History of Pain Management:
from Specificity to Pain as a
Brain Disease
Steven Stanos, DO
Chewed, imbibed, sucked:
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Crocodile dung
Teeth of swine
Hooves of asses
Spermatic fluid of frog
Fly specks
Oil derived from ants, earthworms, and
spiders
• Human perspiration
Shapiro, A. 1963
Anesthesia
Pain Theory
Renee Descarte
1596-1650
Charles Bell
Johannes Muller
• Elements of
Physiology (1842)
• Doctrine of Specific
Nerve Energies
(1843)
Pathways & Circuits
Specificity (von Frey)
Summation (Goldscheider)
Reverberating circuits (Livingston)
Sensory interaction (Noordenbos)
Pain and War: lessons learned
War & Injuries
“It was burning and darting. The
pain was so severe that a touch
anywhere, or shaking the bed, or
a heavy step, caused it to
increase.”
“Under such torments the temper
changes, the amiable grow
irritable, the soldier becomes a
coward, and the strongest man is
scarcely less nervous than the
most hysterical girl.”
Mitchell (1872)
Renee Leriche
Livingston
Livingston
Attaching “meaning” to pain
The BIOMEDICAL Model
• Pain as a
sensory event
reflecting
underlying
disease or
tissue damage
Psychodynamic Theories
• Deep rooted personality
conflicts
• Pain & underlying
emotional conflicts
• Freud: “pain” emotional
response to an actual
loss or injury
• “pain” as “mourning”
Willem Noordenbos
Noordenbos, W. Pain: Problems Pertaining to the Transmission of Nerve
Impulses Which Give Rise to Pain. Amsterdam: Elsevier, 1959.
“Convergence”
John Melzack, PhD
Patrick Wall, PhD
Gate Control Theory
Gate Control Theory
Melzack R. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of
Pain. 3rd ed. Philadelphia, Penn: Lippincott Williams & Wilkins; 1998.
Richard Sternbach, PhD
Learning theory
Personality, Individual
Differences
George Engel, MD
• “Psychogenic Pain and
the Pain-Prone Patient”
• “Pain” as a psychologic
function
Wilbert Fordyce
• Behavioral Methods for Chronic
Pain & Illness
• Operant conditioning
• “Pain behavior”
1. factors that maintain pain problem
can be different from those that
initiated it
2. pain behaviors subject to shift
from structural/ mechanical to
functional/ environmental control
John J Bonica, MD (1917-1994)
International Association for the Study
of Pain (IASP)
Issaquah, Washington - 1973
Pain Behavior
Suffering
Pain Perception
John Loeser, MD
Nociception
Cognitive Revolution: Dennis
Turk, PhD
• Attributions, efficacy,
expectations
• Personal control,
problem solving within
cognitive-behavioral
perspective
• BioPsychoSocial
approach
Biological
PAIN
Psychological
Social
ACCEPTANCE
Neuromatrix
Apkarian AV, et al. J of Neuroscience, 24(46), 2004.
Pain Neuromatrix
• Pain is a brain disease.
• Current imaging techniques important in further
understanding complexities of multidimensional
pain experience and suffering.
• Opioids and placebo networks
• Active physical therapy and cognitive-behavioral
techniques may help reverse cortical changes
related to chronic pain states.
Pharmacology of Pain
• NSAIDs
– Dioscorides (40-90 A.D)
– Willow tree
• Tricyclic antidepressants
– ’50s: Isonoiazid for TB
– ’56: (Kuhn) and antipsychotic to imipramine
• Gabapentinoids
– ’95 (Mellick and Mellick)
– RSD related pain
search for “safer” opioids
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18th Century: Orient
1806 “morphine” isolated
1898: Bayer, heroin
1912: Hague Opium Conference
1914: Harrison Narcotic Act
Drug Delivery Advancements
Felix Hoffmann
“nostrums”
“Nostrums”
Patent medicines
“jobbers”
Tinctures
Paregoric
1900s - US public
spends $59 million
annually
Weight
Loss
Early Drug Regulation
1820
1847
1848
1906
1914
1938
1965
1970
1997
US Pharmacopeia established
American Medical Association
Drug Importation Act
Food and Drugs Act
Harrison Narcotic Act
Federal Food, Drug, and Cosmetic
Act
Drug Abuse Control Amendments
1st Package insert – oral
contraceptive
FDA Modernization Act
New Formulations
BioJobBogger, Nov.18, 2009.
FDA: Looming Issues
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FDA Amendments Act (FDAA) (March 2008)
Risk Evaluation & Mitigation Strategies (REMS) for CII opioids
Applicants submit REMS to ensure benefits outweigh risks
A. Health care providers have training or experience
B. Dispensers specially certified
C. Drug dispensed in certain settings with evidence of safe use
D. Patients subject to monitoring and registry
FDA scrutiny of internet advertising
Propoxyphene: FDA Advisory Committee (Jan.’09):14-12 in
support of removing from market, July ‘09: black box warnning
REMS proposal voted down by FDA July 2010