The work which you are accomplishing is immensely important for the good of humanity, as you seek the ever more effective control of physical pain and of the oppression of mind and spirit that physical pain so often brings with it.
Pope John Paul II (26 July 1987)1
Pain medicine arose during the last half of the twentieth century and accompanied the rise of new clinics and treatment centers devoted specifically to pain. Change accelerated after Ronald Melzack and Patrick Wall published their landmark gate-control theory of pain in 1965,2 which was rapidly absorbed into mainstream biomedical thinking despite unresolved questions that eventually led Melzack to look beyond spinal gates.3 Organizational developments kept pace. In 1973, John Bonica invited some 300 participants to a conference outside Seattle, where they discussed founding a worldwide medical-scientific association focused on pain (discussed in Ref. 4). Soon, several agencies within the US National Institutes of Health assigned priority to pain research and control, creating incentives, and guidelines for progress, and many academic medical centers responded by setting up pain teams. Public health systems and private insurers debated who would pay, how much, and for what. Multinational corporations invested huge sums to market powerful over-the-counter and prescription analgesics. Pain was big business. As the twenty-first century began, the organization that emerged from the now famous Seattle-Issaquah Conference - the International Association for the Study of Pain - had an impressive 6900 individual members in 106 countries (www.iasp-pain.org).
The proliferation of specialized journals and annual meetings on pain, together with new technologies for research and communication, maintains a fast pace of change. In 1991, for example, Melzack criticized the lack of serious interest in cortical dimensions of pain. "What happens in the brain after cortical activation,'' he observed, "is a question most people want to avoid.''5 The same year saw publication of the first studies that use positron emission tomography (PET) to examine the human brain, showing activation in the anterior cingulate cortex of subjects exposed to acutely painful heat.6, 7 Almost instantly, brain imaging contributed remarkable new insights to pain research.8 The mere expectation of pain, as magnetic resonance images (MRI) show, corresponds to activation of a specific area within the human brain.9 A 2007 topical review described a possible direction of pain research - developing treatment methods based on "objective" functional MRI data rather than traditional subjective (50 percent improvement) meth-ods.''10 As in other fields of science and medicine, one formidable challenge is simply to keep up with the speed and trajectory of change.
The challenges extend in many directions, especially as researchers examine pain processes at the cellular level. In tissue cultures from newborn rats, for example, specific neurons from the sympathetic nervous system grow axons that make contact with sensory neurons, which suggests possibilities of interaction between the two separate pain systems.11 Advances in genetics have opened up fruitful areas of pain research that were unknown 50 years ago. We recently learned that certain strains of mice possess genetic variance in nociception and in morphine-induced analgesia.12 Strains of rats possess a congenital hypersensitivity that makes them, in effect, prone to pain.13 Despite the disclaimers about animal models, we will soon see huge advances in understanding genetic components of the human pain process, even as advances in pharmacology reveal how pain-killers ranging from nonsteroidal anti-inflammatory drugs (NSAIDs) to opioids operate with different effects on multiple sites within the nervous system, permitting better use of drugs in combination.14,15 Optimists believe that this accumulating knowledge will ultimately lead to the full-scale control or eradication of pain. Perhaps governments will lock away a few last pains for research purposes in case of national emergencies.
Unfortunately, pain is not likely to surrender its power during our lifetimes, and suffering is an ineradicable part of the human condition. Indeed, as social services and medical systems focus on pain, they find more pain that needs relief. Among adults, the prevalence of chronic benign pain - in which a nociceptive substrate is difficult to find - ranges between 2 and 40 percent of the population, depending on the study.16 In the Netherlands, the cost of back pain alone equals 1.7 percent of the gross national product and lost work as a result of back pain costs the Netherlands on average $1.5 million per hour.17, 18 In the USA, the rate of disability claims associated with low back pain has increased over the rate of population growth by 1400 percent.19 Such massive costs and complex clinical dilemmas help to explain why an IASP Task Force in 1995 recommended that nonspecific low back pain be reconceived not as a medical condition but as "activity intolerance.''20 The controversial recommendation - linking low back pain, jobs, and disability insurance - stands as a reminder that neither pain nor suffering can be wholly reduced to a universal biology of nerves, neurotransmitters, and brain states. The administrative consequences appear to be insurmountable in the USA. In May 2007, the Social Security Administration reported that there were 738,000 disability cases waiting to be heard on appeal (denial) by Administrative Law Judges (ALJ), with an average waiting time of 505 days (www.ssa.gov/legislation/testimony_052307.htm). In the following text, pain and suffering in their implicit complications pose four specific challenges that are indirectly but firmly related to treatment: how to define them, how to classify them, how to understand them, and how to confront the implicit ethical dilemmas they encompass.
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