It was during World War II that John Bonica first began to perceive a need for a new way to treat patients with chronic pain. As Chief of Anesthesiology at Madigan Army Hospital, he received many referrals of patients suffering from pain: phantom limb and other post-amputation syndromes, muscle-related pain, and a variety of obscure neurologic and musculoskeletal disorders.
Like other physicians of the time, he was generally aware that blocking nerve pathways with local anesthetic could be useful in treating pain. Not having had any particular experience with the nerve blocking procedures, he went to the literature and read all he could.
In applying nerve blocks, he noticed that patients with straightforward types of pain responded to therapy, but that patients with complex chronic pain problems did not. And he suddenly realized that he, like most other clinicians, did not know the basic principles involved in complex, chronic pain.
Frustrated at not finding the information he needed in the
literature, Bonica had several colleagues in a variety of
fields--such as neurology, neurosurgery, orthopedics,
psychiatry--examine the patients and then compare notes in
a face-to-face meeting every week. "As far as is known from the
literature and other sources of information, this was the first
time that the
By the end of his stint in the military, Bonica was convinced that the multidisciplinary approach to pain management was the way of the future for treating chronic pain, and that not only was more research needed, but even the most basic textbook on the subject was sorely lacking. After the war, he set out to do something about it.
Bonica went straight away to Tacoma General Hospital and put his ideas into practice. He established a multidisciplinary group to handle pain patients. By 1950, he had compiled records of over 2,000 military and civilian patients he had treated either alone or in collaboration with other physicians, and began to write a book on diagnostic and therapeutic nerve blocks. Published in 1953, The Management of Pain is described now by colleagues as "a monumental classic text."
Bonica joined the UW faculty in 1960 to head up the newly created Department of Anesthesiology, and seized that opportunity to establish a multidisciplinary pain program there. The Pain Center evolved to include outpatient facilities and a clinical program with 10 hospital beds and five special nurses. Estimates are that the center has rehabilitated two-thirds of patients seen with chronic pain, most of whom had not responded to standard medical treatment.
Many of the patients with chronic pain were experiencing stress and depression, underscoring the need for psychologists and psychiatrists on the multidisciplinary team. One of the psychologists was Wilbert Fordyce, who realized the importance of environmental factors in some patients' pain problems. Fordyce played a major role in identifying the importance of behavioral factors in the chronic pain patient and in developing diagnostics and therapeutic strategies for chronic pain.
In 1974, Bonica founded the International Association for the Study of Pain; and a year later, its journal, Pain, began publication. The Association is recognized as the premier pain research association in the world and it has been a major force in stimulating much of the basic scientific work that has been accomplished in the field over the past decades. By 1988, some 1800 to 2000 pain centers had been established in 36 countries around the world, a tribute to the pioneering efforts of Bonica, who is also credited with developing the epidural block to relieve the pain of childbirth. Bonica passed away in 1994.
A more recent development is the Acute Pain Service to treat postoperative or post-traumatic pain; self-administered pain medication for surgical patients is one new approach. "This service has proved highly successful and has demonstrated the superiority of these techniques over the standard method of intramuscularly administering narcotics in relieving moderate to sever acute pain," wrote Bonica.
The Multidisciplinary Pain Center today is recognized as the "standard-setter" in the training of physicians and psychologists in the field of pain treatment, notes center director John D. Loeser. "John Bonica was a unique and great man," he reflects, "who made pain management a subject of scientific and clinical importance, and he did it by himself. He was a major force in the development of this field."