Management of chronic pain

Until 50 years ago chronic pain was not considered to be a medical condition that required special evaluation and treatment facilities. Pain was considered to be an indicator of tissue damage and appropriate medical or surgical treatment was prescribed for this. The many patients who had continuing pain because of the results of disease or trauma or because acute treatment was unable to relieve the condition were not seen as suffering from a recognised pathological entity. It was not until a doctor, Sicilian-born John J. Bonica, had to pay his debts as a medical student through wrestling professionally, and later suffered persistent pain as a result, that chronic pain became a recognised condition in its own right. Bonica started a pain clinic in Tacoma, Washington State, in 1949 and wrote the first textbook on pain treatment, The Management of Pain, in 1953. There are now 2000-3000 pain clinics in the USA and almost 5000 worldwide. It was recognised early that no single specialist could address all the complexities presented by these patients, and Bonica employed physicians and psychologists in his first pain clinic. The multidisciplinary pain clinic is now considered the ideal facility for the treatment of pain. There are now some 250 pain clinics in the UK but the majority of these are run by anaesthetists with little input from other health care professionals. Although this article is primarily concerned with the psychological and psychiatric aspects of the management of chronic pain, a brief account will be given of techniques used by others in this condition.