Carl Edward Noe (editor) - Pain Management for Clinicians: A Guide to Assessment and Treatment

Divinum est opus sedare dolorem

(Divine is the work to subdue pain).

Hippocrates

Pain is an essential part of human life. Through unpleasant experiences, we learn to avoid sharp objects and fear the flames of fire. It is the great teacher that tutors us to avoid emotional harm and physical injury. We cannot learn without pain, Aristotle once wrote. When pain leads to suffering, it ceases to be a teacher and becomes the oldest medical malady. The early twentieth century saw pain evolve from being an inevitable consequence of aging or a religious cleansing of the soul to the subject of scientific study in medicine, supported by academic research, education, and interventions. The struggle to establish pain as an independent specialty came from the challenge of recognizing pain as more than a symptom and the difficulty in defining pain itself. In 1986, the International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. At the same time, the IASP also defined chronic pain as pain that lasts beyond the normal healing time for a given injury, operationalized as pain lasting >3 months. These definitions helped to unify a newly formed field of medicine built upon the early work of Dr. John Bonica, widely regarded as the father of pain management, and his dream of creating multidisciplinary pain management programs for patients. Along with Dr. Bonica in Seattle, the Department of Anesthesia at the University of Texas Southwestern was one of the early institutions to incorporate pain management into the scope of anesthesia and provide a foundation for pain research and treatment. This led to the fundamental work of Dr. Prithvi Raj and Dr. Carl Noe, pioneers in acute regional anesthesia and chronic pain, respectively. Both would go on to be founding members of the Texas Pain Society.

In the late twentieth century, pain was identified as the fifth vital sign after an initiative by the American Pain Society to raise awareness of pain assessment and management. This was followed by mandates from regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requiring the assessment and treatment of pain in all patients. With a distinct body of knowledge, dedicated and focused research, and influential institutional practices and guidelines, pain management has established itself alongside other medical specialties.

Today, over 100 million Americans suffer from chronic pain, with the economic cost related to both healthcare and lost productivity ranging from $560 to 635 billion dollars annually in the United States. Pain remains the most feared symptom for patients, having significant medical, social, psychological, and financial consequences. Even among clinicians, the treatment of pain can be a complex and arduous duty that leaves practitioners feeling helpless and hopeless. For pain practitioners, the fear of addiction dangles like the sword of Damocles, but has not prevented a tendency toward overreliance on opioids. Currently, the United States consumes 80% of the worlds opioids with prescription numbers quadrupling in the past decade. This practice has fueled both a prescription culture and a crisis. Renewed scrutiny over such practices has led to greater research into non-opioid pharmacotherapy and education on safer opioid prescribing practices. It is our hope that the current emphasis on opioid alternatives will portend the start of the post-opioid years for pain management.

Looking forward, tremendous advances in the prevention, detection, and treatment of pain in patients are on the horizon. Scientific advances continue to unravel the mysteries of pain through advanced neuroimaging, molecular cell biology, and discoveries in the genetics of pain. Such advances will offer innovative and improved interventions for the early diagnosis and treatment of pain. This, coupled with the growth of multidisciplinary treatment teams, patient-centered care, and exciting translational research, will yield the greatest reduction in the burden of chronic pain on patients in the decades to come. It is our hope that this work will, in some way, assist in shaping a new era in pain management.