Evolution and current status of pain programs

368 &wna4

ofPain aml SymptomMnnagmmt

Vol. 5 No. 6 DecemberIWO

Evolution and Current Status of Pain Programs John J. &mica, MD Univers&yof W&&@m, Se&L, Washington

During the past ~ua~er~entu~, very imand far-reaching advances have been made in pain research and pain treatment. One of the most important developments has been the proliferation of MuItidiscipIinarylInte~i~iplinary Pain CIinic~C~nte~ (MIPC)and of hospices- two developments that Melzack and Wail1 have called the most important advances in patient care.’ This review provides a cx,mciseand very brief discussion of the evolution, development, and current status of pain clinics/centers,including a summaryof two new directories of such facilities published in 1989.pa The material is presented in three parts: (1) the genesis of the concept of the multi~~pIin~/inte~i~ip~~~ programs for pain diagnosis and treatment and their status during the early period, (2) the period of growth including a summary of the directories published in 1977and 1979, and (3) the current status that inch&es es~mates by variousauthorities and a concise summary of the data in the directorypublished by the AmericanPain !Society (APS) in conjunction with the American Academy of Pain Medicine (AAPM)sand the one pu~ish~ by the Oryx Press,l This will be followed by evaluation of both of these documents. Moredetailed discussion of these issues is found in the recently published second edition of my book, 7% Matqpment of Pain4 and other reviews.~~6 pressive

The genesis of the concept of the muitidisciplmarylinterdisciplinary approach to the diagAddbs repr& tsqucsrsto: John J. Bonica, MD, Department of Anesthesiology, Mail Shop RN-IO, University of W~on, Seattle, WA 98195. Q U.S. CanersFain Relief Commimx, 1990 f%lihed

by lllsevier, New York, New York

no& and t~atment of complex pain probIems occurred during and promptly after World War 11,and the concept was proposed independently by two anesthesio20gists,7*sBecause the chronology of the development of these facilities is not known to many young ~~olo~sts and in view of the confusion that exists among some authorities ~ga~ing the initiation of these programs, a brief summary is presented. The initial factors rksponsible for these developments go back four decades prior to World War II. During this period, the preeminence and widespread acceptance of the specificity theory of pain led to the development of two methods of pain control: the chemical and surgical interruption of “pain” pathways. The chemical interruption of nerve pathways, generally called nerve blocking or ueural blockade, was first developed to produce regional anesthesia (i.e., anestbesia limited to a region of the body without producing unc~sciousness} to obviate the disadvantages and dangers of general anesthesia for surgical operations. During the first four decades of the present century, techniques were devised to “block” virtually every nerve and the various plexuses in the body to permit operation on that part supplied by them. During this period. a number of physicians and surgeons in Germany, Austria, France, Italy, and the United States began to realize that these techniques couid be used as research tools and sub~uentIy applied them to the diagnosis and treatment of various painful conditions. The appIicatio% of paravertrbral somatic and sympathetic blocks were used to confirm in humans the earlier findings from animal experiments carried out by Sherrington and others and in humans by Head in the latter part of the 19th cenhmy, of the specific spinal segments that provide sensory nerves, to various viscera and somatic structures.g §u~uen~y, these

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Evolution and Status of Pain Programs

procedures were used widely, as diagnostic tools in the diagnosis of visceral painful disease and to help differentiate, e.g., epigastric pain caused by chol~ystitis or gastric lesions from that caused by disease of the thoracic viscera. Subseqently, blocks with local anesthetics -were also used as a therapeutic measure in the treatment of a variety of visceral painful diseases. Physicians and surg~ns also began to use blocks of various nerves with alcohol to provide prolonged interruption in the treatment of intractable angina pectoris, cancer pain, tuberculosis, and a variety of other chronic pain syndromes. These fed to publication of books on these subjects by Labat,lO Mandl,” Leriche,‘s and Livingston.ls It is to be noted that, with few exceptions, all of the cont~butjons on the use of nerve blocks for the diagnosis and. therapy of nonsurgical pain made prior to World War II were achieved by surgeons, internists, and other physicians who were not ~esthesiologists. The few excep tions were Woodbridge,r4 Ruth,t5 and Rovenstine and Wertheim,16 who during this period wrote classic review articles on the use of diagnostic and therapeutic blocks for the management of nonsurgical pain and other disorders. These articles encouraged a number of other anesthesiologists to apply diagnostic and therapeutic blocks to the management of patients with pain. As a result of this trend, and other factors, anesthesiologists took over from internists and surgeorts and other physicians the primary responsibility of administering these techniques. It was this trend that was responsible for my assignment to the task of treating military personnel with various pain problems at Madigan Army Hospital, Tacoma, Washington, soon after I entered military service in early 1944. The nforetnentioued books and articles made surgeons and neurologists aware of the value of diagnostic and therapeutic nerve blocks. Consequently, I was referred many patients with causalgia, reflex sympathetic dystrophy, painful phantom limb, and other postamputation pain syndromes, and obscure neurologic and musculoskeletal disorders. While I had acquired a broad experience in surgical anesthesia during my anesthesia training, I received no training in the application of nerve blocks for the management of nonsurgical pain. Therefore, to carry out my assigned task, I read the aforemen-

369

tioned books and reviews and all of the many articles cited in each of these. In applying nerve blocks, I noted that while some patients with causalgia and other straightforward pain problems responded to therapy, patients with complex pain problems did not. This prompted me to search the literature to acquire the necessary knowledge about the broad field of pain, especially chronic pain problems, and found that (a) there was little information about the treatment of chronic pain primarily because little research had been done; (b) other than the aforementioned books, the available knowledge was scattered in numerous basic and clinical science journals and books and, thus, accessible with difficulty to the average physician: and (cf that as a result of these factors, and because of lack of education in medical schools and training for specializations, I, like most other clinicians, did not know basic principles of managing patients with chronic pain. Despite my efforts to consult textbooks on medicine, neurology, neurosurgery, orthopedics, and other disciplines, I continued to experience great frustrations in trying to manage patients with many of the complex pain problems by myself. Consequently, I sought consultation of colleagues in neurology, neurosurgery, orthopedics, psychiatry, and other specialties in the usual n~a~~nerinherent in traditional medical practice. Thus, if I wished to have a iGent with a complex pain problem seen in consultation by an ortimpedist, neurologist, and psychiatrist, each of these individu~s would evaluate the patient in hi office or the patient’s ward and then report his findings to me by telephone and/or writing on the patient’s chart. After the patients had been seen by ail consultants, I attempted to read the evaluation of each consultant and formulate a correct diagnosis and develop the best therapy. It soon became apparent to me that these types of consultation in the isolation of each cons&ant’s oflice or the ward were very slow and ine~cient and prompted me to have frequent face-to-face meetings with the various specialists with interest and expertise in dealing with complex problems, After several months’ experience, it became apparent that the team approach to managing patients with complex pain problems was more efficient and more effective than traditional medical practice, As far as is known

and other sources of information, this was the first time that the multidisciplinary/interdisciplinary approach to pain diagnosis and treatment was conceived and practiced. These early experiences prompted me to begin a @sterna&zclinical study of pain syndromes and their treatment and to become deeply convinced that “co@&+z @in p&?as GouidBer)lorsff~~~ve~ && @ c1rn~~~c~pljn~~~~ t&m, Mch ~~ ig ~~~ w@#&c*te hisk SpsEirJixsdk@owledgtad SAiurto rhdcommongod of making a CDII~E~ diagnosk in &v@i~ srha mostdfectiw theropsldtic stnxb gy.” These early ex~~ences also led to the deep conviction that much more researchneeded to be done on basic mechanisms and pathophysiology of pain and that solution of important pain synd~mes similarly required a rnulti~~i~in~/inte~i~i~na~ effort by a team of scientists and clinicians who contributed their individualiied expertise and skills to such studies. Promptlyafter the war, I put the concept of a multidisciplinaryfacility for the diagnosis and therapy of complex pain problems into pmctice in Tacoma General Hospital, Tacoma, Washington. The group consisted of an anesthesiolo@, neuron, o~ho~st, psychiat~st~ and radiation therapist, all of whom had special interest and expertise in pain. Despite numerous problems inherent in individual private practice, for 15 years the group was su~ces~ul in its objectives and goal-a fact that further strengthened my conviction of the value of the multidisciplinaryapproach. After the war, I had personal discussions with Dr. Wan IL Livingstone, who several years earlier had published his excellent book and whose cliuical research on pain and conceptualization of pain mechanisms madct him one of thii century*s giants in this field. I also communicated with a number of other aneschesiologists who were using diagnostic and therapeutic nerve blocks. In 1949, I had the good fortune to meet another ~e~esio~st, the late F. A, Duncan Alexander, who, unlike others in this specialty,had a broad view of pain and its management.“’ Dr. Alexander had independently developed the same mncept, and in 194‘7h&iated a multi~p~ pain optic and therapeutic program at the Veterans Administration Hospital in McKinney, Texas.6 During bm

&e literature

this early postwar period, a number of other anes~esiolo~s~ organized and ran “pain clinics.” Although some of these programs also involved other physicians as ad hoc consultants, the primary method of diagnosis and therapy consisted of various nerve block procedures, which at the time were the only nonsurgica1 treatment methods besides drugs for pain control. These included programs in the United States, Britain, Canada, Italy, and a number of other countries (see Bonica4 for other references). During the 195Os, there were many “pain clinics,” but only three were really multidisciplinary/interdisciplinary facilities. In addition to the one in Tacoma and the one directed by Alexander in Texas, there was one at the Univerity of Oregon in Portland, directed by Livingstone, that included anesthesiologists and other clinicians and basic and clinical investigators. It is of historical interest to note that although Alexandera and my colleagues and 15-7*18*1g have reported the early chronology of the development of the multidisciplinary pain pans, Crue’““-4*and other write&s have insisted on stating that these types of programs really began in the 1960s. The favorable experiences with these types of programs prompted me, in the early 195Os,to begin espousing the multidisciplinary concept in numerous lectures and published articles, first in various parts of the United States, and beginning in 1954, in other parts of the world. During this period, Alexander also p~mulgated the multidisciplinary concept, but, unfortunately, because of personal illness, he discontinued these efforts by the mid-1950s. Promptly after my ap~intment as chairman of the then newly created Department of Anesthesiology at the University of Washington (VW) in 1960, I set up a multidisciplinarylinterdisciplinary pain program, which over the next decade evolved into a group of 20 persons from 14 different medical disciplines and other health professions. At about the same time, Dr. Benjamin Crue and his associates also initiated a rnulti~~ip~na~ pain program at the City of Hope Medical Center in Duarte, California.*2 Despite my persistent drum heating, consisting of several hundred lectures and the publication of numerous articles in various parts of the world, the rn~tidi~ip~m~ concept was ignored by the medical profession for two decades.

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Evolution and Status of Pain Programs

Growth

Fortunately, in the late 1966s and early 197Os, a number of factors converged to cause an increasing number of other clinicians to put the concept into practice. These included the publication of the Melzack-Wall theory of paint* and the immerse worldwide curiosity about the m~hanism and efficacy of acupuncture as a method of pain therapy and for surgical anesthesia. Another equally important development was the of the founding International Association for the Study of Fain {IASP) in I974 and the publication of itsJournal P& a year later. These and other factors have provoked an impressive surge in pain research that produced much new information and added a new dimension to our understaI~~ng of chronic pain and its treatment. The advances in new knowledge, in ~~~nn~rn.tnication, and in transmission of new information and other factors (see Bonicae for details), have prompted the development of an ever increasing number of pain management facilities. During the 197Os, the proliferation of such facilities was so rapid as to prompt one medical writer to refer to it as “medicine’s new growth industry.“*” Because many of these facilities have been directed by anesthesiologists, the American Society of Anesthesiologists (A§A), through its Committee on Pain Therapy, carried out d survey on such facilities in coilaboration with the IASP and subsequently published the Dirwtary of Pair&Cl&&s in 1977.26 Soon after it was published, as a member of the committee, I undertow the task of auaiyzing the report, which hfa*ed a total of 327 pain cbnits. In collaboration with my colleague, Dr. Stephen Butler, we carefully reviewed the data. After studying the characteristics of each program, including the different number of specialties involved, the number and varieties of diagnostic and therapeutic methods used, and the number of pain syndromes treated, we arbitrarily classified pain programs into the following categories: (a) major comprehensive multidisciplinary, which included more than six disciplines and could manage various types of pain syndromes and carry out education and research programs, usually within a university; (b) comprehensive multidisciplinary program, which had at least four to six disciplines and other characteristics of the first type; (c) small

371

multidisciplinary, which included two to three disciplines; (d) syndrome oriented, specialized in the management of patients with a particular pain syndrome such as headache, back pain, etc.; and (e) modality oriented, which used a single modality such as nerve blocks, acupuncture, biofeedback, etc. Of the 327 facilities, 73% were located in the United States, 13% in Europe, 8% in Asia, 4% in Canada, and the remainder in South America, Australia, and New Zealand. Detailed analysis ol’ the data revealed that 13% belonged to category I, 26% in category II, 34% to cate~ry ID, 2f% to category IV, and 16% to category V. subsequently, I recommended to the A!jA com~amitteethat they adopt the aforementioned classification and also sug gested the term @i&c be used for outpatient facilities and the term CR&Tfor pro~ams with inpatient and outpatient facilities and education and research programs. In 19?9, the ASA Committee carried out a second survey and s~bseq~en$Iy published the ~nt~~ti~al Directmy of Pa.h C~~~si~l~ni~s,2~ which included the classification of these into four types: (a) major comprehensive pain center, (b) comprehensive pain center, (c) syndrome oriented pain center/clinic, and (d) modality oriented pain center/clinic. Subsequently, Brena2s analyzed data in this directory that listed 428 facilities. Table 1 summarizes the findings.

In the recent past, some writers have suggested estimates on the number of pain programs in the United States and worldwide. Aronoff and colleagues2g and Aronoff and Wagner” have suggested there are about 1,000 multidisciplinary facilities in the United States and cite one writer who reported 17 such facilities in Europe. Making the uncertain assumption that the evolution and growth of these facilities have been similar to that prior to 1979. I have ro~&l? estimated that there are betwe :n 1,800 and 2,000 pain facilities in some 36 countries. Of these, 800-1,000 are in the ‘Jnited States, ZOO-225 in Britain, an equal number in Western Europe, 75 in Canada, 80 in Asia-Austraha, am! the remaining countries have between 2 and 26facifities. I have also roughly estimated that of these, there are 150-200 major comprehensive pain centers, 500-550 comprehensive pain centers, 8004350 ~l~ality-o~ented pro-

Journal of Pain and Synptom Management

Bonica

372

Table 1 Distribution of Clinical Models and Medical Specialties in Pain Control Facilities

Asia Major comprehensive pain centers Comprehensive pain centers Modality-oriented Pain clinics Syndrome-oriented pain clinics Total

Australia. New Zealand

Canada

Europe

Total

Latin America

United States

No.

%*

1

1

1

6

0

41

50

12

10

7

9

17

1

78

122

28

13

2

13

40

1

97

166

39

6

1

4

16

1

62

90

21

SO

11

27

79

3

278

428

100

7 1 0 1 0 1 0 1

11 1 0 2 2

96

31 8 9 7

166 41 9 12 10

49 12

x 4

35 6 1 0 0 0 3 13

:: 18

:: 37

: 3 5 13 11

11

25

58

218

336

lioc

Department with primary responsibility 14 Anesthesiology 2 N~rosurgery 0 Orthopedic surgery 0 Psychiatry 1 Psychology 1 Oral surgery RehahilitaGon medicine 2 1 Other 21 Total

*Percent figures have been rounded to nearest unit. Data based on the renort bv Brena SF: Pain control facilities: patterns of operation und problems of organization in the USA. Clm Anes;hesiol’l985;3: 183.

grams, and 300-400 syndrome-oriented programs. Because these were pure guesses based on data provided me by various persons and were therefore very “soft,” I had looked forward to the publicationof the two directoriesin 1989.5” I have carefully studied these two directories with the intent of analyzing the data and categorizing the facilitiesas was done for the 1977 and 1979 directories. Unfortunately, this was not possible for reasons that are mentioned later. While both contain very important and rather comprehensive information, neither includes all of the pain programs. Thus, the number of facilities in the Oryx directq totaled 451 in 47 states in the United States and 46 in eight provinces of Canada, while the APS-AAPM directory lists 236 programs in 39 states in the United States and, as might be expected, does not include facilities in Canada. The Oryx directory lists facilities in Alabama, Delaware, Hawaii, Montana, Rhode Island, and Utah, where none are listed in these states in the AI%-AAPM document. Marked discrepancies regarding the numbers exist in the other 35 states that are included in both directories, and

this is shown in Table 2. Other differences be-

tween the directories are mentioned below in the description of each of these directories. f3yx Directory The directory was compiled from questionnaires mailed to members of the IASP, entries in the &in CenterDirectories of the ASA, a list caf chronic pain propams from the Commissinrl

Table 2

Comparisonof Pain Progmms Listed in Two Directories State

oryx

APS-AAPM

Arizona California Florida Illinois Kansas Michigan Missouri New Jersey New York Ohio Pennsylvania Washington

7 68 21 19 2 11 11 15 34 21 24 12

2 33 13 11 5 6 2 9 15 7 14 7

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of Accreditation of Rehabilitation Facilities (CARF), and other sources. The survey was carried out during the period of April 1988 through February 1989. The information for each facility is listed under three profiles. The yh~ojil~ ofpain centersis presented in alphabetical geographical order by state and city, followed by the provinces and cities of Canada. Within each city, the centers are alphabetized and contain the name, address, and phone number of the facility, along with the year when the center was established and its affiliation or parent organization and accreditation by CARF and/or the Joint CommkGon on the Accreditation of Hospitals (JCAH), rbe medical director, administ~tive director, p~in~i~~l practitioners, incll~ding degree, year, sp~~alty, and certification, and the mention of full-time and part-time stati and their discipline. The program pro$idebriefly characterizes the referral policy, pain syndrome managed, the evaluation and screening procedures, and the treatment modalities available. T~~~~~ p$~~~e describes the general policies of the facility, including what types of financial coverage are accepted, the type of facility (whether outpatient or combined inpatient and outpatient), how many beds are available, and the primary treatment area (out~tient or outpatient and inpatient combined). This section also includes irtformation regarding research and training at rhe facility. Finally, comments describe the unique features of the center, the facilities, philosophy and goals, and/or physical setting. Following description of the pain center are three indexes, including an alphabeti~l Organization Name Index; a Symptom Index, also in alphabetical order, listing the facilities that treat various acute and chronic pain syndromes; and a Treatment Procedure Index that includes a listing of the facilities that use various theriapeutic m~lities that are currently available. Study of the data suggests that most of the facilities manage patients as outpatients and, ?herefore, according to the aforementioned definition, should be considered as “clinics.” While most are listed as “comprehensive” programs, about 15% of the facilities are either syndrome-oriented or single-rn~~ity programs. This directory contains the most comprehensive information on the 477 facilities it lists. Unfortunately, most of the facilities do not indicate the number of full-time and part-time staff

and their disciplines, and, therefore, the facilities cannoz be categorized according to the aforementioned cl~si~catio~. L&k?? This directory contains much of the same information as the Oryx document and is presented in a sitnilar format, except that it is more concise. An implant difference is that specific numbers are given for full-time and part-time Staff. h’fOrmver, instead Of kiting p&t syndromes, it describes the population served br the program, the types of pain syndromes that are not treated (rejection criteria), and briefly mentions the psychologic services provided. It has no information on educational and/or research services provided. As in the Oryx document, this directory emphasizes that inclusion of programs should not be considered an endorsement of the quality of care offered by the listed registrants. In contrast to the Oryx directory, which is intended for use not only by the health professions, but also by lay people, this registry is intended sorely ;or internal use by members of the APS and AAPM.

This review briefly summarizes the evolution, development, and current status of various types of pain programs in the United States and other parts of the py~~h Iti. The recent marked increase in pain research has not only greatly enhanced our knowledge of sensory coding and sensory m~u~tion, but has also bought about a significant change in our conceptualization of clinical pain and pain therapy, particularly with regard to chronic pain syndromes. This in turn has encouraged many physicians and other health professionals to become involved in patients with pain within the context of multidisciplinary pain diagnostic and therapeutic facilities.

I. MelzcAjck R, Wall PD. The challenge of pain. New York: Basic Book, 1982. 2. Steig RL, Dubner R, Lippe PM. Directory of pain management facilities. Chicago: American Pain So& ety, American Academy of Pain Medicine, 1989. 3. Directory of pain treatment centers in the U.S. and Canada. Phoenix: Oryx, 1989.

4. BonicafJ. The management of pain, 2nd ed. Philadelphia: Lea and Febiger, 1990:197-268 and

17. Alexander FAD. Control of pain. In: Hale D, ed. ~~~esiol~~ Philadelph~ Davis, 1954:579-611.

1878-1882. 5. Bonica JJ. Evolution of pain concepts and pain clinics. Clin Anesthesiol 19853 1. 6. Bonica JJ Evolution of mui~~ip~~~/inte~iscipiinary pain programs. In: An>noff GM, ed. Pain centers: a revolution in health care. New YorR: Raven, 1988:9-32. 7. Bon&a JJ. 0rganiaation and function of a pain clinic, In: BoniaJJt ed, Advance in n~u~l~~ International 8ym~ium on Pain, vol 4, New York: Raven, 1974:439-443, 8. Aiewmder FAD, The genesis of the pain clinic. In: Pain abstracts: Second World Congress on Pain, vol I, Se&z: I~temational A~~iation for the Study of I&in, IQ7~:2~U. 9, BonicsJJ, The management of pain, Philadelphia: Lea and Febiger, 1955:16!l- 17% IQ. Labat F. Regional anesthesia: its techniques and ciinicai appii~~. ~iladelphia: WB 8aunders, 1924. 11. Mandl F. Di paravertebmle blockade. Vienna: Springer, 1988. 12. Leriche B. Surgery of pain. Baltimore: William and bus, 1999.

18. Bonica JJ, Beneditti C, Murphy TM. Functions of pain clinics and pain centers, In: Swerdlow M, ed. Relief of intractable pain, 3rd ed. Amsterdam: Else-

13. Livingston WK, Pain mechanisms: physiologic interpretation of causalgia and its related states. New York: Macmillan, 1943. 14. Webb PD. The~~uti~ nerve block with prneaine and ale&ok Am J 8urg 1930;9:278. 15. Ruth H. Diagnostic, prognostic and therapeutic block. JAMA 1994;IQ%419. 16. Rovenstine EA, Wertheim HM. Therapeutic nerve bhxk. JAMA lQ4i;l lf:l5Q9.

vier, 1983:65-84. 19. Booica3J, Black RG. The management of a pain clinic. in: Swerdiow M, ed. Relief of intractable pain. Amsterdam: Excerpta Medica, 1974. 20. Crue BL, et al. What is a pain center? Bull LA Neurolg 8oc 197~41:160. 21. Crue BL, ed, Chronic pain: further observations fern City of Hope National Medical Center. New York: Spectrum, 1979:3- 12. 22, Crue BL M~ltidi~~ipiina~ pain treatment programs: current smtus. Ciin J Pain 1985; 13 I + 23. Aronoff GM, Wae;ner JM. Tht? pain center: development, structure and dynamics. In: Pain centers: a revolution in health care. New York: Raven, 1988:38-54. 24, Me&k R, Wail PD. Pain mechanisms: a new theory. Science 1965;150:917. 25. Leff DN. Management of chronic pain: medicine’s new growth industry. Med World News 197~~t~r:54. 26. Model1 J. Dietary of pain clinics. Oak Ridge, TN:

American Society of Anesthesiologists, 1977. 27, Carton H. International directory of pain centerslclinics. Oak Ridge, TN: American Society of ~~~e~~lo~s* 1977. 28. Brena SF. Pain control facilities: patterns of operation and problems of organizrtion in the USA. Ciin Anesthesioi 1985;3:183. 29. Aponoff CM, Crue Bt, SeresJ, Pain centers: help for the chronic pain patients. Med Pain 1983:4: I.