A brief history of pain management

In the 1600s, European doctors provided opium to alleviate pain in their patients. By 1680, opium was combined with sherry in a mixture known as laudanum.

Moving into the 1800s, morphine was industrially produced, and ether and chloroform began seeing use as anaesthetics for surgery and childbirth.

A debate arose on the ethicality and suitability of operating on unconscious patients, fuelled by concerns that pain relief could hinder the healing process.

Religious writers, for example, believed that inflicted pain strengthened faith and taught new mothers the need for self-sacrifice for their children. Physicians aimed to reduce pain, but also saw it as a symptom of vitality and a sign that a prescription was effective.

Attitudes shifted in the early 1800s, with surgeons taking pride in minimizing pain during and after surgery. Patients no longer had to endure surgeries while conscious, enabling more complex procedures.

Ultimately, pain relief was recognized as valuable, albeit secondary to curative treatment. This controversy highlights how cultural meanings often complicate pain treatment.

In 1855, Alexander Woods devised the hypodermic syringe as we know it, with a hollow needle for subcutaneous injections, facilitating frequent administration.

Back then, opium derivatives were available over the counter for people to self-medicate. By the 1870s however, concerns grew over the negative effects of morphine on some users, most prominently addiction.

In 1899, acetylsalicylic acid (aspirin) was commercialized for headache and gastric distress, gradually becoming the drug of choice for mild to moderate pain.

Entering the 1900s, morphine and heroin came into use as pain medications, posing renewed challenges due to their addictive nature.

The early 1900s also saw the exploration of the interplay between pain sensation and cognition. Psychoanalysts found unexplained pain to be helpful cues to mental or emotional disorders. It became clear that chronic pain increases attention towards pain, generating anxiety and further intensifying pain perception.

Consequently, by the 1920s, patients suffering from unexplained chronic pain were often regarded as deluded and left with no option other than psychotherapy or neurosurgery, where nerve fibres conveying pain sensation to the spinal cord or brain were severed, a drastic and often disabling remedy.

However, dissatisfaction with this situation led some in the medical field, like French surgeon René Leriche, to propose innovative treatments during WWI. Leriche suggested first treating chronic pain patients with local injections of large amounts of procaine, a precursor of cocaine. If pain relief was achieved, the injections could be repeated over long periods, often resulting in remission.

In the 1960s, pain became a dedicated field of medicine, marked by the emergence of specialized research journals and associations like the International Association for the Study of Pain in the 1970s.

The 1980s saw debates on the incidence of addictive behaviour associated with opioids, yet they saw widespread use for long-term pain treatment. In 1982, the World Health Organization introduced guidelines for physicians, recommending a regular schedule of analgesics from nonsteroidal anti-inflammatory drugs to weak opiates like codeine, reserving strong opiates to the strongest forms of pain.

Over the last 30 years, adjunct therapies to opioids for treating chronic pain came to prominence, such as cognitive-behavioural therapies, which assumes that "individuals are active information processors able to change the way they think, feel, and believe." These programs have proven effective at improving mood and decreasing pain disability. However, they have also been criticized for shifting the burden onto the patient, requiring them to alter their own cognition and behaviour for pain relief.

Finally, observations of tricyclic antidepressants increasing levels of available norepinephrine were noted to alleviate chronic pain in depressed patients, supposedly by interacting with endorphin-mediated analgesia.

Despite the productivity of recent pain research, the fact remains: No one treatment works universally for every patient, even for pain of the same type and aetiology.

Sources:

Marcia Meldrum, "A Capsule History of Pain Management"

Roger Collier, "A short history of pain management"