Publications
APS Bulletin • Volume 16, Number 2, 2006
Past Presidents’ Perspectives
Mark Sullivan, MD PhD, Department Editor
An Interview with Charles S. Cleeland, PhD, APS President, 1995–1996
How Did You Get into the Field of Pain?
My development as a pain clinician and researcher was circuitous. I was trained first as a clinical psychologist, with a dissertation in psychopharmacology. I went on to complete a 2-year National Institutes of Health (NIH)–funded postdoctoral fellowship in neuropsychology at the University of Wisconsin. As a fellow and young assistant professor, I was fortunate to work with Professor Francis Forster, Chair of Neurology, in the area of sensory-evoked epilepsy. Forster had been on one of the first scientific exchanges to what was then the U.S.S.R. He brought back the idea of reducing the frequency of sensory-evoked seizures using a Pavlovian deconditioning model. This process involved presenting the evoking stimulus and then terminating it at the first signs of seizure on the electroencephalogram (EEG). It worked for many patients, but the time and laboratory costs made it impractical for treatment. With Forster’s encouragement, I worked with patients who had spasmodic dystonias, a painful and disfiguring condition for which there was, at that time, no treatment. I found that a mix of operant (biofeedback) and classical conditioning could provide some relief. News of this modest success soon brought the referral of many patients with chronic pain. I found (as did many others at the time) that muscle relaxation, with or without biofeedback, could provide some relief for this often-neglected group. I was intrigued by the intractability of chronic pain, and I vowed to learn more. I have been learning ever since.
At the end of the 1970s, Professor Paul Carbone came to the University of Wisconsin to head the Clinical Cancer Center. He encouraged me to establish a research program to better understand and treat cancer pain. NIH money for this new area was relatively easy to obtain then, and I established the Wisconsin Pain Research Group. Professor Carbone also encouraged me to develop studies within the Eastern Cooperative Oncology group, and we learned a great deal from the studies that were done within that context. At that time, I became a consultant to the World Health Organization’s Cancer Pain Relief Program. We developed pain assessment tools (e.g., Brief Pain Inventory) that were easy for patients to complete and easy to translate.
In addition to orchestrating and conducting studies of assessment and treatment of pain, I developed a laboratory group that studied cortical mechanisms of pain using EEG, functional magnetic resonance imaging, and magnetoencephalography. I was fascinated by what these studies revealed about brain activity in persons who reported variations in pain and pain impact.
What Are You Doing Now?
In 1995, I came to the University of Texas M.D. Anderson Cancer Center to develop a Pain Research Group. With the number of cancer patients seen at M.D. Anderson, it was hard to escape the observation that pain was but one of a set of symptoms that distressed people with cancer, symptoms that included fatigue, nausea, emotional distress and outright depression, sleep disturbance, and loss of appetite. We began to think of these symptoms as imposing a symptom burden on the patients, an experiential counterpoint to the tumor burden that the cancer caused (Cleeland & Reyes-Gibby, 2002). These symptoms are so intertwined that it was easy to think that they might have at least some common biology and treatment targets. I helped create the Department of Symptom Research, where I’m currently chair, to focus on the measurement, mechanisms, and treatment of multiple symptoms. We continue our efforts to refine symptom measurement and conduct clinical trials for pain and symptom relief, but much of our effort is spent collaborating with other departments and institutions to try to understand why symptoms occur and how novel treatments might prevent or modulate them.
M.D. Anderson has a mix of basic and clinical science, including basic molecular biology, imaging, genetics, biostatistics, and cancer epidemiology. We have found that many of the researchers in these areas are intrigued by the idea that understanding the mechanisms of soft outcomes such as pain, fatigue, and sleep disturbance might involve tractable scientific questions. Our cancer center also has world-class cancer clinicians, many of whom are concerned about their patients’ symptom burden, much of which is produced by the aggressive treatment that they must use to cure cancer. These clinicians are also frustrated by the appalling lack of ways to help their patients cope with this symptom burden. The presence of both basic and clinical researchers makes a major cancer center a good place to explore the basic biologic and behavioral bases of symptom expression and to point the way to new treatment options.
What Has Been the Most Significant Contribution to the Field of Pain?
Probably the most significant change (the major contribution) that I have observed over my career is the gradual acceptance of pain, both as a clinical condition and a focus of serious research. Implicit in this acceptance is a move away from blaming the patient with pain for being weak in reporting pain, and from the attitude that pain comes with the territory with cancer or another disease or injury, and that one should just endure it. The acceptance of pain paves the way for seriously treating other things that can distress those who are ill, such as fatigue, distress, or other components of symptom burden.
How Do You View Current U.S. Pain Research and Treatment?
Despite increasing awareness of pain’s heavy societal burden, recent compilations of the spending track record of both the NIH and foundations for pain research demonstrate that pain is an orphan disease, certainly not in the sense that few suffer with it, but in that little research funding is being provided to understand pain and its mechanisms (see Bradshaw, Nakamura, & Chapman, 2005). Biomedical research has traditionally been disease oriented and funded by research silos for cancer, as well as other diseases, such as diabetes, heart disease, and neurologic disease. This has been the research support history for both the NIH and private foundations. Pain and symptoms cut across all these silos. There are new areas of research that suggest diverse diseases may have common pathways, such as inflammation. Pain and other symptoms may also have common pathways—pathways that need to be explored.
In addition to more funding, I see a need to develop a strategic research plan to prioritize the most important short-term and long-term goals, identify priorities in clinical research in pain treatment and prevention, and ensure that a sufficient number of young scientists are being trained to execute this strategy.
Research in pain and other symptoms is being turfed by the standard research funding agencies to big pharmaceutical companies. One result of this is that we lack large sample clinical research into the symptomatic benefits of the old and now generic treatment approaches that many of us use. Newer approaches (such as new molecules and new delivery systems) wait until patents are established and registration trials are completed before noncommercial investigators can explore their true worth. Without more traditional nonindustry research, a true evidence-based approach to pain prevention and management will elude us.
Pain management suffers from lack of an evidence base. For many pain conditions there are a number of treatment options , but there is very little evidence to help the patient and the provider select the most effective, least intrusive, and best-tailored treatment for an individual patient.
What Is Your Forecast for the Future?
I hope that biomedical science will continue to develop problem-based, rather than disease-based, strategic models of research. Research in pain and other symptoms would benefit. The recent developments of the NIH Roadmap Initiative are promising in this regard.
References
Bradshaw, D. H., Nakamura, Y., & Chapman, C. R. (2005), National Institutes of Health grant awards for pain, nausea, and dyspnea research: An assessment of funding patterns in 2003. Journal of Pain, 6, 277–293.
Cleeland, C. S., & Reyes-Gibby, C. C. (2002). When is it justified to treat symptoms? Measuring symptom burden. Oncology (Williston Park), 16(9 Suppl 10), 64–70.
Charles Cleeland is director of the University of Texas M.D. Anderson Cancer Center Department of Symptom Research.
Please direct your comments or suggestions about this article to John L. Reeves, Department Editor, at reeves@ucla.edu.