Management of Pain in the United States—A Brief History and Implications for the Opioid Epidemic
Pain management in the United States reflects attitudes to those in pain. Increased numbers of disabled veterans in the 1940s to 1960s led to an increased focus on pain and its treatment. The view of the person in pain has moved back and forth between a physiological construct to an individual with pain where perception may be related to social, emotional, and cultural factors. Conceptually, pain has both a medical basis and a political context, moving between, for example, objective evidence of disability due to pain and subjective concerns of malingering. In the 20th century, pain management became predominately pharmacologic. Perceptions of undertreatment led to increased use of opioids, at first for those with cancer-related pain and then later for noncancer pain without the multidimensional care that was intended. The increased use was related to exaggerated claims in the medical literature and by the pharmaceutical industry, of a lack of addiction in the setting of noncancer pain for these medications—a claim that was subsequently found to be false and deliberatively deceptive; an epidemic of opioid prescribing began in the 1990s. An alarming rise in deaths due to opioids has led to several efforts to decrease use, both in patients with noncancer conditions and in those with cancer and survivors of cancer.
Keywords: Pain management in the United States, pain and disability in politics in the United States, political impact in the United States on pain management, opioid epidemic, opioid deaths, pain management in patients with cancer, cancer survivorship and pain management.
Between 1999 and 2016, more than 630 000 persons in the United States died from drug overdoses—most of these drug-related deaths were due to opioids prescribed for pain.1 From 1999 to 2010, overdose deaths due to opioid pain relievers increased continuously, a time known as the first wave of the opioid epidemic. After this wave, the second and the third waves of opioid overdose deaths due to heroin and illicitly manufactured fentanyl (IMF), respectively, affected the United States significantly.1–6 There was an increase in deaths from 52 404 in 2015 to 72 000 deaths (provisional) by 2017.7–9 A recent suggested revision to the classification of prescription opioid-related deaths removes synthetic opioids (such as fentanyl) from this category to better characterize those deaths as, increasingly, from illicit opioids. This reclassification has important implications for strategies to address the problem as we discuss under possible solutions.10 This article reviews the evolution of the understanding of pain and the impact of pain (initially with disability of WW II veterans as the proxy for the subjective symptom of pain) on the political, legal, and regulatory systems in the United States as a template for the increase in use of opioids in the past 2 decades. Finally, we discuss current solutions to the opioid epidemic—guidelines, policies, monitoring and other approaches. Space does not permit an expansion of the sociological background—the article by Dasgupta5 explores these causes of the rise in abuse of both illicit and prescription opioids.
Modern theories of pain began with Descartes in the mid-1600s with his theory of pain specificity. A painful stimulus on the surface of the body was transmitted by a nerve through the spinal cord to a site in the brain where pain was perceived.11–15 This theory had several implications—pain was a physiologic concept that was seemingly straightforward, but left out were the emotional, cultural, or social modification of the message, and only one site in the brain processed pain input. Most importantly, the body and the mind were separate in this conceptualization. The understanding of pain evolved over the next 3 centuries—metaphysical explanations and the influence of the church waned; suffering and psychological components were further downplayed; however, by the 1900s, the notion of suffering and the psychological component again was acknowledged. Finally, the concept of modulation of the pain message assumed more importance with the 1968 publication of the Gate Control Theory of Pain.13 The further evolution of this theory has helped reinsert components of suffering—psychological, spiritual, and cultural that were discounted over the past 4 centuries. This theory was advanced in part due to the political and cultural ethos that was extant and evolving pari passu with the understanding of the mechanism of pain from a simple transmission along a defined pathway to modulation of the message by areas of the brain that respond to related factors such as culturally learned stoicism.15
The therapies for pain began to evolve in the United States in the middle of the 19th century with the development and use of morphine for injured Civil War soldiers. In the late 1800s and early 1900s, there was reticence on the part of some physicians and some patients to use anesthetics and analgesics and instead to rely on nonpharmacologic measures. By the middle of the 1900s (with the return of the injured World War II soldiers), therapy was predominately pharmacologic, in part related to the same political and cultural ethos.16
Bourke11 has chronicled stories of acute pain before the widespread use of anesthetic agents such as ether and chloroform, whose use began in the late 1840s, and later in injured soldiers and civilians in the Civil War era. A dilemma arose in former soldiers who continued to use morphine after the war. This usage for ongoing chronic pain lead to restrictions on morphine in the early part of the 1900s and heroin in the 1920s.14,16
Usage of veteran’s services was modest before World War II. Henry Beecher and John Bonica, both anesthesiologists after the war, chronicled that soldiers with severe and sometimes lethal wounds, denied pain, and focused on a return to their comrades on the battlefield. Others in obvious pain improved with the use of barbiturates to relieve anxiety. These observations led to a renewed acknowledgment of the role of psychological, cultural, and social (eg, bonding on the battlefield) factors.
Continued pain after the war injury and after return to civilian life posed increasing challenges to US society, which were manifested in a dramatic rise in the number of disabled veterans and the need to provide services for them. Wailoo documents the role that politics, both governmental and medical, played in decisions in the late 1940s and 1950s in the management of chronic pain and disability as its proxy. When the disability was due to the subjective symptom of pain, those who argued to believe the individual such as Beecher and Bonica were confronted by those seeking to quantify the problem for either monetary compensation or deny the existence of the problem. The confluence of veterans from WW I, WW II, and the Korean War led to a rise in the number with disabilities from 0.5 million in 1940 to 3 million by 1960. Tables 1 to 4 summarize key points from Wailoo’s work from the period of 1945 until 1979, which are important in understanding the path to the current epidemic.