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19 Articles in Volume 20, Issue #4
20/20 with Dr. Nathaniel Katz: Pain Research and Future Therapeutics
A 20-Year Timeline: Pain Therapeutics and Regulations
A Comparison of the Alpha-2-Adrenergic Receptor Agonists for Managing Opioid Withdrawal
A Pain Assessment Primer
After the Task Force: A Conversation with Vanila A. Singh, MD
Ask the PharmD: Can opioids and benzodiazepines ever be used together?
Cognitive Strategies and Mindful Awareness for Integrative Pain Care
COVID: Clinical Considerations for Acute and Post-Infection Symptoms
Editorial: Fudin and Gudin Tackle Pain Care History – Asking, Have We Done a 180?
From Hands-On to Home-Based Care: Physical Therapy Undergoes a Paradigm Shift Due to Pandemic
MS-Related Pain and Spasticity: Are Cannabinoids an Option?
New Biological Agents for Psoriatic Arthritis: A Monoclonal Antibody Primer
Pandemic Presents Unexpected Opportunity to Embrace Multimodal Analgesia and the Integrative Care Team
Provider Perspective on Knee OA: Injections and RFA Options
Redefining the “Pain Specialist” of Today
Resident’s Corner: Climbing the Learning Curve in Pain Management
The Evolution of Pain Management: Experts Weigh In
Tips from the Field: How to Enhance Practice Efficiency
Tumor Necrosis Factor (TNF) Inhibitors: A Clinical Primer

A 20-Year Timeline: Pain Therapeutics and Regulations

A look at how far we’ve come and where we’re going, from game-changing therapeutics to practice-shifting guidelines.

Pain can be traced back to the beginnings of the Kingdom Animalia with the pain experience as natural to these species as feathers are to birds and gills to fish. Pain was, and always has been, an evolutionary adaptation, a biological shield forged into the DNA of animals well before the existence of Homo sapiens, Homo erectus, Homo neanderthalensis, and Homo naledi. However, it has been we, the Homo sapiens, who have taken extraordinary measures to not only identify the cause of such stimuli but also to manage its impact and quell the advantage of protection that it was originally designed to induce.

Seemingly, throughout each century of Homo sapiens existence, there have been vaunted efforts to control the torment of pain. There is evidence of the use of trepanning (creating a surgical hole in the skull for a variety of ailments including pain) by the earliest pioneers of the Agricultural Revolution over 12,000 years ago, willow bark by the early settlers of the Mesopotamian Empire before 4000 BC, turmeric in India before 1000 BC, acupuncture in China before 100 BC, and coca leaves in Peru more than 1,000 years ago, all to manage pain.

René Descartes hypothesized the mind-body dualistic nature of pain at the turn of the 17th Century while opium (defined as juice by the Greeks) was becoming a mainstay for pain management throughout an increasingly connected world. The 19th Century saw the first use of chloroform as an anesthetic by William T. G. Morton and James Young Simpson, and that same opium that had been used for centuries was finally manipulated chemically into morphine, and subsequently by Bayer Company of Germany into diacetylated morphine (heroin) for treatment of pain.

 

Medication Classes Explode, Showcasing Pros and Cons

The 20th Century, of course, saw its own Cambrian-like explosion of development of several novel pain medication classes, interventions (such as corticosteroid injections and intrathecal opioid pumps), and procedures (including spinal cord stimulator placement). Pain theories continued to expand, as new pathologies and the interconnected roles of behavioral health were identified as potential insights to explain the natural causes of pain, which could then be used for its treatment.

The targeted approach of treating any type of chronic pain (regardless of whether it was associated with cancer or trauma) slowly became the prevailing school of thought, while those like John Bonica fostered and endorsed the benefits of interdisciplinary pain treatment for the most optimal pain management care. The finale of the progress made in the 20th Century was capped by the introduction of OxyContin by Purdue Pharma in 1996 and the US Department of Veterans Affairs recognizing pain as the fifth vital sign three years later, thus appearing to foster in a new era of comprehensive analgesic care that was to set the stage for even greater analgesic achievements to come in the century to follow.

Alas, however, in many respects, this both has and has not been the case.

The optimism of the 1990s rapidly dissipated in the beginning of the 21st Century, replaced by a littering of human suffering and tragedy, as the “opioid epidemic” ravaged the United States. Although the first decade showed that sharp rises in opioid overdose deaths paralleled precipitous increases in opioid prescribing rates, these last 10 years have proved far greater rates of opioid-related deaths (namely from illicit fentanyl products and heroin) despite opioid prescribing rates plummeting drastically. Governments at the federal, state, and local levels have responded by attempting to create necessary, but sometimes dangerous regulation and guidance to help curtail opioid prescribing in general, as well as to ramp up efforts in treating those with opioid use disorder and providing life-saving emergency treatment to those most vulnerable. A good portion of this effort has unfortunately been detrimental to the treatment of those in chronic pain.

Download a PDF of the Timeline.

 

Comprehensive, Integrative Care as the Path Forward

Despite this chaos, there remains hope. Several novel and enhanced therapeutic classes of pain medications have been introduced to the market throughout the past 20 years, and several more have been discovered. The comprehensive and interdisciplinary management of chronic pain is now recommended and endorsed by almost all pain organizations, societies, and federal guidance documents, and includes the essential role that behavioral health and socioenvironmental factors can play (enter biopsychosocial approaches).

There is greater recognition of potential risks of all classes of pain medications, greater ability for their mitigation, and greater proficiency at avoiding these risks altogether during the initial stages of pain medication research and development. While funding and general government regulation continue to raise important hurdles the pain community must surmount, there is a chance that the rest of this century, if not the next 20 years, will allow for the most significant breakthroughs we as Homo sapiens have ever imagined in the treatment of chronic pain.

The timeline herein highlights the progressions and setbacks, ups and downs, and achievements within the field of pain management over the first 20 years of the 21st Century in honor of PPM’s 20th anniversary. (Timeline reviewed by the PPM Editorial Advisory Board.)

 

 

More on Pain Management’s Evolution

See also, how fellow practitionersresidents and advanced practice providers are navigating the pain management learning curve and what pain research icon Nathanial Katz, MD, thinks about future therapeutics in our 20/20 Side Chat series. Plus: Gudin and Fudin ask, have we done a 180 in pain care?

For patient perspectives, see our Q&A with the U.S. Pain Foundation's Cindy Steinberg and our report on voices from the opioid crisis.

Last updated on: August 14, 2020
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