Publications
APS Bulletin • Volume 14, Number 1, 2004
Past Presidents’ Perspectives
Wilbert E. Fordyce, PhD, Department Editor
Pain Management: Not Just for Pain Specialists
Kenneth L. Casey, MD, APS President, 1984 - 1985
How did you get involved in pain?
As part of the physiology requirement at the University of Washington Medical School, I wrote my first scientific paper with a mentor, the late Arnie Towe, PhD, a somatosensory neurophysiologist. This led me into basic research and, with strong encouragement from Fred Plum, MD, toward neurology as a clinical field. After internship, I did my service time (MDs were being drafted in 1962) at NIH under Paul D. MacLean (“The Triune Brain”), in the section on limbic integration and behavior. When Paul left for sabbatical in my second year, I was left alone with lots of electrophysiological gear and cages of squirrel monkeys. After reading “On the Nature of Cutaneous Sensory Mechanisms” by Melzack and Wall (Melzack & Wall, 1962), I conceptually merged the limbic and somatosensory systems. I decided pain would be an emerging and exciting field and proceeded with my first pain experiment (Casey, 1966). I had no idea how understated my vision of the future of pain research would seem now.
What did you do next?
After completing my clinical training in neurology, I continued with animal studies of pain neurophysiology (with Tom Morrow, PhD). Positron emission tomography and functional magnetic resonance imaging made it possible to do neurophysiological studies in normal humans and in patients with pain linked to neurological disease. The animal studies moved to the background, and I began to concentrate on the functional analysis of the forebrain responses of normal and pathological pain in humans. I am especially interested in the pathophysiology of central pain, which I see frequently in neurological practice.
How do you view current U.S. pain research and treatment?
Pain research is now in the mainstream of basic neuroscience. Pain-related papers and abstracts comprise a significant percentage of annual contributions in neuroscience. At the annual meeting of the Society for Neuroscience, for example, it is not possible for me to seriously view all of the pain-related posters. Pain is now a recognized target area for research at NIH. There are at least five major journals with pain in the title, and most of these publish basic research as well as clinical articles on pain. We have an international organization (IASP) with a growing number of national chapters and a foundation (APF) for patient advocacy. In the purely clinical area, nearly every major medical and dental center has a pain clinic, and there are opportunities to gain certification in “pain medicine.” There is heightened awareness about pain among various accreditation agencies, much of the practicing healthcare community, and the public. Despite all of this, I have the strong impression that, in the daily operation of most large medical-dental centers, the salience of the prevention, diagnosis, and treatment of pain lags far behind what should be expected given the above information. It appears much knowledge about the diagnosis and practical treatment of pain has not filtered down to daily practice at the bedside. In many centers, this partially may be due to the lack of teaching about pain in the early years of training for health professionals. Pain has increasing competition for a place in the curriculum.
What’s your forecast for the future?
The information explosion is affecting all areas of biomedical research, including basic and clinical research related to pain. In basic research, there will be an increasing trend in advances made by teams of scientists, from the molecular mechanisms of inflammation to the analysis of interacting pathways mediating components of the pain experience in conscious humans.and the genetic underpinnings of it all. The scientists from these disciplines will have different scientific languages, making communication increasingly difficult. This will accelerate the development of individuals and organizations with the goal of synthesizing current knowledge into a coherent package for those outside these areas of research. These “synthesizers” will facilitate communication among scientists and convey the practical, clinically relevant aspects of emerging knowledge to healthcare practitioners and, eventually, to the public. As the information explosion continues, this job will become increasingly difficult. Pain management should not be left in the hands of pain specialists alone; the IASP and APS should concentrate their efforts to continuously update basic and clinical information for the benefit of researchers, students, practitioners, and patients.
References
Casey, K.L. (1966). Unit analysis of nociceptive mechanisms in the thalamus of the awake squirrel monkey. Journal of Neurophysiology 29, 727–750.
Melzack, R. & Wall, P.D. (1962). On the nature of cutaneous sensory mechanisms. Brain 85, 331–356.
Please direct your comments or suggestions about this article or department to Wilbert E. Fordyce, PhD, Department Editor, at wfordyce@msn.com.