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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.
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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
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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
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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.
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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 ...