Guide to Pain Management in Low-Resource Settings

History, Defi nitions, and Contemporary Viewpoints Wilfried Witte and Christoph Stein Th e experience of pain is fundamental and has been part of the cultural development of all societies. In the history of pain, “supernatural” powers played an equally important role as natural factors. To view pain as the result of a “communication” between mankind and divine powers has been a fundamental assumption in many societies. Th e more societies are separated from Western medicine or modern medicine, the more prevalent is this view of pain. On the other hand, a purely medical theory based on natural phenomena independent of divine powers developed very early on. It happened to a greater extent in ancient China, while in ancient India medicine was heavily infl uenced by Hinduism and Buddhism. Pain was perceived in the heart—an assumption familiar to ancient Egyptians. Th e medical practitioners in pharaonic times believed that the composition of body fl uids determined health and disease, and magic was indiscriminable from medicine. Ancient Greek medicine borrowed heavily from its Asian and Egyptian predecessors. Th e introduction of ancient medical knowledge into medieval Europe was mainly mediated through Arabic medicine, which also added its own contributions. Latin was the language of scholars in medieval Europe, and ideology was guided by Judeo-Christian beliefs. Despite multiple adaptations, medical theory remained committed to ancient models for centuries. Pain had an important role. Th e Bible illustrates the need to withstand catastrophes and pain in the story of Job. Strength of faith is proved by Job’s humility toward God. Humility is still an ideal in Christian thought today. In the New Testament, Jesus Christ fi nishes his life on earth as a martyr hanging and dying at the cross. His suff ering marks the way to God. To bear suff ering in life is necessary to be absolved from sin. Th e message of pain is to show mankind the insuffi ciency of life on earth and the brilliance of being in heaven. Th us, whatever science may say about pain, an approach based only on a physiological concept does not take into account the religious or spiritual meaning of pain. Th e most important and radically mechanistic scientifi c theory of pain in early modern age derives from the French philosopher René Descartes (1596 – 1650). In his concept, the former assumption that pain was represented in the heart was relinquished. Th e brain took the place of the heart. In spite of (or because of) its onesidedness, Descartes’ theory opened the gate for neuroscience to explain the mechanisms of pain. Th e question of how pain should be treated has led to diff erent answers over time. If supernatural powers had to be pleased to get rid of pain, certain magical rituals had to be performed. If scientifi cally invented remedies were not used or not available, ingredients from plants or animals had to be used to ease the pain. Especially, the knowledge that opium poppies have analgesic eff ects was widespread in ancient societies such as Egypt. For a long time, opium was used in various preparations, but its chemical constituents were not known. Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th is material may be used for educational 3 and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text. 4 Wilfried Witte and Christoph Stein Th e isolation of the opium alkaloid morphine was fi rst accomplished in 1803 by the German pharmacist Friedrich Wilhelm Sertürner (1783–1806). Th e industrial production of morphine began in Germany during the 1820s, and in the United States in the 1830s. During the late 18th to the mid-19th century, the natural sciences took over the lead in Western medicine. Th is period marked the beginning of the age of pathophysiological pain theories, and scientifi c knowledge about pain increased step by step. Th e discovery of drugs and medical gases was a cornerstone of modern medicine because it allowed improvements in medical treatment. It was modern anesthesia in particular that promoted the development of surgery. General anesthesia using ether was introduced successfully in Boston on October 16, 1846, by the physician William Th omas Morton (1819–1868). Th e importance of this discovery, not only for surgery but for the scientifi c understanding of pain in general, is underscored by the inscription on his tombstone: “Inventor and Revealer of Inhalation Anesthesia: Before Whom, in All Time, Surgery was Agony; By Whom, Pain in Surgery was Averted and Annulled; Since Whom, Science has Control of Pain.” Th is statement suggested that pain would vanish from mankind just by applying anesthesia. Surgery itself changed to procedures that were not necessarily connected with a high level of pain. Th us, the role of surgery changed. Surgeons had more time to perform operations, and patients were no longer forced to suff er pain at the hands of their surgeons. Further innovations followed. One year later, in 1847, chloroform was used for the fi rst time for anesthesia in gynecology by the Scottish physician James Young Simpson (1811–1879). In Vienna, the physician Carl Koller (1857–1944) discovered the anesthetic properties of cocaine in 1884. At about the same time, during the last two decades of the 19th century, the U.S. neurologist James Leonard Corning (1855–1923) and the German surgeon August Bier (1861–1949) carried out trials of spinal anesthesia with cocaine solutions. Modern anesthesia enabled longer and more complex surgical procedures with more successful long-term outcomes. Th is advance promoted the general consensus that the relief of somatic pain was good, but it was secondary to curative therapy: no pain treatment was possible without surgery! Th us, within the scope of anesthetic practice, pain management as a therapeutic goal did not exist at that time. Chronic pain was not a topic at all. Th e fi rst decades of morphine use may be seen as a period of high expectations and optimism regarding the ability to control pain. Th e fi rst drawback to this optimism was the discovery made in the American Civil War (1861–1865), when cases of morphine dependence and abuse appeared. As a consequence, restrictions on the distribution of opiates were begun. Th e negative view of morphine use was enhanced by experiences in Asia, where an extensive trade in opium and morphine for nonmedical purposes was already established during the 19th century. Th erefore, at the beginning of the 20th century, societal anxiety regarding the use of morphine became strong and developed into opiophobia (i.e., the fear of using opioids), which was a major step backwards for pain management in the following decades. Wars stimulated pain research because soldiers returned home with complex pain syndromes, which posed insurmountable problems for the available therapeutic repertoire. Following his experience after 1915 during the First World War, the French surgeon René Leriche (1879– 1955) began to concentrate on “pain surgery,” mainly addressing the autonomic nervous system. Leriche applied methods of regional anesthesia (infi ltration with procaine, sympathetic ganglionic blockade) as well as surgery, particularly periarterial sympathectomy. He not only rejected the idea of pain as a necessary evil but also criticized the reductionist scientifi c approach to experimental pain as a purely neuroscientifi c phenomenon. He viewed chronic pain as a disease in its own right (“douleur-maladie”), not just as a symptom of disease. Regional anesthesia was the mainstay of pain therapy applied by the French surgeon Victor Pauchet (1869–1936). Already, before his experiences in the war, he had authored the fi rst edition of his textbook L’Anesthésie Régionale in 1912. Th rough Louis Gaston Labat (1876–1934), a physician from Paris who later practiced in the United States, his wisdom became known in the New World and was an important stimulus for the dissemination of regional anesthesia in the United States between the two World Wars. In the 1920s, the notion that regional anesthesia could be used not only for surgery but also for chronic pain spread throughout the United States. After the Second World War these ideas were taken up by John Joseph Bonica (1914–1994), who had emigrated with his parents from Sicily to the United States at the age of 11 years. As an army surgeon entrusted with the responsibility of giving anesthesia, he realized that the care of wounded soldiers was inadequate. Th e patients were left alone with their pain after surgery. Bonica observed that pain frequently became chronic and that many of these patients fell prey to alcohol abuse or depressive disorders. Bonica’s answer to this problem, which also affected other pain patients, was to establish pain clinics where physicians of diff erent disciplines, psychologists, and other therapists worked together in teams to understand the complexity of chronic pain and treat it adequately. Anesthesiology remained Bonica’s specialty. Only a few pain clinics existed in the United States when he published the fi rst edition of his textbook Pain Management in 1953. Th is landmark may be regarded as the date of birth of a new medical discipline. Nevertheless, it took many years before a broader audience became interested in pain therapy. In the year 1973, to make this topic more popular, Bonica founded the International Association for the Study of Pain (IASP). In the following years, national chapters of the IASP were founded around the globe. In 1979, IASP coined the important defi nition of pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage,” which is still valid. Th is defi nition was important because for the fi rst time it implied that pain is not always a consequence of tissue damage but may occur without it. Western science then began to realize that “somatic” factors (tissue damage) cannot be separated from History, Defi nitions, and Contemporary Viewpoints 5 “psychological” factors (learning, memory, the soul, and aff ective processes). Together with the recognition of social infl uences on pain perception, these factors form the core of the modern biopsychosocial concept of pain.