History of Pain Management from Specificity to Pain

History of Pain Management: from Specificity to Pain as a Brain Disease Steven Stanos, DO

Chewed, imbibed, sucked: • • • 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, W. Pain: Problems Pertaining to the Transmission of Nerve Impulses Which Give Rise to Pain. Amsterdam: Elsevier, 1959.

“Convergence” John Melzack, Ph. D Patrick Wall, Ph. D

Gate Control Theory

Gate Control Theory Melzack R. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. 3 rd ed. Philadelphia, Penn: Lippincott Williams & Wilkins; 1998.

Richard Sternbach, Ph. D 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 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, Ph. D • Attributions, efficacy, expectations • Personal control, problem solving within cognitive-behavioral perspective • Bio. Psycho. Social 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 – ’ 50 s: Isonoiazid for TB – ’ 56: (Kuhn) and antipsychotic to imipramine • Gabapentinoids – ’ 95 (Mellick and Mellick) – RSD related pain

search for “safer” opioids Ø Ø Ø 18 th 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 1900 s - 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 1 st Package insert – oral contraceptive FDA Modernization Act

New Formulations Bio. Job. Bogger, Nov. 18, 2009.

FDA: Looming Issues • • • 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