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In the past 30 years, pain centers have revolutionized the management of complex chronic pain problems. Before discussing important clinical issues, a brief history is presented to give the reader background and perspective.


Several factors contributed to the development of the multidisciplinary pain center. One common observation was need for a facility for the vast group of patients who did not respond to conservative treatment measures and were not appropriate for, or did not respond to, interventional approaches. These patients had chronic pain syndromes with concomitant poor coping, dysfunctional pain behaviors, excessive health care utilization, self-limitations in activity level, medication dependency problems, emotional disturbance, work loss, and global life disruption. (I have emphasized for many years that the term chronic pain syndrome is not a diagnosis, but a descriptive term having some or all of the foregoing noted characteristics.) Another observation was the increasing recognition of the importance of psychosocial factors in the development and maintenance of chronic pain syndrome. This clinical observation made by Beecher1 in 1959 was strengthened further through theoretic formulations.2


In the 1950s, our methods for treating chronic pain consisted primarily of bed rest, medication, nerve blocks, or surgery. Currently, bed rest generally is thought to be contraindicated for most chronic nonmalignant pain syndromes. Opioids, often the medications of choice during the 1950s, then fell into disfavor through the 1980s. They are now again being used selectively to treat nonmalignant pain with the recognition that opioids may provide adequate analgesia to maintain high-activity level and prevent work loss and disability.3 The indications for nerve blocks and surgery are being redefined and used more selectively. Whereas pain centers once were considered treatments of last resort, currently this is often the judgment reserved for invasive treatments. Concepts regarding the treatment of chronic pain changed dramatically, as has the health care system generally in the United States. Health care providers have recognized that early patient referrals may eliminate needless or multiple surgeries, reduce health care costs, and promote the patient’s return to productivity, and earlier referral to pain centers appeared to be more commonplace. Insurance carriers ultimately benefit from chronic pain programs when successful outcomes reduce health care costs. Ineffective surgical procedures, multiple physician visits, medication dependency, iatrogenic complications, and lost workdays may be reduced.4,5


Throughout the 1960s, pain centers were rare in the United States and even less common outside this country. These facilities were on the fringes of medical acceptability even during the early 1970s. Patients who had multiple surgeries or numerous nerve blocks were not considered to have been treated radically, and yet, patients treated in pain programs with operant conditioning, biofeedback, psychotherapy, and rehabilitation often caused many raised eyebrows.


In 1976, Medical World News listed approximately 30 major comprehensive pain centers distributed throughout the United States. By 1979, this number had grown to 278 (according to a questionnaire survey conducted by the American Society ...

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