coverage for interventional pain credentialing available depending on the level
pain procedures, the advancement of patient safety, of education of the student/practitioner.
advancement of cost-effectiveness, and establish-
ment of accountability in the performance of inter- American Society for Pain Management Nursing
ventional procedures. Also included in the goals of
the ASIPP are the pursuit of excellence in education Founded in 1990, the American Society for Pain
in interventional pain management, the improve- Management Nursing (ASPMN) is an organization of
ment of practice management, the enhancement of professional nurses dedicated to promoting and pro-
regulatory compliance, and the elimination of fraud viding optimal care of individuals with pain through
and abuse. The ASIPP journal is indexed and called education, standards, advocacy, and research. Their
Pain Physician. goals include providing access to specialized care for
patients experiencing pain, providing education of
The American Academy of Hospice and the public regarding self-advocacy for their pain
Palliative Medicine needs, and providing a network for nurses working
in the pain management field. This society also spon-
The American Academy of Hospice and Palliative sors educational conferences and is formulating a
Medicine (AAHPM) was founded in 1988 to advance means of adding compensational value to the spe-
the specialty of hospice medicine in the United cialty of pain management nursing.
States. The academy’s goals include providing educa-
tion and clinical practice standards, fostering research, The National Headache Foundation
facilitating personal and professional development,
and sponsoring public policy advocacy for the termi- Founded in 1970, the National Headache Foundation
nally ill and their families. The academy’s philoso- (NHF) works to create an environment in which
phy includes the belief that the proper role of the headaches are viewed as a legitimate health problem.
physician is to help the sick, even when cure is not The foundation’s goals include the promotion of
possible. In addition, the academy aims to help research into the causes and treatment of headache,
patients achieve an appropriate and easy passage to and the education of the public regarding the legiti-
death as one of the most important and rewarding macy of headaches as a biologic disease.
services that a physician can provide. The academy
endorses the philosophy that the medical profession The World Institute of Pain
should attend to all the needs of the dying patient
and family, and should encourage and promote The World Institute of Pain (WIP) is an international
patient autonomy. organization that aims to promote the best practice
of pain medicine throughout the world. Its goals are
The American Academy of Orofacial Pain to educate and train personnel of member pain
centers by the utilization of local hands-on training
The American Academy of Orofacial Pain (AAOP) is international seminars and exchange of clinicians.
an organization of health care professionals dedi- Updating member pain centers with state-of-the-art
cated to the alleviation of pain and suffering through pain information via newsletters, scientific seminars,
education, research, and patient care in the field of and journal and book publications are additional
orofacial pain and associated disorders. Goals of the goals. One of the most important goals of WIP is to
AAOP include the establishment of acceptable crite- develop an international examination process for
ria for the diagnosis and treatment of orofacial pain testing and certifying qualified interventional pain
and temporomandibular disorders, sponsorship of physicians. Showing proficiency in both general pain
annual meetings and a medical journal, and en- knowledge and the safe performance of interven-
couragement for the study of orofacial pain and tional procedures, the successful candidates are
tempo-romandibular disorders at undergraduate and awarded the designation of fellow of interventional
postgraduate levels of dental education. pain practice (FIPP). The journal of the WIP, Pain
Practice, is indexed.
The American Academy of Pain Management
The World Society of Pain Clinicians
The American Academy of Pain Management (AAP
Management), founded in 1988, is an inclusive inter- The World Society of Pain Clinicians (WSPC) is an
disciplinary organization serving clinicians who treat international organization whose goals are to bring
people with pain through advocacy and education, together clinicians with a common interest in the
and by setting standards of care. The AAP Manage- treatment of pain. Also, the goals are to stimulate
ment is open to a diverse group of pain clinicians, education and learning in the field of pain, and to
and emphasizes inclusivity of all health care special- encourage the dissemination of information on pain
ties. The organization boasts a large, diverse member- throughout the world. The WSPC also endorses and

9. The History of Pain Medicine 11
encourages the audit and scientific research on all PAIN AND THE HOSPICE MOVEMENT
aspects of pain, especially treatment. The WSPC
sponsors a biannual international congress of clinical Hospice is a medieval term representing a welcome
aspects of pain and has its own journal, Pain Clinic. place of rest for pilgrims to the Holy Land. The concept
of hospice dates back to the reign of Emperor Julian
The International Spine Interventional Society the Apostate when Fabiola, a Roman matron, created
a place for sick and healthy travelers and cared for
The International Spine Interventional Society (ISIS) the dying.40 Hospitals in general were regarded as
is a society of physicians interested in the develop- Christian institutions, and in medieval times, most
ment, implementation, and standardization of per- hospitals were used as hospices and vice versa.41
cutaneous techniques for precision diagnosis of During the 11th century, several hospices were
spinal pain. The organization sponsors forums for based in and operated by monasteries. The 17th
exchange of ideas, encourages research undertaking, century Catholic priest St. Vincent DePaul founded
and holds public lectures. The mission of ISIS includes the Sisters of Charity in Paris as a home for the poor,
the consolidation of developments in diagnostic the sick, and the dying. St. Vincent DePaul’s work for
needle procedures, the identification and resolution the poor and the sick created a significant impact not
of controversies, the public dissemination of devel- only on the Catholic Church but also on other con-
opments, and the recommendation of standards of temporary religions. The Protestant pastor Fliedner
practice based on scientific data. was so influenced that he founded Kaiserwerth 100
years later. Nuns from the Sisters of Charity and
The International Neuromodulation Society Kaiserwerth accompanied Florence Nightingale to
Crimea to care for wounded soldiers and other citi-
Founded in 1989, the International Neuromodula- zens who were either sick or dying.42
tion Society (INS) is a multidisciplinary international In 1902, the Irish Sisters of Charity founded St.
society promoting therapeutic neuromodulation at a Joseph’s Hospice, staffed by Cecily Saunders 50 years
clinical and scientific level. The primary means of later. Dr. Saunders was the first full-time hospice
exchanging knowledge consist of regular scientific medical officer, and she was regarded as the founder
meetings and the journal Neuromodulation. The first and medical director of St. Christopher’s Hospice in
national chapter of the INS was the American Neu- England. She was initially trained as a nurse and
romodulation Society. served in the Second World War. After she became
injured, she received training as a medical social
worker. She subsequently developed a keen interest
American Pain Foundation
in terminal cancer patients and underwent training
in medical school to become a physician. She empha-
Founded in 1997 by three past presidents of the APS,
sized the importance of taking the patient at his or
the American Pain Foundation (APF) is an indepen-
her word during pain assessment and scheduling the
dent, nonprofit, grassroots organization serving
dosing of opioids on a time-contingent basis as com-
people with pain through information, advocacy,
pared to an as-needed dosing schedule. She also
and support. Its goals include serving as an informa-
advocated the need for frequent pain assessments so
tion clearinghouse for people with pain, promoting
as to effectively manage cancer patients’ pain. In
recognition of pain as a critical health issue, and
addition, she sought to convince the medical com-
advocating for changes in professional training regu-
munity that it was totally unnecessary and inhu-
latory policies and health care delivery systems to
mane for cancer patients to die in pain.43 For all her
ensure that people with pain have access to proper
efforts and leadership, she is regarded as the “mother
medical care. The APF was the first pain organization
of palliative care” and was knighted for her contribu-
specifically formed to serve the interests of people
tions to the hospice movement and the care of the
experiencing pain associated with diverse disorders
dying cancer patient. Dame Saunders’ views and
associated with the presence of significant pain.
works are widely taught in medical and nursing
schools today and form the basis of palliative care.
The National Pain Foundation
Founded in 1998, the National Pain Foundation PAIN AND THE FUTURE
(NPF) seeks to advance the recovery of persons in
pain through education, information, and support. Pain medicine has come a long way. A review of the
The NPF empowers patients by helping them become history of pain demonstrates that until the time of
actively involved in the design of their treatment Bonica, pain management was considered to be uni-
plan. The organization’s website has interactive fea- modal, unidisciplinary, and largely managed haphaz-
tures that encourage patients to identify the informa- ardly and without any clear structural organization.
tion that they need to manage their pain in the most Today, new drugs, innovative techniques, and cre-
understandable way. The NPF strives to fill the gap ative procedures have expanded the scope of pain
in the understanding, awareness, and accessibility of medicine. In addition, new research is contributing
pain treatment options. daily to modern concepts of pain and its manage-

10. 12 General Considerations
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the development of pain medicine. Wilkins, 1949.
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