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 SIXTH EDITION
Enhanced
DIGITAL
VERSION
Included

PRACTICAL
MANAGEMENT
OF PAIN

Honorio T. Benzon
James P. Rathmell
*
0 Christopher L, Wu
Dennis C. Turk
Charles E. Argoff
Robert W. Hurley
Andrea L. Chadwick

I I SI \ II R
Practical Management of Pain
Practical Management of Pain

SIXTH EDITION

Honorio T. Benzon, MD Charles E. Argoff, MD

Professor Professor of Neurology
Department of Anesthesiology Albany Medical College
Northwestern University Feinberg School of Medicine Vice Chair Department of Neurology
Chicago, Illinois Director, Comprehensive Pain Center
Director, Pain Management Fellowship
James P. Rathmell, MD, MBA Albany Medical Center
Albany, New York
Chair
Department of Anesthesiology, Perioperative Robert W. Hurley, MD, PhD
and Pain Medicine
Brigham and Women’s Hospital Professor
Leroy D. Vandam Professor of Anaesthesia Associate Dean
Harvard Medical School Department of Anesthesiology
Boston, Massachusetts Department of Neurobiology and Anatomy
Wake Forest University School of Medicine;
Christopher L. Wu, MD Executive Director
Pain Service Line
Clinical Professor of Anesthesiology Atrium Health - Wake Forest Baptist
Department of Anesthesiology Winston Salem, North Carolina
Hospital for Special Surgery;
Clinical Professor of Anesthesiology Andrea L. Chadwick, MD, MSc, FASA
Department of Anesthesiology
Weill Cornell Medicine Associate Professor
New York City, New York Department of Anesthesiology, Pain,
and Perioperative Medicine
Dennis C. Turk, PhD University of Kansas School of Medicine
Kansas City, Kansas
John and Emma Bonica Professor of Anesthesiology &
Pain Research
Department of Anesthesiology & Pain Medicine
University of Washington
Seattle, Washington
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

PRACTICAL MANAGEMENT OF PAIN, SIXTH EDITION ISBN: 978-0-323-71101-2


Copyright © 2023 by Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without permission
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In particular, because of rapid
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any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2014, 2008, 2000, 1992, and 1986.

Executive Content Strategist: Michael Houston

Senior Content Development Specialist: Lisa Barnes
Publishing Services Manager: Shereen Jameel
Senior Project Manager: Manikandan Chandrasekaran
Design Direction: Margaret Reid

Printed in India

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 To my wife, Juliet – thank you for your encouragement and support.
To our children and their spouses – Hazel and Paul, Hubert and Natalie.
To our grandchildren – Annalisa and Jonathan, Hunter and Jackson.
To my co-editors for working with me over three editions.
To all authors who took time off their busy schedules to write their chapters.
To all patients with pain – with basic, translational, and clinical advances, we hope
your suffering will be better understood and treated.
Honorio T. Benzon
To Nori Benzon, who, through yet another revision of this text, this one during the course of a pandemic,
led the project with patience, persistence, and kindness; it is a great privilege to work with you.
To my wife and children – Bobbi, Lauren, James, and Cara – thank you for your tremendous support.
James P. Rathmell
This work is dedicated to my parents (Shy-Hsien and Tsai-Lien), children (Emily and Alex), partner
(Cynthia Cummis), and mentors. I am grateful for their continued support and encouragement.
Christopher L. Wu
To my many mentors, collaborators, and colleagues; way too many to list, but all of whom have contributed
greatly to my understanding of the people and especially the plight of people who experience persistent pain.
They have truly enriched my journey. And with gratitude to LORRAINE, more than a wife, a partner, and
my best friend; for her consistent and unyielding patience, tolerance, and sacrifices throughout our marriage.
Dennis C. Turk
To my wife and best friend Pat – what an adventure we are having together!
To our children David, Melanie, and Emily – it has been a joy to watch you grow into unique and
amazing adults.
To Nori Benzon – for asking me to be a part of this project and for his persistence and diligence in assuring
its completion in such a dignified manner. To each of the co-editors – I am so grateful to have had the
opportunity to work with and learn from you as we completed this venture together.
And to those who experience acute and chronic pain – it is my sincere hope that our ongoing determination
to better understand the multiple mechanisms of pain and how to best treat painful conditions will lead to
greater pain relief and less suffering.
Charles E. Argoff
To my wife and best friend, Meredith, for her unending support.
To my daughter, Alexandra, and sons, Sebastian and Gibson, my greatest joys.
To my parents, Morrison and Brenda, and my sister, Erin, who have always kept me grounded.
To my mentors, Donna Hammond, Steve Cohen, and Chris Wu, for fostering my interests and,
when needed, reining me in.
To my collaborators, for questioning every sentence I put down on paper.
Robert W. Hurley
To my wife and best friend, Carrie, for showing me the power of authenticity and how embodying that
principle allows one to fulfill their greatest potential in life and work. You are my why.
To my children, Stellan and Emmett, your support of mommy’s “doctor work” is infinitely
appreciated. Keep reaching for the stars; there is no limit to what you can achieve if you are true to yourself.
To Nori Benzon, Rob Hurley, Dan Clauw, Nirmala Abraham, Chad Brummett, and Talal Khan, my
mentors, sponsors, and cheerleaders. I have nothing but deep gratitude for the support, guidance, and
friendship you have bestowed upon me over the years.
To the patients who enrich my life by entrusting me to care for them, thank you for your strength despite
adversity, vulnerability, and willingness to embark on a journey of healing with me.
Andrea L. Chadwick
Contributors

Gregory A. Acampora, MD Charles E. Argoff, MD

Faculty Psychiatrist Professor of Neurology
Department of Psychiatry Albany Medical College
Massachusetts General Hospital; Vice Chair Department of Neurology
Assistant Professor of Psychiatry Director, Comprehensive Pain Center
Harvard Medical School; Director, Pain Management Fellowship
Consultant Psychiatrist Albany Medical Center
Department of Anesthesiology Critical Care and Pain Medicine Albany, New York
Massachusetts General Hospital
Boston, Massachusetts Javier De Andrés Ares, MD, PhD, FIPP
Chair, Pain Unit
Meredith C.B. Adams, MD, MS Pain Unit-Anesthesia
Assistant Professor Hospital Universitario La Paz
Department of Anesthesiology Madrid, Spain
Wake Forest Baptist Health
Winston-Salem, North Carolina Ralf Baron, MD
Professor and Chair
Deepti Agarwal, MD Division of Neurological Pain Research and Therapy
Lake Forest Hospital Department of Neurology
Assistant Professor of Clinical Anesthesiology University Hospital Schleswig-Holstein Campus Kiel
Northwestern University Feinberg School of Medicine Kiel, Germany
Chicago, Illinois
Declan Barry, PhD
Aurelio Alonso, DDS, MS, PhD Director
Assistant Professor APT Foundation Pain Treatment Services;
Director of Orofacial Pain Associate Professor
Department of Anesthesiology, Division of Pain Medicine, Department of Psychiatry and Child Study Center
Center for Translational Pain Medicine Yale School of Medicine
Duke Innovative Pain Therapies New Haven, Connecticut
Duke University
Durham, North Carolina Himayapsill Batista Quevedo, PharmD
PGY2 Pain and Palliative Care Pharmacy Resident
Thomas Anthony Anderson, PhD, MD Department of Pharmacy
Associate Professor Albany Straton VA Medical Center
Department of Anesthesiology, Perioperative and Pain Medicine Albany, New York
Stanford School of Medicine
Stanford, California Mark Beitel, PhD
Director of Research
Magdalena Anitescu, MD, PhD, FASA Pain Treatment Service
Professor of Anesthesia and Pain Medicine The APT Foundation;
Section Chief, Pain Management Associate Research Scientist
Director, Multidisciplinary Pain Medicine Fellowship Child Study Center;
Department of Anesthesia and Critical Care Assistant Clinical Professor
University of Chicago Medicine Department of Psychiatry, and Lecturer, Ethnicity,
Chicago, Illinois Race, and Migration
Yale University
New Haven, Connecticut

vi
 Contributors vii

Fabrizio Benedetti, MD Staja Q. Booker, PhD, RN

Professor Assistant Professor
Department of Neuroscience Department of Biobehavioral Nursing Science
University of Turin Medical School College of Nursing
Turin, Italy; University of Florida
Director Gainesville, Florida
Medicine & Physiology of Hypoxia
Plateau Rosà, Switzerland Kim J. Burchiel, MD, FACS
John Raaf Professor
John C. Benson, MD Department of Neurological Surgery
Assistant Professor Professor, Department of Anesthesiology and
Department of Radiology Perioperative Medicine
Mayo Clinic Oregon Health & Science University
Rochester, Minnesota Portland, Oregon

Honorio T. Benzon, MD Nicholas E. Burjek, MD

Professor Assistant Professor of Anesthesiology
Department of Anesthesiology Department of Anesthesiology
Northwestern University Feinberg School of Medicine Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois Northwestern University Feinberg School of Medicine
Chicago, Illinois
Hubert A. Benzon, MD
Attending Anesthesiologist Yi Cai, MD
Department of Pediatric Anesthesiology Fellow, Pain Medicine
Ann & Robert H. Lurie Children’s Hospital of Chicago Department of Anesthesiology
Associate Professor of Anesthesiology University of San Diego
Northwestern University Feinberg School of Medicine San Diego, California
Chicago, Illinois
Kenneth D. Candido, MD
Anuj Bhatia, MBBS, MD, PhD, FRCPC, FRCA, FFPMRCA Chairman, Department of Anesthesiology
Associate Professor Illinois Masonic Hospital
Department of Anesthesia and Pain Medicine Clinical Professor of Anesthesiology
University of Toronto University of Illinois at Chicago
University Health Network - Toronto Chicago, Illinois
Western Hospital, Women’s College Hospital
Toronto, Ontario, Canada Andrea L. Chadwick, MD, MSc, FASA
Associate Professor
Ravneet Bhullar, BSc, MD, FASA Department of Anesthesiology, Pain, and Perioperative Medicine
Associate Professor and Director University of Kansas School of Medicine
Division of Chronic Pain Management Kansas City, Kansas
Department of Anesthesiology
Albany Medical Center Ronil V. Chandra, MBBS, MMed, FRANZCR, CCINR
Albany, New York Associate Professor
Department of NeuroInterventional Radiology
Klaus Bielefeldt, MD, PhD Monash Health;
Professor Medicine (Gastroenterology) Associate Professor
George E. Wahlen Department of Veterans Faculty of Medicine, Nursing and Health Sciences
Affairs Medical Center Monash University
University of Utah Medical School Melbourne, Australia
Salt Lake City, Utah
Kailash Chandwani, MD
Anna Blanchfield Medical Director Pain Management
Department of Neuroscience and Experimental Therapeutics UNC Health Southeastern
Albany Medical College Lumberton, North Carolina
Albany, New York
Andrew K. Chang, MD, MS
Milana Bochkur Dratver, BS, MS Vincent P. Verdile, MD, ‘84 Endowed Chair for
Medical Student Emergency Medicine
Department of Urology Vice Chair of Research and Academic Affairs
Massachusetts General Hospital Professor of Emergency Medicine
Boston, Massachusetts Albany Medical Center
Albany, New York
viii Contributors

Yun-Yun K. Chen, MD University College London

Department of Anesthesiology London, Great Britain;
Perioperative and Pain Medicine Visiting Research Scholar
Brigham and Women’s Hospital Department of Sociology
Boston, Massachusetts University of Witwatersrand
Johannesburg, South Africa
Jianguo Cheng, MD, PhD
Professor of Anesthesiology David Copenhaver, MD, MPH
Director, Pain Management Chief, Pain Medicine Division
Cleveland Clinic Director of Cancer Pain Management
Cleveland, Ohio Director of Pain Medicine Tele-Health;
Professor
Delia Chiaramonte, MD, MS Division of Pain Medicine
Division Chief Integrative and Palliative Medicine, Department of Anesthesiology and Pain Medicine
Gilchrist/Greater Baltimore Medical Center Department of Neurological Surgery
Affiliate Assistant Professor Department of Lawrence J. Ellison Ambulatory Care Center
Pharmacy Practice and Science, Sacramento, California
University of Maryland
Baltimore, Maryland Megan H. Cortazzo, MD
Associate Professor of Physical Medicine and Rehabilitation
Roger Chou, MD Department of PM&R
Professor University of Pittsburgh School of Medicine
Department of Medical Informatics and Clinical Epidemiology Pittsburgh, Pennsylvania
Oregon Health & Science University
Director Samantha Curran, BS
Pacific Northwest Evidence-based Practice Center Clinical Research Assistant
Oregon Health & Science University Department of Anesthesiology
Portland, Oregon Brigham & Women’s Hospital
Boston, Massachusetts
Daniel J. Clauw, MD
Professor of Anesthesiology Chris D’Adamo, MD
Department of Medicine (Rheumatology) and Psychiatry Assistant Professor
Director, Chronic Pain and Fatigue Research Center Departments of Family and Community Medicine and
University of Michigan Medical School Epidemiology and Public Health
Ann Arbor, Michigan Center for Integrative Medicine
University of Maryland School of Medicine
Steven P. Cohen, MD Baltimore, Maryland
Chief, Pain Medicine
Department of Anesthesiology & Critical Care Medicine Dana Dailey, PT, PhD
Johns Hopkins Medical Institutions; Assistant Professor
Professor Department of Physical Therapy
Department of Anesthesiology, Neurology and Physical Medicine St. Ambrose University
& Rehabilitation and Psychiatry & Behavioral Sciences Davenport, Iowa;
Johns Hopkins School of Medicine Research Scientist
Baltimore, Maryland; Physical Therapy and Rehabilitation Sciences
Professor University of Iowa
Anesthesiology and Physical Medicine & Rehabilitation Iowa City, Iowa
Walter Reed National Military Medical Center
Uniformed Services University of the Health Sciences Carlton D. Dampier, MD
Bethesda, Maryland Professor
Department of Pediatrics
Heather A. Columbano, MD Emory University School of Medicine
Assistant Professor Atlanta, Georgia
Department of Anesthesiology
Medical Director of Spine Medicine Elise J.B. De, MD, FACS
Associate Program Director Pain Fellowship FACS Associate Professor Surgery
Atrium Health Wake Forest Baptist Harvard Medical School;
Winston-Salem, North Carolina Department of Urology
Massachusetts General Hospital
Silvie Cooper, PhD Boston, Massachusetts
Lecturer (Teaching)
Applied Health Research
 Contributors ix

James Deering, MD Robert R. Edwards, PhD

Carolinas Pain Institute and Chronic Pain Research Institute Associate Professor
Winston-Salem, North Carolina Department of Anesthesiology, Perioperative and Pain Medicine
Brigham and Women’s Hospital
Lauriane Delay, PhD Harvard Medical School
Postdoctoral Researcher Boston, Massachusetts
Department Anesthesiology
University of California, San Diego Lori-Ann Edwards, MB, BS
San Diego, California; Resident
Department of Pharmacology Department of Anesthesiology
NeuroDol Temple University Hospital
Clermont-Ferrand Philadelphia, Pennsylvania
Auvergne, France
Dalya Elhady, MD
David J. Derrico, RN, MSN, CNE Fellow
Assistant Clinical Professor Department of Pain Medicine
Department of Biobehavioral Nursing Science The University of Texas MD Anderson Cancer Center
University of Florida Interventional Pain Specialist
College of Nursing Private Practice
Gainesville, Florida Houston, Texas
Anthony H. Dickenson, BSc, PhD Bonnie S. Essner, PhD
Professor of Neuropharmacology Assistant Professor
Department of Neuroscience Department of Psychiatry and Behavioral Sciences
Physiology and Pharmacology Northwestern University Feinberg School of Medicine
University College London Pritzker Department of Psychiatry and Behavioral Health
London, Great Britain Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois
Felix E. Diehn, MD
Associate Professor Scott M. Fishman, MD
Department of Radiology Professor and Executive Vice-Chair
Division of Neuroradiology Department of Anesthesiology and Pain Medicine
Mayo Clinic University of California, Davis School of Medicine;
Rochester, Minnesota Chief, Pain Medicine
Department of Pain Medicine/Anesthesiology
Massimiliano DiGiosia, DDS University of California, Davis School of Medicine;
Associate Professor Director
Diagnostic Sciences Center for Advancing Pain Relief
Adams School of Dentistry-University of North Carolina University of California, Davis
Chapel Hill, North Carolina Sacramento, California
Ryan S. D’Souza, MD
Dermot Fitzgibbon, MB, BCh, BAO
Assistant Professor
Professor
Director of Neuromodulation
Department of Anesthesiology & Pain Medicine
Department of Anesthesiology and Perioperative Medicine
University of Washington School of Medicine;
Mayo Clinic Hospital
Medical Director
Rochester, Minnesota
Seattle Cancer Care Alliance
Robert Duarte, MD Seattle, Washington
Montefiore Medical Center
Bronx, New York Grace Forde, MD
Director of Neurological Services
Andrew Dubin, MD, MS Neurology-Pain Management
Professor of Physical Medicine and Rehabilitation North American Partners In Pain Management
Department of Physical Medicine and Rehabilitation Lake Success, New York
University of Florida
Gainesville, Florida Elisa Frisaldi, PhD
Research Fellow in Neurophysiology
Lauren K. Dunn, MD, PhD Department of Neuroscience
Associate Professor University of Turin Medical School
Department of Anesthesiology Turin, Italy
University of Virginia
Charlottesville, Virginia
 x Contributors

Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP, FFSMB Carlos E. Guerrero, MD, FIPP
Clinical Pharmacy Specialist and Founder/Former Director Anesthesiologist and Pain Management Specialist
PGY2 Pain & Palliative Care Pharmacy Residency University Hospital Fundacion Santa Fe
Pharmacy Department Bogota, Colombia;
Stratton VA Medical Center Professor Universidad El Bosque
Albany, New York; Professor Universidad de los Andes
Adjunct Associate Professor Bogota, Colombia
Pharmacy Practice
Western New England University College of Pharmacy Amit Gulati, MD
Springfield, Massachusetts; Associate Attending
Adjunct Associate Professor Anesthesiology and Critical Care
Pharmacy Practice Memorial Sloan Kettering Cancer Center
Albany College of Pharmacy and Health Sciences New York, New York
Albany, New York;
President Amir Hadanny, MD
Remitigate Therapeutics Department of Neurosurgery
Delmar, New York Albany Medical Center
Albany, New York
Timothy Furnish, MD
Clinical Professor Thomas Hadjistavropoulos, PhD, ABPP, FCAHS
Department of Anesthesiology Professor and Research Chair in Aging and Health
University of California, San Diego Health Department of Psychology and Centre on Aging Health
San Diego, California University of Regina
Regina, Saskatchewan, Canada
Katherine E. Galluzzi, DO, CMD, FACOFPd
Professor and Chair Carlyle Peters Hamsher, MD
Department of Geriatric and Palliative Medicine Assistant Professor
Philadelphia College of Osteopathic Medicine Department of Anesthesiology
Philadelphia, Pennsylvania Atrium Health Wake Forest Baptist
Winston Salem, North Carolina
Marina Gaeta Gazzola, BS
MD Student Michael C. Hanes, MD
Yale School of Medicine; Jax Spine & Pain Centers
Research Assistant the APT Foundation Jacksonville, Florida
New Haven, Connecticut
Gretchen Hermes, MD, PhD
Katherine Gentry, MD, MA Medical Director
Assistant Professor, Anesthesiology and Pain Medicine APT Foundation;
University of Washington School of Medicine Assistant Professor
Affiliate Faculty, Treuman Katz Center for Pediatric Bioethics Department of Psychiatry
Seattle Children’s Hospital Yale University School of Medicine
New Haven, Connecticut
Christopher Gilmore, MD
Carolinas Pain Institute Keela A. Herr, PhD, RN, AGSF, FGSA, FAAN
Center for Clinical Research Kelting Professor & Associate Dean for Faculty
Winston-Salem, North Carolina College of Nursing
The University of Iowa
Gilson Gonçalves dos Santos, PhD Iowa City, Iowa
Department of Anesthesiology
University of California Louise Hillen, MD
San Diego, California Associated Anesthesiologists, P.A.
Plymouth, Minnesota
Debra B. Gordon, RN, DNP, FAAN
Co-Director Harborview Integrated Pain Care Program Joshua A. Hirsch, MD
Department of Anesthesiology & Pain Medicine Vice-Chair
University of Washington Department of Radiology
Seattle, Washington Harvard Medical School
Department of Radiology
Massachusetts General Hospital
Boston, Massachusetts
 Contributors xi

Marshall T. Holland, MD, MS Charles Inturrisi, PhD

Assistant Professor of Neurosurgery Professor
Department of Neurosurgery Department of Pharmacology
University of Alabama at Birmingham Marnix E. Weill Cornell Medicine
Heersink School of Medicine New York, New York
The University of Alabama at Birmingham
Birmingham, Alabama Mohammed A. Issa, MD
Clinical Instructor
Rebecca Hoss, PharmD Departments of Anesthesiology and Psychiatry
SUD and Analgesia Pharmacy Specialist Brigham and Women’s Hospital, Harvard Medical School
Department of Pharmacy Boston, Massachusetts
University of California Medical Center
Sacramento, California Robert N. Jamison, PhD
Professor
Margaret Hsu, MD Departments of Anesthesiology and Psychiatry
Assistant Professor Brigham and Women’s Hospital
Department of Anesthesiology Harvard Medical School
University of Washington Medical System Boston, Massachusetts
Seattle, Washington
Ru-Rong Ji, PhD
Yul Huh, MD Professor and Director
Center for Translational Pain Medicine Center for Translational Pain Medicine
Department of Anesthesiology Department of Anesthesiology
Duke University Medical Center Duke University Medical Center
Durham, North Carolina Durham, North Carolina

Christine L. Hunt, DO, MS Rebecca L. Johnson, MD, FASA

Assistant Professor Associate Professor of Anesthesiology
Pain Medicine Department Department of Anesthesiology and Perioperative Medicine
Mayo Clinic Mayo Clinic
Jacksonville, Florida Rochester, Minnesota

Marc A. Huntoon, MD Jatin Joshi, MD

Professor with Tenure Assistant Professor
Department of Anesthesiology Department of Anesthesiology
Vice Chair Weill Cornell Medicine
Department of Anesthesiology, New York, New York
VCU Health, Virginia Commonwealth University
Richmond, Virginia Leonardo Kapural, MD, PhD
Director
Robert W. Hurley, MD, PhD Carolinas Pain Institute at Brookstown
Professor Wake Forest Baptist Health;
Associate Dean Professor of Anesthesiology
Department of Anesthesiology Wake Forest University
Department of Neurobiology and Anatomy School of Medicine
Wake Forest University School of Medicine; Winston-Salem, North Carolina
Executive Director
Pain Service Line Robert D. Kerns, PhD
Atrium Health - Wake Forest Baptist Professor of Psychiatry
Winston Salem, North Carolina Neurology and Psychology
Yale University
Frank J.P.M. Huygen, MD, PhD, FFPMCAI (hon) New Haven, Connecticut
Professor and Chair
Department of Anesthesiology and Pain Medicine Dost Khan, MD
Erasmusmc University Hospital Assistant Professor
Rotterdam, The Netherlands; Department of Anesthesiology
Professor Northwestern University Feinberg School of Medicine
Department of Anesthesiology and Pain Medicine Chicago, Illinois
University Medical Center Utrecht
Utrecht, The Netherlands
xii Contributors

Olga Khazen Julian Maingard, BBiomedSc, MBBS, FRANZCR, CCINR, EBIR

Department of Neuroscience and Experimental Therapeutics Consultant Interventional Neuroradiologist Austin Health;
Albany Medical College Consultant Interventional Neuroradiologist St Vincent’s Health;
Albany, New York Senior Lecturer
Faculty of Medicine, Nursing and Health Sciences
Jessica Kruse, MA Monash University
Doctoral Candidate Melbourne, Australia;
Ferkauf Graduate School of Psychology Senior Lecturer
Yeshiva University School of Medicine
New York, New York Deakin University

Nebojsa Nick Knezevic, MD, PhD Una E. Makris, MD, MSc

Vice-Chair for Research and Education Associate Professor
Associate Program Director Department of Internal Medicine
Department of Anesthesiology University of Texas Southwestern Medical Center;
Advocate Illinois Masonic Medical Center; Staff Physician
Clinical Professor Medical Service, Rheumatology
Department of Anesthesiology North Texas Health Care System
University of Illinois; Dallas, Texas
Clinical Professor
Department of Surgery Khalid Malik, MD, MBA, FRCS
University of Illinois Professor
Chicago, Illinois Department of Anesthesiology
Division Chief, Pain Medicine
Preetma Kaur Kooner, MD University of Illinois
Assistant Professor Chicago, Illinois
Department of Anesthesiology and Pain Medicine
University of Washington Timothy P. Maus, MD
Seattle, Washington Professor of Radiology
Department of Radiology
Evangeline P. Koutalianos, MD Mayo Clinic
Assistant Professor of Physical Medicine & Rehabilitation Rochester, Minnesota
SUNY Upstate Medical University
Syracuse, New York Zachary L. McCormick, MD
Associate Professor
Christopher M. Lam, MD Chief, Spine and Musculoskeletal Medicine
Assistant Professor Division
Department of Anesthesiology, Pain and Perioperative Medicine Department of Physical Medicine and Rehabilitation
University of Kansas School of Medicine University of Utah School of Medicine
Kansas City, Kansas Salt Lake City, Utah

Daniel B. Larach, MD, MTR, MA Anne Marie McKenzie-Brown, MD

Assistant Professor Associate Professor
Department of Anesthesiology Department of Anesthesiology
Vanderbilt University School of Medicine Emory University School of Medicine
Nashville, Tennessee Atlanta, Georgia

James Littlejohn, MD, PhD Samantha M. Meints, PhD

Assistant Professor of Clinical Anesthesiology Clinical Pain Psychologist
Division of Critical Care Medicine Department of Anesthesiology
Weill Cornell Medicine Perioperative and Pain Medicine
New York, New York Brigham and Women’s Hospital;
Instructor
Mary Leemputte, MD Harvard Medical School
Fellow in Pain medicine Boston, Massachusetts
Massachusetts General Hospital
Boston, Massachusetts Matthew Meroney, MD
Associate Professor
Department of Anesthesiology
University of Florida College of Medicine
Gainesville, Florida
 Contributors xiii

Jee Youn Moon, MD, PhD, FIPP, CIPS Ariana M. Nelson, MD

Associate Professor Associate Professor
Department of Anesthesiology and Pain Medicine Anesthesiology and Perioperative Medicine
Seoul National University College of Medicine Division of Pain Medicine
Seoul, Korea University of California, Irvine
Irvine, California;
Juan C. Mora, MD Physician, Aerospace Medicine Research
Assistant Professor Exploration Medical Capability Element
Department of Anesthesiology NASA (National Aeronautics and Space Administration)
University of Florida College of Medicine
Gainesville, Florida Diane Novy, MD
Professor
Brian Morrison, DC Department of Anesthesiology
Baltimore, Maryland The University of Texas-Houston Health Science Center
Department of Psychiatry and Behavioral Sciences
Natalie Moryl, MD The University of Texas-Houston Health Science Center
Memorial Sloan Kettering Cancer Center University Center for Pain Medicine and Rehabilitation at
New York, New York Hermann Hospital
Houston, Texas
Jana M. Mossey, PhD, MPH, MSN
Professor Emerita Shannon Nugent, PhD
Epidemiology and Biostatistics, Dornsife School of Public Health Assistant Professor
Drexel University Department of Psychiatry
Philadelphia, Pennsylvania Oregon Health and Science University
Portland, Oregon
Tasha B. Murphy, PhD
Behavioral Medicine Research Group Akiko Okifuji, PhD
School of Social Work Professor
University of Washington Division of Pain Medicine
Seattle, Washington Department of Anesthesiology
University of Utah
Antoun Nader, MD Salt Lake City, Utah
Professor of Anesthesiology and Orthopedic Surgery
Department of Anesthesiology Dikachi Osaji, BA, MS
Northwestern University Research
Chicago, Illinois Department of Anesthesia, Perioperative and Pain Medicine
Brigham and Women’s Hospital
Geeta Nagpal, MD Boston, Massachusetts
Associate Professor Jan Alberto Paredes Mogica, MD
Department of Anesthesiology Health Sciences
Northwestern Memorial Hospital Faculty of Medicine
Chicago, Illinois Anahuac University
Huixquilucan, Mexico
Lynn Nakad, MSN, RN
Research Assistant Sagar S. Parikh, MD
University of Iowa Interventional Pain Physician
College of Nursing Pain Fellowship Program Director
Iowa City, Iowa JFK Johnson Rehabilitation Institute
Hackensack Meridian Healt
Mithun Nambiar, MBBS, BMedSc Hoboken, New Jersey
Department of NeuroInterventional Radiology, Monash Health;
Adjunct Lecturer Ryan Patel, BA, PhD
Faculty of Medicine, Nursing and Health Sciences Research associate
Monash University Department of Neuroscience, Physiology and Pharmacology
Melbourne, Australia University College London
Captain, Royal Australian Army Medical Corps, Australian London, Great Britain
Defence Force
Feyce M. Peralta, MD, MS
Associate Professor
Department of Anesthesiology
Northwestern University Feinberg School of Medicine
Chicago, Illinois
xiv Contributors

Julie G. Pilitsis, MD, PhD Mohammed I. Ranavaya II, MD

Chair and Professor Resident Physician- General Surgery
Department of Neuroscience & Experimental Therapeutics University of Louisville
Albany Medical College Hiram C. Polk, Jr., MD Department of Surgery
Professor of Neurosurgery Louisville, Kentucky
Department of Neurosurgery
Albany Medical College Ahmed M. Raslan, MD
Albany, New York Associate Professor
Department of Neurological Surgery
Mohammad Piracha, MD Oregon Health & Science University
New York Presbyterian/Weill Cornell Medical Center Portland, Oregon
Department of Anesthesiology
New York, New York James P. Rathmell, MD, MBA
Chair
Andrew J. B. Pisansky, MD, MS Department of Anesthesiology, Perioperative and Pain Medicine
Assistant Professor Brigham and Women’s Hospital
Department of Anesthesiology Leroy D. Vandam Professor of Anaesthesia
Vanderbilt University Harvard Medical School
Nashville, Tennessee Boston, Massachusetts

Markus Ploner, PhD, Dr.med. Mathieu Roy, PhD

Professor of Human Pain Research Assistant Professor
Department of Neurology, Center for Interdisciplinary Pain Department of Psychology
Medicine, and TUM-Neuroimaging Center Alan Edwards Center for Research on Pain
Technical University of Munich McGill University
Munich, Germany Montreal, Canada

Elisabeth B. Powelson, MD John E. Rubin, MD

Clinical Instructor Instructor in Anesthesiology
Department of Anesthesiology & Pain Medicine Division of Regional Anesthesiology and Acute Pain Medicine
University of Washington Department of Anesthesiology
Seattle, Washington Weill Cornell Medicine
New York, New York
David A. Provenzano, MD
Juliane Sachau, MD
Pain Diagnostics and Interventional Care
Resident
Sewickley, Pennsylvania
Division of Neurological Pain Research and Therapy
Department of Neurology
Rene Przkora, MD, PhD
University Hospital Schleswig-Holstein Campus Kiel
Professor
Kiel, Germany
Department of Anesthesiology
University of Florida College of Medicine Patrick Schober, MD, PhD
Gainesville, Florida Amsterdam University Medical Center
Bijlmer, Amsterdam, The Netherlands
Jamila I. Ranavaya, BS, MD
Resident Physician Kristin L. Schreiber, MD, PhD
Combined Internal Medicine-Pediatrics Residency Associate Professor
Joan C. Edwards School of Medicine at Marshall University Anesthesiology, Perioperative, and Pain Medicine
Huntington, West Virginia Brigham and Women’s Hospital
Boston, Massachusetts
Mohammed I. Ranavaya, MD, JD
Professor and Chief Elizabeth K. Seng, PhD
Division of Occupational Medicine Associate Professor
Joan C. Edwards School of Medicine at Marshall University; Ferkauf Graduate School of Psychology
President Yeshiva University;
American Board of Independent Medical Examiners; Research Associate Professor
Medical Director Albert Einstein College of Medicine
Appalachian Institute of Occupational and Environmental Bronx, New York
Medicine
Huntington, West Virginia
 Contributors xv

Ravi Shah, MD Jordan Starr, MD

Associate Professor of Anesthesiology Acting Assistant Professor
Department of Pediatric Anesthesiology Department of Anesthesiology and Pain Medicine
Ann & Robert H. Lurie Children’s Hospital University of Washington
Northwestern University Seattle, Washington
Chicago, Illinois
Kylie Steinhilber, MA
Aziz Shaibani, MD Department of Psychology
Director Suffolk University
Nerve and Muscle Center of Texas Boston, Massachusetts
Houston Neurocare
Clinical Professor of Medicine Natalie H. Strand, MD
Baylor College of Medicine Associate Professor Anesthesiology and Pain Medicine
Houston, Texas Department of Anesthesiology, Division of Pain Medicine
Mayo Clinic
Liang Shen, MD, MPH Phoenix, Arizona
Assistant Professor of Clinical Anesthesiology
Department of Anesthesiology Mark D. Sullivan, MD, PhD
Weill Cornell Medicine Professor
New York, New York Department of Psychiatry and Behavioral Sciences
Adjunct Professor, Anesthesiology and Pain Medicine
Stephen D. Silberstein, MD
Adjunct Professor, Bioethics and Humanitie
Professor
University of Washington
Department of Neurology
Seattle, Washington
Thomas Jefferson University;
Director
Santhanam Suresh, MD, MBA, FAAP
Jefferson Headache Center
Arthur C. King Professor
Thomas Jefferson University Hospital
Department of Pediatric Anesthesiology
Philadelphia, Pennsylvania
Senior Vice-President, Chief of Provider Integration
Priyanka Singla, MBBS, MD Ann & Robert H Lurie Children’s Hospital of Chicago
Resident Professor of Anesthesiology & Pediatrics
Department of Anesthesiology Northwestern University’s Feinberg School of Medicine
University of Virginia Chicago, Illinois
Charlottesville, Virginia
David J. Tauben, MD
Lee-Anne Slater, MBBS (Hons), FRANZCR, MMed, CCINR Clinical Professor Emeritus
Consultant Interventional Neuroradiologist Monash Health; Department of Medicine, Division of General Medicine
Senior Lecturer Department of Anesthesia and Pain Medicine
Faculty of Medicine, Nursing and Health Sciences University of Washington
Monash University Seattle, Washington
Melbourne, Australia
Gregory W. Terman, MD, PhD
Kathleen A. Sluka, PT, PhD Professor
Professor Department of Anesthesiology and Pain Medicine
Department of Physical Therapy and Rehabilitation Science University of Washington
Department of Neuroscience and Pharmacology Seattle, Washington
Pain Research Program
University of Iowa Reda Tolba, MD
Iowa City, Iowa Department Chair Pain Management
Anesthesiology Institute, Cleveland Clinic
Brett R. Stacey, MD Abu Dhabi, UAE;
Professor Clinical Professor of Anesthesiology
Department of Anesthesiology & Pain Medicine Cleveland Clinic Lerner College of Medicine
Division Chief, Pain Medicine Cleveland Clinic Foundation
Department of Anesthesiology & Pain Medicine Cleveland, Ohio
University of Washington
Seattle, Washington Dennis C. Turk, PhD
John and Emma Bonica Professor of Anesthesiology &
Steven P. Stanos, DO Pain Research
Executive Medical Director, Rehabilitation & Performance Medicine Department of Anesthesiology & Pain Medicine
Swedish Pain Services University of Washington
Swedish Heatlh System Seattle, Washington
Seattle, Washington
xvi Contributors

Mark D. Tyburski, MD Jeanine A. Verbunt, MD, PhD

Co-Chief, Department of Pain Medicine Department of Rehabilitation Medicine
The Permanente Medical Group Research School CAPHRI
Sacramento/Roseville, California Maastricht University
Maastricht, The Netherlands;
Etienne Vachon-Presseau, PhD Adelante Centre of Expertise in Rehabilitation and Audiology
Faculty of Dentistry Hoensbroek, The Netherlands
Alan Edwards Center for Research on Pain
McGill University Thomas R. Vetter, MD, MPH
Montreal, Quebec, Canada Professor
Department of Surgery and Perioperative Care
Koen van Boxem, MD, PhD, FIPP Department of Population Health
Department of Anesthesiology Dell Medical School at the University of Texas at Austin
Critical Care and Multidisciplinary Pain Center Austin, Texas
Ziekenhuis Oost-Limburg
Lanaken - Genk, Belgium; Elayne Viera, MD
Department of Anesthesiology and Pain Medicine Postgraduate Program on Physical Education
Maastricht University Medical Center Universidade Católica de Brasília
Maastricht, The Netherlands Taguatinga, Brazil

Maarten van Eerd, MD, PhD, FIPP Daniela Vivaldi, DDS

Department of Anesthesiology and Pain Management Clinical Associate
Amphia Ziekenhuis Department of Anesthesiology, Division of Pain Medicine,
Breda, The Netherlands; Center for Translational Pain Medicine
Leiden University Medical Centre (LUMC), Duke Innovative Pain Therapy
Department of Anesthesiology, Intensive Care and Pain Medicine Duke University
Leiden, The Netherlands Durham, North Carolina

Jan van Zundert, MD, PhD, FIPP Iris Vuong, MD

Professor in Pain Medicine Resident in Internal Medicine
Department of Anesthesiology and Pain Medicine Department of Internal Medicine
Maastricht University Medical Center University of California, Davis School of Medicine
Maastricht, The Netherlands; Sacramento, California
Head of Multidisciplinary Pain Centre
Department of Anesthesiology, Critical Care and Pain Medicine Graham Wagner, MD
Ziekenhuis Oost-Limburg Assistant Professor
Lanaken - Genk, Belgium Department of Physical Medicine and Rehabilitation
University of Utah
Carol G.T. Vance, PT, PhD Salt Lake City, Utah
Department of Physical Therapy and Rehabilitation Science
University of Iowa Sayed E. Wahezi, MD
Iowa City, Iowa Associate Professor
Department of Physical Therapy Department of Rehabilitation Medicine
St Ambrose University Program Director, Pain Medicine Fellowship
Davenport, Iowa Montefiore Medical Center
Bronx, New York

Thibaut Vanneste, MD Gary A. Walco, PhD

Department of Anesthesiology, and Multidisciplinary Professor
Pain Center Department of Anesthesiology and Pain Medicine
Ziekenhuis Oost-Limburg University of Washington;
Lanaken - Genk, Belgium; Director of Pain Medicine
Department of Anesthesiology and Pain Medicine Department of Anesthesiology and Pain Medicine
Maastricht University Medical Center Seattle Children’s Hospital
Maastricht, The Netherlands Seattle, Washington

Angelica A. Vargas, MD Mark S. Wallace, MD

Assistant Professor of Anesthesiology Professor
Northwestern University Feinberg School of Medicine; Department of Anesthesiology
Department of Pediatric Anesthesiology Ann & Robert H. Lurie University of California, San Diego Health System
Children’s Hospital San Diego, California
Chicago, Illinois
 Contributors xvii

David Andrew Walsh, PhD, FRCP Christopher L. Wu, MD

Professor of Rheumatology Clinical Professor of Anesthesiology
Department of Academic Rheumatology Department of Anesthesiology
University of Nottingham Hospital for Special Surgery;
Nottingham, Great Britain Clinical Professor of Anesthesiology
Department of Anesthesiology
Ning Nan Wang, MDCM, FRCPC Weill Cornell Medicine
Clinical Fellow New York City, New York
Anesthesiology and Pain Medicine
Toronto Western Hospital Tony L. Yaksh, PhD
Toronto, Ontario, Canada Professor
Department of Anesthesiology
Ajay Wasan, MD, MSc University of California San Diego
Professor La Jolla, California
Department of Anesthesiology and Psychiatry
University of Pittsburgh Nantthasorn Zinboonyahgoon, MD
Pittsburgh, Pennsylvania Associate Professor
Chief, Division of Pain Medicine
Erica L. Wegrzyn, BS, PharmD Department of Anesthesiology
Clinical Pharmacy Specialist, Pain Management Faculty of Medicine
Stratton VA Medical Center Siriraj Hospital
Albany, New York Mahidol University
Bangkok, Thailand
Karin N. Westlund, PhD
Professor and Vice-Chair for Research Xander Zuidema, MD, PharmD
Department of Anesthesiology and Critical Care Medicine Department of Anesthesiology and Pain Management
University of New Mexico Health Science Center Diakonessenhuis Utrecht
Albuquerque, New Mexico Utrecht, The Netherlands;
Department of Anesthesiology and Pain Management
David A. Williams, PhD Academic Medical Center Maastricht
Professor Maastricht, The Netherlands
Department of Anesthesiology
University of Michigan
Ann Arbor, Michigan

Harriet Wittink, MD
Professor and Chair
Lifestyle and Health Research Group
Utrecht University of Applied Sciences
Utrecht, The Netherlands
Preface

The Practical Management of Pain, first published in 1986, is
one of the established textbooks on pain management. In 2008,
several of the current editors took over editorial leadership of
the fourth edition of the book. As pain is multidimensional,
starting in the fourth edition and continuing in the present
edition, we the editors, represent several disciplines related to
pain: anesthesiology, neurology, and psychology.
The Practical Management of Pain has evolved due to our in-
creasing understanding of pain and its underlying mechanisms,
which is reflected throughout this volume. Topics such as local
anesthetics, neuraxial anesthesia, technique of peripheral nerve
blocks, and associated topics were discontinued to focus on
pain-related topics. In this updated and expanded edition, we
have enlisted an outstanding set of clinicians and researchers
with considerable expertise in all facets of pain and its man-
agement to provide contemporary information as to why and
how best to evaluate and treat patients experiencing pain. We
believe that this volume truly represents state-of-the-art knowl-
edge and understanding of pain and its management.
To represent the growing body of knowledge in the field, we
have added Andrea Chadwick to this edition. Dr. Chadwick
brings particular expertise in the areas of fibromyalgia, non-
opioid management of pain, radiation exposure, among other
topics.
The production of a textbook involves the contributions,
encouragement, and support of a number of people. We thank
the authors, Michael Houston, Lisa Barnes, Manikandan
Chandrasekaran, Baljinder Kaur of Aptara, and everyone re-
lated to the development of this edition.
Honorio T. Benzon, MD
James P. Rathmell, MD
Christopher L. Wu, MD
Dennis C. Turk, PhD
Charles E. Argoff, MD
Robert W. Hurley, MD, PhD
Andrea L. Chadwick, MD

xix
Contents

Part 1: General Considerations 13 Pharmacogenetics in Pain Management, 151

Erica L. Wegrzyn, Himayapsill Batista Quevedo, Jeffrey Fudin,
1 History Is a Distillation of Rumor, 3 Charles E. Argoff
Natalie Moryl, Charles Inturrisi
14 Psychosocial and Psychiatric Aspects of Chronic
2 Classification of Acute Pain and Chronic Pain Pain, 159
Syndromes, 11 Dennis C. Turk, Tasha B. Murphy
Juan C. Mora, Rene Przkora, Matthew Meroney
15 Comprehensive Approach to Evaluating Patients
3 Organizing an Inpatient Acute Pain Service, 16 With Chronic Pain, 173
Preetma Kaur Kooner, Gregory W. Terman Dennis C. Turk, Brett R. Stacey, Elisabeth B. Powelson
4 Interdisciplinary Pain Management, 39 16 Mechanism-Based Treatment and Precision
Steven P. Stanos Medicine, 183
Jianguo Cheng, Yul Huh, Ru-Rong Ji
5 The Healthcare Policy of Pain Management, 57
Thomas R. Vetter 17 Placebo and Nocebo Effects in Clinical Trials and
6 Quality Assessment, Improvement, and Patient Clinical Practice, 194
Fabrizio Benedetti, Elisa Frisaldi, Aziz Shaibani
Safety in Pain Management, 67
Debra B. Gordon, James P. Rathmell
Part 3: Clinical Evaluation and Assessment
7 Education, Training, and Certification in Pain
Medicine, 87 18 History and Physical Examination of the Patient
James P. Rathmell, Anne Marie McKenzie-Brown With Pain, 207
Charles E. Argoff, Grace Forde, Sayed E. Wahezi, Robert Duarte
Part 2: Basic Considerations 19 Electromyography and Evoked Potentials, 219
Andrew Dubin
8 Neurophysiology of Pain: Peripheral, Spinal,
Ascending, and Descending Pathways, 95 20 Radiologic Assessment of Patient With Spine
Karin N. Westlund Pain, 232
Felix E. Diehn, John C. Benson, Timothy P. Maus
9 Neurochemistry of Nociception, 110
Tony L. Yaksh, Gilson Gonçalves dos Santos, Lauriane Delay, 21 Biomarkers of Pain: Quantitative Sensory
Elayne Viera Testing, Conditioned Pain Modulation, Punch
10 Neuroimaging Techniques, 125 Skin Biopsy, 290
Juliane Sachau, Ralf Baron
Mathieu Roy, Étienne Vachon-Presseau, Markus Ploner,
Ariana M. Nelson 22 Psychological and Behavioral Assessment, 299
Jessica Kruse, Robert D. Kerns, Elizabeth K. Seng
11 Individual Differences in Experience and
Treatment of Pain: Race, Ethnicity, and Sex, 138 23 Disability Assessment, 315
Samantha M. Meints, Dikachi Osaji, Kylie Steinhilber, Mohammed I. Ranavaya, Mohammed I . Ranavaya II,
Robert R. Edwards Jamila I. Ranavaya
12 Communication and Clinician Relationships to
Improve Care for Patients With Chronic Pain, 146
David J. Tauben, Mark D. Sullivan

xxi
xxii Contents

Part 4: Clinical Conditions: Evaluation 39 Cervicogenic Headache, Post-meningeal

Puncture Headache, and Spontaneous
and Treatment Intracranial Hypotension, 545
24 Chronic Post-surgical Pain Syndromes: Lori-Ann Edwards, Louise Hillen, Deepti Agarwal, Dost Khan,
Prediction and Preventive Analgesia, 333 Reda Tolba
Nantthasorn Zinboonyahgoon, Yun-Yun K. Chen, 40 Orofacial Pain, 560
Kristin L. Schreiber Aurelio Alonso, Massimiliano DiGiosia, Daniela Vivaldi
25 Evaluation and Pharmacologic Treatment of 41 Visceral Pain, 582
Postoperative Pain, 347 Klaus Bielefeldt
Lauren K. Dunn, Priyanka Singla
42 Pelvic Pain, 593
26 Regional and Multimodal Treatments of Jan Alberto Paredes Mogica, Milana Bochkur Dratver,
Perioperative Pain, 355 Elise J.B. De
Ryan S. D’Souza, Rebecca L. Johnson
43 Pediatric Chronic Pain Management, 620
27 Evaluation and Treatment of Postoperative Angelica A. Vargas, Ravi Shah, Bonnie S. Essner, Santhanam Suresh
Pain in Patients With Opioid Use Disorder, 374
Yi Cai, Gregory A. Acampora, T. Anthony Anderson 44 Geriatric Pain Management, 637
Keela A. Herr, Staja Q. Booker, Lynn Nakad, David J. Derrico
28 Evaluation and Treatment of Acute Pain in
Children, 385 45 Managing Pain During Pregnancy and
Ravi Shah, Santhanam Suresh, Nicholas E. Burjek Lactation, 647
Geeta Nagpal, Feyce M. Peralta, James P. Rathmell
29 Low Back Pain Disorders, 396
Khalid Malik, Ariana M. Nelson 46 Rheumatologic Conditions, 663
David Andrew Walsh
30 Buttock and Sciatica Pain, 413
Graham Wagner, Ariana M. Nelson, Steven P. Cohen, 47 Pain Management in Patients With
Zachary L. McCormick Comorbidities, 675
Natalie H. Strand, Andrea L. Chadwick
31 Facet Pain: Pathogenesis, Diagnosis, and
Treatment, 432
Steven P. Cohen, Javier De Andrés Ares
Part 5: Pharmacologic, Psychologic,
and Physical Medicine Treatments and
32 Neurosurgical Approaches to Pain
Management, 453 Associated Issues
Marshall T. Holland, Ahmed M. Raslan, Kim J. Burchiel
48 Major Opioids and Chronic Opioid Therapy, 689
33 Evaluation and Treatment of Cancer-Related David Copenhaver, Rebecca Hoss, Megan H. Cortazzo,
Pain, 461 Iris Vuong, Scott M. Fishman
Dermot Fitzgibbon, Margaret Hsu
49 Minor Analgesics: Non-Opioid and Opioid
34 Evaluation and Treatment of Neuropathic Pain Formulations, 703
Syndromes, 479 Steven P. Stanos, Mark D. Tyburski, Sagar S. Parikh
Christopher M. Lam, Andrea L. Chadwick, Robert W. Hurley
50 The U.S. Opioid Crisis and the Legal and
35 Evaluation and Treatment of Complex Regional Legislative Implications, 720
Pain Syndrome, 500 Jordan Starr, Mohammed A. Issa, Ajay Wasan
Frank J.P.M. Huygen
51 Evaluation for Opioid Management: Opioid
36 Evaluation and Treatment of Pain in Selected Misuse Assessment Tools and Drug Testing in
Neurologic Disorders, 507 Pain Management, 727
Amir Hadanny, Anna Blanchfield, Olga Khazen, Charles E. Argoff, Robert N. Jamison, Samantha Curran
Julie G. Pilitsis
52 Pain and Addictive Disorders: Challenge and
37 Chronic Widespread Pain, 520 Opportunity, 734
Meredith C.B. Adams, Daniel J. Clauw Shannon Nugent, Mark Beitel, Gretchen Hermes,
Marina Gaeta Gazzola, Declan Barry
38 Headache Management, 530
Stephen D. Silberstein 53 Anti-depressants, 743
Anthony H. Dickenson, Ryan Patel, Charles E. Argoff
 Contents xxiii

54 Adjunct Medications for Pain Management, 752 69 Minimally Invasive Procedures for Vertebral
Daniel B. Larach, Andrea L. Chadwick, Charles E. Argoff, Compression Fractures, 939
Robert W. Hurley Mithun Nambiar, Lee-Anne Slater, Joshua A. Hirsch,
Ronil V. Chandra, Julian Maingard
55 Skeletal Muscle Relaxants, 763
Ravneet Bhullar, Evangeline P. Koutalianos, Charles E. Argoff, 70 Biopsychosocial Pre-screening for Spinal Cord
Andrew Dubin and Peripheral Nerve Stimulation Devices, 950
Andrew J.B. Pisansky, Ajay Wasan, Mohammed A. Issa
56 Cannabinoids for Pain Management, 769
Ning Nan Wang, Anuj Bhatia 71 Spinal Cord Stimulation, Peripheral Nerve
Stimulation, Restorative Neurostimulation,
57 Topical Analgesics, 777
Deep Brain Stimulation, and Motor Cortex
Magdalena Anitescu, Charles E. Argoff
Stimulation, 957
58 Psychological Approaches in Pain Leonardo Kapural, James Deering, Christopher Gilmore
Management, 782
72 Intrathecal Drug Delivery, 963
Dennis C. Turk, Akiko Okifuji
Timothy Furnish, Carlyle Peters Hamsher, Mark S. Wallace
59 Evidence-Based Rehabilitation Approaches to
73 Radiation Safety and Radiographic Contrast
Acute and Chronic Pain Management, 792
Agents, 980
Dana Dailey, Kathleen A. Sluka, Carol G.T. Vance
James P. Rathmell, Honorio T. Benzon
60 Physical Rehabilitation for Patients With Chronic
74 Infection and Anticoagulation Considerations in
Pain, 800
Pain Procedures, 996
Harriet Wittink, Jeanine A. Verbunt
Michael C. Hanes, Honorio T. Benzon, David A. Provenzano
61 The Integrative Approach to Pain
Management, 809 Part 7: Pain Management in Special
Delia Chiaramonte, Brian Morrison, Chris D’Adamo
Situations and Special Topics
62 Patient Education and Self-Management, 823
David A. Williams, Silvie Cooper 75 Pain Management in Primary Care, 1015
Katherine E. Galluzzi
Part 6: Neural Block and Interventional 76 Pain Management in the Emergency
Techniques Department, 1034
Andrew K. Chang
63 Neurolytic Agents, Neuraxial Neurolysis, and
Neurolysis of Sympathetic Axis for Cancer 77 Management of Pain in Sickle Cell Disease, 1039
Carlton D. Dampier
Pain, 835
Heather A. Columbano, Amit Gulati, Robert W. Hurley 78 Burn Pain, 1045
Jatin Joshi, Mohammad Piracha, Christopher L. Wu
64 Head and Neck Blocks, 857
Antoun Nader, Jee Youn Moon, Mary Leemputte, 79 Pain Evaluation and Management in Patients
Kenneth D. Candido With Limited Ability to Communicate Because of
65 Interlaminar and Transforaminal Therapeutic Dementia, 1052
Thomas Hadjistavropoulos, Una E. Makris
Epidural Injections, 874
Ariana M. Nelson, Honorio T. Benzon, Magdalena Anitescu, 80 Disparities in Pain Care: Descriptive
Marc A. Huntoon Epidemiology-Potential for Primary
66 Radiofrequency Treatment, 892 Prevention, 1059
Jana M. Mossey
Koen van Boxem, Maarten van Eerd, Thibaut Vanneste,
Xander Zuidema, Jan van Zundert 81 Pain Management in the Critically Ill Patient, 1069
Liang Shen, John E. Rubin, James Littlejohn
67 Pain Interventions for the Knee, Hip, and
Shoulder, 908 82 Pain Management at the End of Life and Home
Christine L. Hunt, David A. Provenzano, Kailash Chandwani Care for the Terminally Ill Patient, 1076
Dalya Elhady, Diane Novy
68 Myofascial Injections and Fascial Plane
Blocks for Perioperative and Chronic Pain
Management, 924
Ariana M. Nelson, Carlos E. Guerrero, Andrea L. Chadwick
xxiv Contents

Part 8: Research, Ethics, Healthcare Policy, 85 Ethical Issues in Pain Research, 1123
Katherine Gentry, Gary A. Walco
and Future Directions in Pain Management
86 Treatment Development: Directions and Areas in
83 Clinical Trial Design Methodology and Need of Investigation, 1128
Data Analytic Strategies for Pain Outcome Steven P. Cohen, Nebojsa Nick Knezevic, David A. Williams,
Studies, 1095 Christopher L. Wu
Nebojsa Nick Knezevic, Patrick Schober, Roger Chou,
Thomas R. Vetter Index, 1139
84 Outcome Domains and Measures in Acute and
Chronic Pain Clinical Trials, 1111
Honorio T. Benzon, Hubert A. Benzon, Dennis C. Turk
1
History Is a Distillation of Rumor
NATALIE MORYL, CHARLES INTURRISI
THOMAS CARLYLE (1795-1881)
Management of pain, such as the management of any disease, is as
old as the human race. In the view of Christians, the fall of Adam
and Eve in the Garden of Eden produced a long life of suffer-
ing pain for men and women. This act allegedly sets the stage for
several disease concepts, including the experience of pain in labor
and delivery, the concept that hard work is painful, the notion
that blood, sweat, and tears are needed to produce fruit; the intro-
duction of pain and disease to human existence; establishment of
the fact that hell and its fires are painful; and the expectation that
heaven is pure, delightful, spiritually pleasing, and of course, pain
free. From a historical perspective, humans have deliberately and
knowingly inflicted on one another many experiences associated
with pain—from the earliest wars to the more recent irrational
shooting incidents in Sandy Hook Elementary School in New-
town, Connecticut, and Marjory Stoneman Douglas High School
in Parkland, Dallas from the scourging of Jesus to contemporary
strife in the Middle East, the Rwandan genocide, the Irish “reli-
gious” fratricide, and the conflicts in Bosnia and the Balkans. All
wars, including the great wars, World War I and World War II, the
American Civil War, the Korean War, and the Vietnam War, have
been associated with untold pain, suffering, and death.
In these concepts, pain is viewed as a negative experience and
one that is associated with disease and death. Many diseases,
including infections, plagues, and genetic and acquired disorders,
including cancer and COVID-19, can cause significant pain. In
contrast to acute pain that may teach us a lesson, that is, we would
not touch a hot stove the second time after the initial touch brings
sharp short-lived pain, chronic pain offers no such benefits. It
interferes with our quality of life, sleep, work, and enjoyment of
life and often causes anxiety, depression, and decreased mobility,
which may precipitate or worsen other medical conditions result-
ing from inactivity. Most recently, social media has created a plat-
form for those who may ordinarily suffer in silence the freedom to
share and open up about their suffering and pain. Social media has
become a powerful tool for people with pain to share their stories
and reach new audiences across the globe, creating new patient
communities. This has empowered patients with pain to set up
new expectations during treatment of conditions commonly asso-
ciated with pain, such as cancer, diabetes, HIV, and others.
Medical and technological advances in the 21st century have
changed the outcomes of many diseases and the probability of
survivorship. Cultural and religious changes in many societ-
ies have also changed the way patients view the disease. Vari-
ous advocacy groups have empowered patients and caregivers to
change what is viewed as acceptable during various treatments.
Patients’ experience has been gaining priority not only for patients
but also for research, clinicians, and the medical system overall.
Originally conceived in 2001 by the National Institutes of Health,
the patient-reported outcomes measurement information system
(PROMIS) has involved hundreds of medical researchers and psy-
chometricians and received approximately $250 million in fund-
ing.1,2 Further research showed that not only patients wanted to
drive communications by reporting their distress with pain and
other symptoms, but both caregivers and clinicians found regular
communications from the patient reporting pain and other symp-
toms useful for clinical care.
This chapter focuses on some of the major historical events that
have led to the current conceptualization of pain and its treatment
as an independent specialty in modern medicine.
Pain and Religion
The early concept of pain as a form of punishment from supreme
spiritual beings for sin and evil activity is as old as the human race.
In the book of Genesis, God told Eve that following her fall from
grace, she would endure pain during childbirth: “I will greatly
multiply your pain in childbearing; in pain you shall bring forth
children, yet your desire shall be for your husband, and he shall
rule over you” (Genesis 3:16). This condemnation led early Chris-
tians to accept pain as a normal consequence of Eve’s action and to
view this consequence as being directly transferred to them. Thus
any attempt to decrease the pain associated with labor and delivery
was treated by early Christians with disapproval and disapproval.
It was not until 1847, when Queen Victoria was administered
chloroform by James Simpson for the delivery of her eighth child,
Prince Leopold, that contemporary Christians and, in particular,
Protestants accepted the notion that it was not heretical to pro-
mote painless childbirth as part of the obstetric process.
From the Old Testament, Job has been praised for his endur-
ance of pain and suffering. While Job’s friends wondered whether
these tribulations were an indication that he had committed some
great sin for which God was punishing him (Job x:17), Job was
considered a faithful servant by God, not guilty of any wrongdo-
ing. He was described as a man who was “blameless and upright”
and one who feared God and turned away from evil.3
In the 5th century, St. Augustine wrote that “all diseases of
Christians are to be ascribed to demons; chiefly do they tor-
ment the fresh baptized, yea, even the guiltless newborn infant,”
thus implying that not even innocent infants escape the work of
demons. In the 1st century, many Christians were rebuked and
3
4 PA RT 1 General Considerations
suffered ruthless persecution, including death, because of their
belief in Jesus as the Messiah. Some who were subsequently
described as martyrs endured their suffering in the belief that
they did it for the love of Christ, and they felt that their suffer-
ing identified them with Christ’s suffering on the cross during
his crucifixion.4 This may be the earliest example of the value of
psychotherapy as an important modality in managing pain. Thus
some present-day cancer patients with strong religious beliefs view
their pain and suffering as part of their journey toward eternal
salvation. This concept has led to several scientifically conducted
and government-sponsored studies evaluating intercessory prayer
as an effective modality for controlling cancer pain.
To fully appreciate the historical concept of pain, it is impor-
tant to reflect on the origins of the term “pain patient.” The word
pain comes from the Latin word poena, which means that “pun-
ishment.” The word patient is derived from the Latin word patior,
meaning “to endure suffering or pain.” Thus it is not too outra-
geous to appreciate that in ancient days persons who experienced
pain were interpreted to have received punishment in the form of
suffering that was either dispensed by the gods or offered up to
appease the gods for transgressions.5,6
In some cultures, the tribal concept of pain came from the
belief that it resulted from an “intrusion” from outside the body.
These “intruders” were thought to be evil spirits sent by the gods
as a form of punishment. In this setting, the role of medicine men
and shamans flourished because these were the persons assigned to
treat the pain syndromes associated with internal disease. Since it
was thought that spirits entered the body by different avenues, the
rational approach to therapy was aimed at blocking the particular
pathway chosen by the spirit.
In Egypt, the left nostril was considered to be the specific site
where the disease entered. This belief was confirmed by Papyri and
Berlin, who stated that the treatment of headache involved expul-
sion of the offending spirit by sneezing, sweating, vomiting, urina-
tion, and even trephination.7,8 In New Guinea, it was believed that
evil spirits entered via a spear or an arrow, which then produced
spontaneous pain.7 Thus it was common for the shaman to occa-
sionally purge the evil spirit from a painful offending wound and
neutralize it with his special powers or special medicines. Egyp-
tians treat some forms of pain by placing an electric fish from
the Nile over the wounds to control pain.8,9 The resulting electri-
cal stimulation that produced relief of pain actually works by a
mechanism similar to transcutaneous electrical nerve stimulation
(TENS), which is frequently used today to treat pain. The Papyrus
of Ebers, an ancient Egyptian manuscript, contains a wide variety
of pharmacologic information and describes many techniques and
recipes, some of which still have validity.8,9
Early Native Americans believed that pain was experienced
in the heart, whereas the Chinese and India identified multiple
points in the body where pain might originate or might be self-
perpetuating.10 Consequently, attempts were made to drain the
body of these “pain points” by inserting needles, a concept that
may have given birth to the principles of acupuncture therapy,
which is well over 2000 years old.11
The ancient Greeks were the first to consider pain to be a sen-
sory function that might be derived from peripheral stimulation.12
In particular, Aristotle believed that pain was a central sensation
arising from some form of stimulation of the flesh, whereas Plato
hypothesized that the brain was the destination of all peripheral
stimulation. Aristotle advanced the notion that the heart was the
origin or processing center for pain. He based his hypothesis on
the concept that an excess of vital heat was conducted by the blood
to the heart, where pain was modulated and perceived. Because of
his great reputation, many Greek philosophers followed Aristotle
and embraced the notion that the heart was the center for pain
processing.13 In contrast, another Greek philosopher, Stratton,
and other distinguished Egyptians, including Herophilus and Eis-
tratus, disagreed with Aristotle and proposed the concept that the
brain was the site of pain perception, as suggested by Plato. Their
theories were reinforced by actual anatomic studies showing the
connections between the peripheral and central nervous systems.14
Nevertheless, controversies between the opposing theories of
the brain and the heart as the center for pain continued. It was
not until 400 years later that the Roman philosopher Galen reju-
venated the works of the Egyptians Herophilus and Eistratus and
greatly re-emphasized the model of the central nervous system.
Although Galen’s work was compelling, he received little recogni-
tion until the 20th century.
Toward the period of the Roman Empire, steady progress was
made in understanding pain as a sensation similar to other sensa-
tions in the body. Developments in anatomy and, to a lesser extent,
in physiology helped establish that the brain, not the heart, was
the center for the processing of pain.15 While these advances were
taking place, simultaneous advances were occurring in the devel-
opment of therapeutic modalities, including the use of drugs (e.g.
opium), as well as heat, cold, massage, trephination, and exercise,
to treat painful illnesses. These developments led to the establish-
ment of the principles of surgery for treating diseases. Electric-
ity was first used by the Greeks of that era, as they exploited the
power of the electrogenic torpedo fish (Scribonius longus) to treat
the pain of arthritis and headache. Electrostatic generators, such as
the Leyden jar, were used in the late Middle Ages, resulting in the
re-emergence of electrotherapy as a modality for managing medi-
cal problems, including pain. However, there was a relative stand-
still in the development of electrotherapy as a medical modality
until the electric battery was invented in the 19th century. Several
attempts have been made to revive its use as an effective medical
modality, but these concepts did not catch on and were largely
used only by charlatans and obscure scientists and practitioners.
Over the centuries, many modes of anesthesia/analgesia have
been developed and refined so that their mortality and morbidity
have become negligible. General anesthesia was formally discov-
ered by William Morton in 1846. In 1847, while even the concept
of analgesia for the relief of labor pain was considered heretical and
unchristian, Simpson used chloroform to provide anesthesia for
the labor pains of Queen Victoria during the delivery of her eighth
child, Prince Leopold.9 This action helped legitimize the practice
of pain relief during childbirth. Around the same time, a hollow
needle and syringe were invented. Many local anesthetic agents
have been discovered in this era. In 1888, Corning described using
a local anesthetic, cocaine, to treat nerve pain. Techniques for local
and regional anesthesia for both surgery and pain disorders have
proliferated rapidly.
The history of anesthesia is full of instances wherein attempts
to relieve pain were initially met with resistance and sometimes
violence. In the mid-19th century, Crawford Long from the state
of Georgia in the United States attempted to develop and provide
anesthesia, but contemporary Christians of that state considered
him a heretic for his scholarly activity. As a result, he had to flee for
his life from Georgia to Texas. Although surgical anesthesia was
well-developed in the late 19th century, religious controversy over
its use required Pope Pius XII to give his approval before anesthesia
could be used extensively for surgical procedures.6 Pope Pius XII
wrote, “The patient, desirous of avoiding or relieving pain, may

without any disquietude of conscience, use the means discovered
by science which in themselves are not immoral.” More recently,
the Church endorsed palliative care, including pain management
using high-dose opioids or sedatives at the end of life (even if life-
shortening) as long as the palliative therapies were proportionate
and used to treat refractory symptoms in a terminally ill patient.
Pope John Paul II stated: “Moreover, while patients in need of
pain killers should not be made to forego the relief that they can
bring, the dose should be effectively proportionate to the intensity
of their pain and its treatment.” (http://www.ldysinger.stjohnsem.
edu/@magist/1978_JP2/Addresses/04_11_pal-care.htm).
Pain and Pain Theories
Throughout the Middle Ages and the Renaissance, the debate on
the origin and processing center of pain raged. Fortunes fluctuated
between proponents of the brain theory and proponents of the
heart theory, depending on which theory was favored.
Heart theory proponents appeared to prosper when William
Harvey, recognized for his discovery of the circulation, supported
the heart as the focus for pain sensation. However, Descartes dis-
agreed vehemently with the Harvey hypothesis, and his descrip-
tion of pain conducted from peripheral damage through nerves to
the brain led to the first plausible pain theory, that is, the specificity
theory.16 In his 1664 Treatise of Man, René Descartes traced a pain
pathway and described pain as “a specific sensation, with its own
sensory apparatus independent of touch and other senses.”
In the 1850s, by examining the effect of incisions in the spinal
cord, Schiff16 demonstrated that touch and pain were sensations
independent of each other. He postulated that pain had its own
specific nervous system pathways from the spinal cord that trav-
eled to the brain. Further work along the same lines by Bliz,17
Goldscheider,18 and von Frey19 contributed to the concept that
separate and distinct receptors exist for the modalities of pain,
touch, warmth, and cold.
During the 18th and 19th centuries, new inventions, new
theories, and new thinking emerged. This period was known
as the Scientific Revolution, and several important inventions
took place, including the discovery of the analgesic properties of
nitrous oxide, followed by the discovery of local anesthetic agents
(e.g. cocaine). Anatomy has also developed rapidly as an impor-
tant branch of science and medicine; most notably, the discovery
of the anatomic division of the spinal cord into sensory (dorsal)
and motor (ventral) divisions. In 1840 Mueller proposed that
based on anatomic studies, there was a straight-through system of
specific nerve energies in which specific energy from a given sensa-
tion was transmitted along sensory nerves to the brain.20 Muel-
ler’s theories led Darwin to propose the intensive theory of pain,21
which maintained that the sensation of pain was not a separate
modality but instead resulted from a sensory overload of sufficient
intensity for any modality. This theory was modified by Erb22 and
then expanded by Goldscheider18 to encompass the roles of both
stimulus intensity and central summation of stimuli. Although
the intensive theory was persuasive, the controversy continued,
with the result that by the mid-20th century, the specificity theory
was universally accepted as the more plausible theory of pain.
With this official, though not unanimous blessing of the con-
temporary scientific community, strategies for pain therapy began
to focus on identifying and interrupting pain pathways. This ten-
dency was both a blessing and a curse. It was a blessing in that
it led many researchers to explore surgical techniques that might
interrupt pain pathways and consequently relieve pain, but it was
CHAPTER 1 History Is a Distillation of Rumor 5
a curse in that it biased the medical community for more than half
a century into believing that pain pathways and their interruption
were the total answer to the pain puzzle. This trend began in the
late 19th century by Letievant, who first described specific neurec-
tomy techniques for treating neuralgic pain.23 Afterward various
surgical interventions for chronic pain were developed and used,
including rhizotomy, cordotomy, leukotomy, tractotomy, myelot-
omy, and several other operative procedures designed to interrupt
the central nervous system and consequently reduce pain.24 Most
of these techniques were abysmal failures that did not relieve pain
and occasionally resulted in more pain than previously present.
Pain as a Disease
The cardinal features of disease as recognized by early philosophers
included calor, rubor, tumor, and dolor. The English translation is
heat, redness, swelling, and pain. One of the important highlights
in the history of pain medicine was the realization that even though
heat, redness, and swelling may disappear, pain can continue and
be unresponsive on occasion to different therapeutic modalities.
When pain persists long after the natural pathogenic course of
disease has ended, a chronic pain syndrome develops with char-
acteristic clinical features, including depression, disability, disuse,
and decreased mobility, causing other medical conditions such as
obesity and arthritis to worsen. The risk of another comorbidity
of chronic pain increases with chronic opioid exposure that, in
some instances, can be complicated by dependency and opioid use
disorder, formally known as addiction. John Dryden once wrote,
“For all the happiness mankind can gain is not in pleasure, but in
rest from pain.” Thus many fatal nonpainful diseases are not as
feared as relatively trivial, painful ones.
Physicians and healers have focused their attention on manag-
ing pain. Thus in managing cancer, an important measure of suc-
cessful treatment is the success with which any associated pain is
managed. Although many technological advances have been made
in medicine, it is only within the past 10 to 20 years that signifi-
cant strides have been made in dealing with chronic pain as a dis-
ease entity per se—one requiring specialized assessment, workup,
diagnosis, and specialized therapeutic interventions targeting the
cause of pain and pain itself.
Pain in the 20th Century
In 1907, Schlosser reported significant relief of neuropathic
pain for long periods with the injection of alcohol into damaged
and painful nerves. Reports of similar treatment came from the
management of pain resulting from tuberculous and neoplastic
invasion.25 In 1926 and 1928, Swetlow and White, respectively,
reported on the use of alcohol injections into thoracic sympathetic
ganglia to treat chronic angina. In 1931, Dogliotti described the
injection of alcohol into the cervical subarachnoid space to treat
pain associated with cancer.26
One consequence of war has been the development of new
techniques and procedures to manage injuries. During World War
I (1914-1918), numerous injuries were associated with trauma
(e.g. dismemberment, peripheral vascular insufficiency, and frost-
bite). In World War II (1939-1946), peripheral vascular injuries
as well as phantom limb phenomena, causalgia, and many sympa-
thetically mediated pain syndromes occurred. Leriche developed
the technique of sympathetic neural blockade with procaine to
treat the causalgic injuries of war.27 John Bonica, himself an army
surgeon during World War II, recognized the gross inadequacy of
6 PA RT 1 General Considerations
managing war injuries and other painful states of veterans with
the existing uni-disciplinary approaches.28 This led him to pro-
pose the concept of multi-disciplinary, multimodal management
of chronic pain, including behavioral evaluation and treatment.
Bonica also highlighted the fact that all kinds of pain were being
undertreated; his work has borne fruit in that he is universally
considered the “father of pain,” and he was the catalyst for the
formation of many established national and international pain
organizations. Bonica’s lasting legacy is his historic volume The
Management of Pain, first published in 1953. The clinic that he
developed at the University of Washington in Seattle remains a
model for the multi-disciplinary management of chronic pain.
As a result of his work, the American Pain Society (APS) and
the International Association for the Study of Pain (IASP) were
formed. Anesthesiology was developed as a division of surgery and
did not reach full autonomy until after World War II. With the
discovery of new local anesthetics, regional anesthesia began to
flourish in the United States. Bonica’s wife had a very difficult
delivery, alerting Dr. Bonica to the gap in childbirth analgesia. He
played a major role in advancing the safe use of epidural anesthesia
to manage the pain associated with labor and delivery in the 20th
century. Regional anesthesia suffered a significant setback in the
United Kingdom with negative publicity surrounding the 1954
cases of Wooley and Roe, in whom serious and irreversible neuro-
logical damage occurred after spinal anesthesia. It took three more
decades to fully overcome this setback and to see regional anesthe-
sia widely accepted as safe and effective in the United Kingdom.
Several persons contributed significantly to the development of
regional anesthesia, including Corning, Quincke-August Bier, Pit-
kin, Etherington-Wilson, Barker, and Adriani.
An outstanding contribution in the field of research was the
development and publication of the gate control theory by Melzack
and Wall in 1965.29 This theory, which was built on the preexisting
and prevalent specificity and intensive theories of pain, provided a
sound scientific basis for understanding pain mechanisms and for
developing other concepts on which sound hypotheses could be
developed. The gate control theory emphasizes the importance of
both ascending and descending modulation systems and provides a
solid framework for the management of different pain syndromes.
The gate control theory almost single-handedly legitimized pain as a
scientific discipline and led not only to many other research endeav-
ors building on the theory but also to the maturity of pain medi-
cine as a science.30 As a consequence, the American Academy of Pain
Medicine (AAPM), the American Society of Regional Anesthesia and
Pain Medicine, the IASP, and the World Institute of Pain (WIP) have
become serious and responsible organizations that deal with various
aspects of pain medicine, including education, science, certification,
and credentialing of members of the specialty of pain medicine.
Dr. Jan Sternsward, Chief of the Cancer Unit at the World
Health Organization (WHO), collaborated with IASP to focus on
cancer pain and palliative care for cancer patients worldwide. In
1982, representatives from IASP, including Drs. Mark Swerdlow,
John Bonica, Robert Twycross, Kathleen Foley, and Fumi Takeda
met in Italy and developed what eventually became the 1986
report entitled cancer pain relief. With IASP, WHO made a his-
toric statement declaring pain relief a human right issue and called
on member states to make pain-relieving drugs available, includ-
ing oral morphine, which was on the WHO essential drug list.
Memorial Sloan Kettering’s James Ewing Hospital (MSK) was
a focal point for the main site to evaluate new analgesics in patients
with cancer pain. A young internist, Dr. Raymond Houde, with
the assistance of a research nurse, Ada Rogers, and a psychologist,
Stanley Wallenstein, began work on opioid pharmacology, includ-
ing equianalgesic opioid doses in 1951. From Henry Beecher at
Harvard and from his own experiments with student volunteers at
Michigan, he learned that the perception of pain was modified by
multiple variables—emotional state, expectations or fears for the
future, previous medications or treatments, and the course of the
disease itself. Houde’s meticulous and patient-sensitive methods
were recognized in the late 1950s as the standard for analgesic tri-
als. A neurologist, Kathleen Foley, brought together various pro-
grams to form the first designated pain service in a cancer setting
in the United States. In addition to Dr. Houde and Ada Rogers,
it included Charles Inturrisi, professor of pharmacology at Weill
Cornell Medical College, and Gavril Pasternak, professor of neu-
rology, who was developing a laboratory to study opiate receptors
in the brain. This program combined basic and clinical research,
along with a training program as well as a supportive care pro-
gram for patients with complicated pain started by a PhD nurse
practitioner, Nessa Coyle. Dr. Kathleen Foley published the first
taxonomy of cancer pain syndromes.
Pain and the Impact of Psychology
The history of pain medicine is incomplete without acknowledg-
ing the noteworthy contributions of psychologists. Their influen-
tial research and clinical activities have been an integral part of a
revolution in the conceptualization of the pain experience.31 For
example, in the early 20th century, the role of the cerebral cor-
tex in the perception of pain was controversial because of a lack
of understanding of the neuroanatomic pathways and the neu-
rophysiologic mechanisms involved in pain perception.32,33 This
controversy largely ended with the introduction of the gate control
theory by Wall and Melzack in 1965.29 The gate control theory has
stood the test of time in subsequent research using modern brain-
imaging techniques such as positron emission tomography, func-
tional magnetic resonance imaging, and single-photon emission
computed tomography have also described the activation of mul-
tiple cortical and subcortical sites of activity in the brain during
pain perception. Further elaboration of the psychological aspects
of the pain experience includes the three psychological dimen-
sions of pain: sensory-discriminative, motivational-affective, and
cognitive-evaluative.34
Psychological researchers have greatly advanced the field of
pain medicine by reconceptualizing both the etiology of pain
experience and treatment strategy. Early pain researchers concep-
tualized pain experience as a product of either somatic pathol-
ogy or psychological factors. However, psychological researchers
have convincingly challenged this misconception by presenting
research that illustrates the complex interaction between biomedi-
cal and psychosocial factors.35–37
This biopsychosocial approach to pain encourages the realiza-
tion that pain is a complex perceptual experience modulated by a
wide range of biopsychosocial factors, including emotions, social
and environmental contexts, and cultural background, as well as
beliefs, attitudes, and expectations. As the acutely painful experi-
ence transitions into a chronic phenomenon, these biopsychoso-
cial abnormalities develop permanency. Thus chronic pain affects
all facets of a person’s functional universe at great expense to the
individual and society. Consequently, logic dictates that this mul-
timodal etiology of pain requires a multimodal therapeutic strat-
egy for optimal cost-effective treatment outcomes.38,39
Additional contributions from the field of psychology
include therapeutic behavioral modification techniques for pain

management. Techniques such as cognitive behavioral interven-
tion, guided imagery, biofeedback, and autogenic training are the
direct results of using the concepts presented in the gate control
theory. In addition, neuromodulatory therapeutic modalities such
as TENS, peripheral nerve stimulation, spinal cord stimulation,
and deep brain stimulation are also logical offspring of the con-
cepts presented in the gate control theory.
The evaluation of candidates for interventional medical proce-
dures is another valuable historical contribution from the field of
psychology. Not only is the psychologist’s expertise in the identi-
fication of appropriate patients valuable for the success of thera-
peutic procedural interventions for the management of pain, but
the psychologist’s expertise is also helpful in identifying patients
who are not appropriate candidates for procedural interventions.
Thus psychologists have contributed positively to the cost effec-
tiveness and utility of diagnostic and therapeutic pain medicine.
Psychologists’ contribution to the care of patients with cancer pain
is invaluable. Psychological research in cancer led by Dr. Jimmie
Holland et al., MSK led to the development of a new field of
psycho-oncology that is essential in addressing the pain and suf-
fering of patients with cancer pain.
Pain and Pain Organizations
World Health Organization (WHO)
When diplomats met to form the United Nations in 1945, one of
the things they discussed was the establishment of a global health
organization. A year later, in New York, the International Health
Conference in New York approved the Constitution of the WHO.
In 1986, the WHO published the first analgesia step ladder and a
detailed report on cancer pain relief, highlighting the prevalence
and assessment of cancer pain, its undertreatment, recommended
therapeutic modalities, and the need to educate healthcare work-
ers and the general public. Among the few countries, the United
States was represented by Dr. John J. Bonica, President of the
IASP, and Dr. Kathleen Foley, Chair of the Pain Service, Depart-
ment of Neurology, Sloan Kettering Cancer Center in New York.
The International Association for the Study
of Pain (IASP)
The IASP is the largest multi-disciplinary, international associa-
tion in the field of pain. Founded in 1973 by John J. Bonica,
MD, the IASP is a nonprofit professional organization dedicated
to furthering research on pain and improving the care of patients
experiencing pain. Membership is open to scientists, physicians,
dentists, psychologists, nurses, physical therapists, and other
health professionals actively engaged in pain and to those who
have a special interest in the diagnosis and treatment of pain. The
IASP has members of more than 100 national chapters.
The goals and objectives of the IASP are to foster and encourage
research on pain mechanisms and pain syndromes and improve
the management of clinical pain. One of the instruments used to
disseminate new information is the journal Pain. In addition, the
IASP promotes and sponsors a highly successful biennial world
congress, as well as other meetings. The IASP encourages the
development of national chapters for the national implementation
of the IASP’s international mission. In addition, the IASP encour-
ages the adoption of a uniform classification, nomenclature, and
definition of pain and pain syndromes.
CHAPTER 1 History Is a Distillation of Rumor 7
Special interest groups within the IASP include pain in chil-
dren, neuropathic pain, herbal medicine, and cancer pain. The
IASP also promotes and administers chronic pain fellowship pro-
grams for deserving candidates worldwide.
The American Pain Society (APS)
Spurred by the burgeoning public interest in pain management
and research, as well as by the formation of the Eastern and West-
ern United States Chapters of the IASP, the APS was formed in
1977 as a result of a meeting of the Ad Hoc Advisory Commit-
tee on the Formation of a National Pain Organization. Its main
function was to carry out the mission of the IASP at a national
level through interprofessional collaborations between basic and
clinical pain researchers and clinicians. APS was dissolved in 2019
through Chapter 7 bankruptcy resulting from the OxyContin
scandal. APS maintains that it was another victim of the opioid
crisis after being “named a defendant in numerous spurious law-
suits related to opioids prescribing and abuse” Although APS has
been dissolved, its journal, the Journal of Pain, continues inde-
pendent of the APS that originated it. The United States Associa-
tion for the Study of Pain is a new professional society for United
States-based pain researchers.
Commission on the Accreditation of
Rehabilitation Facilities
In 1983, the Commission on Accreditation of Rehabilitation
Facilities (CARF) was the first to offer a system of accreditation
for pain clinics and pain treatment centers. The CARF model was
based on a rehabilitation system that emphasized both physical
and psychosocial rehabilitation of patients suffering from pain.
CARF promoted multi-disciplinary pain management programs
offering not only medical but also mandatory psychological and
physical therapy modalities for the management of pain. Its major
goals included objective measures such as increased physical func-
tion, reduced intake of medication, and return-to-work issues.
The American Academy of Pain Medicine (AAPM)
AAPM was formed in 1983 at a meeting of the APS in Washing-
ton, DC, when a group of physicians formed a separate American
Academy of Algology, later renamed the AAPM. Their goal was
to address the deficiency in evaluating pain physicians’ compe-
tence by creating uniform standards for training and credential-
ing. AAPM sponsored the American College of Pain Medicine,
which organized, developed, and administered the first credential-
ing examination in 1992. The American College of Pain Medicine
is not now called the American Board of Pain Medicine (ABPM).
The goals of the AAPM include the promotion of quality care
through research, education, and reimbursement. The Clinical
Journal of Pain, the initial journal of the AAPM, is not affiliated
with any pain medicine society. The AAPMs present journal is
Pain Medicine. Both journals are well-respected.
The American Society of Regional Anesthesia
and Pain Medicine (ASRA)
ASRA is the largest subspecialty medical society in anesthesiol-
ogy and the leader in regional anesthesia and acute and chronic
pain medicine. The society is based in the United States; other
societies on regional anesthesia are based in Europe, Asia, and
8 PA RT 1 General Considerations
Latin America. The international societies of regional anesthesia
have changed the name of their highly cited journal, Regional
Anesthesia, to Regional Anesthesia and Pain Medicine.
The American Society of Interventional Pain
Physicians (ASIPP)
ASIPP is a national organization that represents the interests of
interventional pain physicians. The society was founded in 1998
by Dr. L. Manchikanti and associates to improve the delivery
of interventional pain management services in various settings,
including hospitals, ambulatory surgical centers, and medical
offices. ASIPP has become a successful advocate for the political
and regulatory aspects of pain medicine. The ASIPP journal is
indexed and called Pain Physician.
The American Academy of Hospice and Palliative
Medicine (AAHPM)
AAHPM was founded in 1988 as an Academy of Hospice Physi-
cians, and in 1996 it changed its name to the AAHPM to reflect a
goal of this organization to control pain and other symptoms not
only at the end of life but throughout the disease trajectory, from
diagnosis through survivorship or end of life. AAHPM works
closely with the American Board of Hospice and Palliative Medi-
cine and disseminates its research through affiliation with a well-
established Journal of Pain and Symptom Management. The goals
of the multi-disciplinary AAHPM include providing education
and clinical practice standards, fostering research, and sponsoring
public policy advocacy for the chronically and terminally ill and
their families.
The American Academy of Orofacial Pain
The American Academy of Orofacial Pain (AAOP) is an organiza-
tion of healthcare professionals dedicated to the alleviation of pain
and suffering through education, research, and patient care in the
field of orofacial pain and associated disorders. The AAOP goals
include the establishment of acceptable criteria for the diagnosis
and treatment of orofacial pain and temporomandibular disor-
ders, sponsorship of research, and annual meetings. Their journal,
together with the European, Asian, Australian, and New Zealand
Academy of Orofacial Pain, is the Journal of Oral and Facial Pain
and Headache.
The American Academy of Pain Management
(AAP Management)
AAP Management was founded in 1988 and changed its name to
the Academy of Integrative Pain Management (AIPM) in 2016.
The AIPM has promoted an integrative, interdisciplinary model
of pain management. The AIPM closed its operations in 2019.
American Society for Pain Management
Nursing (ASPMN)
Founded in 1990, ASPMN is an organization of professional
nurses dedicated to providing access to specialized care for patients
experiencing pain, providing education to the public regarding
self-advocacy for their pain needs, and providing a network for
nurses working in the pain management field. The ASPMN Jour-
nal is Pain Management Nursing.
The International Headache Society (IHS)
The International Headache Society is based in London. Its lead-
ership is worldwide and is known for their international classifi-
cation of headache disorders, now in its third edition. Another
notable guideline is their International Classification of Orofa-
cial Pain. In addition, their journal, Cephalalgia, has a fairly high
impact factor.
The World Institute of Pain (WIP)
The WIP is an international organization that aims to promote
the best practice of pain medicine throughout the world through
training via international seminars and exchange of clinicians and
education via newsletters, scientific seminars, and publications.
One of the most important initiatives if the WIP is to develop
an international examination process to certify qualified interven-
tional pain physicians. After showing proficiency in both general
pain knowledge and safe performance of interventional proce-
dures, successful candidates are awarded the designation of Fel-
low of Interventional Pain Practice (FIPP). In addition, the journal
of the WIP, Pain Practice, is indexed and has a very respectable
impact factor.
The Spine Intervention Society (SIS)
The SIS, formerly called the International Spine Injection Society,
is known for its leadership in interventional pain medicine. Their
landmark monograph, Practice Guidelines for Spinal Diagnostic
and Treatment Procedures, is the gold standard for spine interven-
tions. Together with the AAPM, their journal is Pain Medicine.
The International Neuromodulation
Society (INS)
Founded in 1989, INS is a unique multi-disciplinary, interna-
tional society that consists of not only clinicians and scientists
but also engineers dedicated to the scientific development and
awareness of neuromodulation – the alteration of nerve activity
through the delivery of electromagnetic stimulation or chemical
agents to targeted sites of the body. The INS promotes the field
through meetings and its journal Neuromodulation.
American Pain Foundation (APF)
Founded in 1997 by the APS (see above for the current status
of APS), APF was the first pain organization specifically formed
to serve the interests of people with diverse disorders associated
with the presence of significant pain. Its goals include patient
education, promoting recognition of pain as a critical health
issue, and patient access to proper medical care. Regrettably,
the organization dissolved in early 2012 because of financial
difficulties.
International Association of Hospice and Palliative
Care (IAHPC))
IAHPC was founded in 1980. From this, the Academy of Hos-
pice Physicians grew. Two new independent organizations were
formed: the AAHPM and the International Hospice Institute and
College. IAHPC serves as a global platform to inspire, inform, and
empower individuals, governments, and organizations to increase
access and optimize the practice of palliative care.
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doing they may be considered in connection with the remarks of their
critics and a just comparison made. In presenting the views of
Quaker educators reference may be made to salient points in the
criticism, which seem out of keeping with the ideas set forth and
without foundation as matters of fact.
There are quite a number of men, in the brief [Sidenote: Only a
period studied, who stand out clearly and express few of the leaders’
themselves definitely in favor of education, though statements to be
considered]
they do not consider it the first requisite for a
minister of the gospel.[76] From this number it will be feasible to
select only a few for the chief consideration, relegating the remainder
to a place of comparative unimportance and incidental notice. The
work of George Fox, though he was poorly educated, had a
remarkable effect on the educational work of the society. But it is not
necessary to review that in the present chapter as it has been
presented in the first.[77]
By far the most familiar of all characters in Quaker history is that of
William Penn. And to his influence must be attributed largely the
hearty interest in education shown, not only in Philadelphia, but also
in the surrounding communities. He was well educated, but it is not
desired to make a case for or against him on the basis of his
education; let us judge by his written or spoken expression and
actual procedure in practice. No attempt is made to prove or
disprove his contentions as to what was right or wrong, necessary or
unnecessary in education. The questions asked in his case and the
others that follow is: What did they approve or disapprove of in
education?
Not only in works that might be called strictly [Sidenote: Penn
educational did Penn give educational advice, recommends
valuable alike to youth and to parents, the directors practical virtues]
of youth. His advice to his children on the value of
diligence and its necessity for success, and the propriety of frugality,
even in the homes of the rich, embodies many of the most essential
principles in education at any time. It is especially applicable to the
education of the man of business, emphasizing the importance of the
practical duties in life. Some pointed statements are especially
worthy of repetition.
[Sidenote:
Diligence ... is a discreet and understanding Diligence]
application of onesself to business; ... it loses
not, it conquers difficulties.... Be busy to a [Sidenote:
Frugality]
purpose; for a busy man and a man of business
are two different things. Lay your matters and diligence
succeeds them, else pains are lost.... Consider well your end,
suit your means to it, and diligently employ them, and you will
arrive where you would be....[78] Frugality is a virtue too, and
not of little use in life, the better way to be rich, for it hath less
toil and temptation.... I would have you liberal, but not
prodigal; and diligent but not drudging; I would have you
frugal but not sordid.[79]

This bit of philosophy is educational in its bearing in very much the

same way as that of Benjamin Franklin.
In the letters to his wife and children, referring to the care for their
education, he is more specifically concerned with actual school
education.
[Sidenote: School
For their learning, be liberal. Spare no cost, education
for by such parsimony all is lost that is saved; recommended;
but let it be useful knowledge such as is the useful
emphasized]
consistent with truth and godliness, not
cherishing a vain conversation or idle mind; but ingenuity
mixed with industry is good for the body and the mind too. I
recommend the useful parts of mathematics, as building
houses, or ships, measuring, surveying, dialing, navigation;
but agriculture especially is my eye. Let my children be
husbandmen and housewives; it is industrious, healthy,
honest and of good example, ...[80]
 His preference, as might be expected from an [Sidenote: Private
Englishman of that time, was for a tutorial system tutors desired]
of education. His reasons therefore seem to have
been based chiefly on moral grounds.

Rather have an ingenious person in the house to teach

them, than send them to schools; too many evil impressions
being received there.[81]

The above quotation alone would seem to be adequate proof that

Penn did not oppose education, but urged it for others and in his own
family. But still more convincing and irrefutable evidence is found in
the preamble to this school charter, whence an extract is taken.
[Sidenote: Public
Whereas, the prosperity and welfare of any education
people depend in great measure upon the good essential for the
welfare of a
education of youth, and their early instruction in people]
the principles of true religion and virtue, and
qualifying them to serve their country and themselves, by
breeding them in writing and reading and learning of
languages, and useful arts and sciences, suitable to their sex,
age and degree; which cannot be effected in any manner or
so well as by erecting public schools for the purposes
aforesaid, therefore....[82]

If, as must be admitted, the previous statement [Sidenote: His

points out the lack of any opposition to the ordinary ideals expressed
rudimentary education that is necessary for the in action]
everyday walks of life, the last one certainly does [Sidenote: Yearly
the same in reference to his attitude towards a meeting
higher classical education. Moreover, this is not a recommend
French, High and
mere skeleton of words never clothed with the flesh Low Dutch,
of action. The principles set forth in the charter Danish, etc.]
were actually incorporated in the work of the
schools established in Philadelphia, and we find them maintaining a
classical school for languages and higher mathematics.[83] The
practical elements received the just emphasis which belonged to
them; it was necessary that the boys and girls be made able to earn
a living and be at least ordinarily intelligent citizens. The example of
Philadelphia was followed by other communities; practical needs
were given the first consideration and a higher classical education
offered when it became possible. Not only were these studies, which
we would term higher education, mentioned by Penn and other
writers among Quakers, but they were taken up and recommended
by the yearly meeting. For example, in 1737, the minutes
recommend that as opportunity can be found, children should be
privileged to learn “French, High and Low Dutch, Danish, etc.”[84]
This particular recommendation was made by the meeting because
of a felt need.[85] If then in case of a need for a particular subject,
they were willing to recommend that it be taught, can it be truly said
that they opposed all education?
It may be well to examine Barclay, since it is with [Sidenote:
him and his writings that Cox takes issue. In his Barclay’s position
Apology for Christian Divinity Vindicated is to be defined]
found a very clear statement of his position on the
subject, and he voices it as the principle of the whole society as well.
He seems to be answering some critic, who has taken him to task for
his educational views:
[Sidenote: In his
He goes on after his usual manner saying, I Apology]
inveigh against all human learning that has
been made use of any ways in Theology; but where he finds
this asserted I know not, whether the words he would declare
it from, to wit: that man hath rendered the plain and naked
truth obscure and mysterious by his wisdom, will bear such a
consequence is left to the reader’s judgment. But he thinks he
has found out our secret design of being against learning and
schools of learning, which is neither our affirmation nor our
principle, but his own false supposition. We would, saith he,
have all those banished, that we might more easily prevail
with our errors. But methinks the man should be more wary in
 venting his own false imaginations, unless he would bring
some ground for them; for his assertion is so far untrue, that if
he had been rightly informed, he might have known that we
have set up schools of learning for teaching of the languages
and other needful arts and sciences,[86] and that we never
denied its usefulness; only we denied it be a qualification
absolutely necessary for a minister, in which case alone we
have opposed its necessity.[87]

Another character of very great importance in [Sidenote:

this connection is Anthony Benezet. Born, 1713, at Benezet’s early
St. Quentin in France, of “an ancient and life and education]
respectable family” he spent his early years in
France and then in Holland, whither his father had fled for refuge.[88]
A few months were spent in Rotterdam and the family then moved to
London where the father entered into the mercantile business and
retrieved to some extent his fallen fortunes. This enabled him to give
Anthony sufficient education to qualify him for that business, for
which, however, he seemed to evince but little taste. Being of a very
religious nature, he became a member of Friends at about fourteen
years of age, and in that society found the field of his whole life’s
activity, which was chiefly educational.[89] Considerable space will be
devoted to his work in respect to the education of Negroes, so that
will be entirely omitted in this place.[90] He was a voluminous writer,
producing chiefly tracts and letters, and a great majority of these
have a definite educational bearing. Because of the great number of
them it is impossible really to do them justice, but an attempt will be
made to state a few brief theses for which he unchangingly stands.
First, education is a religious and social duty.[91] [Sidenote:
It is exceedingly interesting to notice that he looks Education a
function of
upon education as in the first place a governmental government, but
function, if the governments of this world were often neglected
influenced by true wisdom, they would make the as such; hence
individual effort
proper education of youth their first and special necessary]
care;[92] but since governments have neglected to
do this, it occurs to him that it is a service for which Quakers are
remarkably well fitted. It is a service for which the wage is very small
and which secures no return of special social favors for the laborer.
But they, being a quiet people, not wishing to gain great wealth or to
shine in social positions, can find their sphere of activity in the
education of the youthful members of society.
Second, a special care in the education of the [Sidenote:
poor is urged.[93] This should become the duty and Children
represent
secure the interest of the well-to-do public spirited “capital”; they
man, for if the upper class does not safeguard it, must be
they cannot be educated. The poor child educated]
represents so much unimproved property, the
owner being unable to improve it, which, if taken over by
philanthropists, may become of some consequence to himself and
perform great services for society at large. Such a movement would,
besides being a great aid to the poor and uneducated, be also a
worthy occupation for those who at present have nothing but time
and money to spend. It would help them to realize that there is
something real in the world, something greater than wealth and
broader than religious denominations. The heart of Benezet knew no
bounds; in his philanthropy he included all classes.
Third, a definite stand is made for higher standards for teachers.

I do not know how it is amongst you, but here any person of

tolerable morals, who can read and write, is esteemed
sufficiently qualified for a schoolmaster; when indeed, the
best and wisest men are but sufficient for so weighty a
charge.[94]

He endeavors to show that the work of a teacher is pleasant and

should interest a better class of masters than it has in the past. The
experiences of Benezet in the school work were of most pleasant
nature. Not only by his own statement, but judged also by the
accounts given in his memoirs by Robert Vaux, it seems that he was
unusually kind and sympathetic as a master, which won him the
greatest respect of his pupils.[95] The tasks of schoolteaching are
only unpleasant when being performed merely for the sake of the
wage obtained. Those who attempt to teach large numbers for the
sake of a large income find it disagreeable; they form the class of
teachers against whom he would discriminate.[96] Add to these three
principles, his great contribution toward the freedom and education
of the Negroes, his long life of service, and we have all for which he
lived. It is stated that he had no private life; at any rate it sinks into
oblivion in comparison with his interest and active work in public
philanthropies.[97]
The educational influence of John Woolman in [Sidenote: John
regard to Negro and Indian education will be Woolman, his
position in regard
mentioned in another chapter,[98] but concerning to education]
education generally he was equally outspoken, and
being a member of some consequence he was [Sidenote: The
able to make his influence felt. Like Benezet, he responsibility
tutors and
of

regarded education as a social duty, both to each parents]

individual and to the community of individuals. This
duty could not be performed by immoral tutors and schoolmasters,
for the pupil could be made to rise no higher than the master; so the
result would be an immoral society.[99] The responsibility, in the last
analysis, for the right conduct of schools falls upon the parents. If
they are indifferent, nothing can be accomplished for the schools, for
the whole community is no better or more insistent in its demands
than the individuals constituting it. For this reason he urges individual
philanthropy to come to the aid of the schools, which are badly
neglected; those who possess wealth can do no better, for, as he
says:

Meditating on the situation of schools in our provinces, my

mind hath, at times, been affected with sorrow, and under
these exercises it hath appeared to me, what if those that
have large estates were faithful stewards, and laid no rent or
interest nor other demand, higher than is consistent with
universal love; and those in lower circumstances would under
 a moderate employ, shun unnecessary expense, even to the
smallest article; and all unite humbly in seeking the Lord, he
would graciously instruct and strengthen us, to relieve the
youth from various snares, in which many of them are
entangled.[100]

If to this list of advocates of education, it is [Sidenote: Tuke,

necessary to add others, mention should be made Whitehead,
of Henry Tuke, George Whitehead, and William Crouch as
advocates of
Crouch. In defending certain differences between education]
the Quaker doctrine and that of other
denominations, the former discusses this one, in not considering
human learning essential to a minister of the gospel.[101] The
reasons adduced are chiefly biblical; the knowledge of human
literature is not recommended by the New Testament as being
necessary for a minister, and this is considered conclusive proof.
Moreover, it is pointed out that Paul, though a well educated man,
disclaimed the value of his education for that service, and wished
always to appear to the people as an unlettered man of God.[102] But
Tuke goes on to explain that though it is not essential for a minister,
learning is not unesteemed nor its usefulness slighted.[103] Members
are desired to direct their attention to education, for a right use of it
may promote religion and benefit civil society.[104] That the use of
Latin and Greek is not decried may be seen in the work of Penn and
Whitehead, who were both scholars, and whose works are full of
classical references and illustrations. In one instance their chief
argument against swearing is produced from certain references to
the works of Socrates and Xenocrates, pointing out that the Greeks
were aware of a higher righteousness excelling that of the legal
Jews.[105] The same point of view with reference to a knowledge of
the classics is taken by William Crouch, as is understood at once by
this statement:

They acknowledge the understanding of languages,

especially of Hebrew, Greek and Latin, formerly was and still
 is very useful, yet they take them not therefore to be
necessary to make a minister nor so profitable as that one
unacquainted with them must be styled an idiot, illiterate and
of no authority.[106]

Moreover, from various sources one is assured [Sidenote: The

that a classical education was not abhorred by the Latin School of
Quakers of Philadelphia. The work offered in the Philadelphia
exemplifies
classical school was for any one who had the contention of
ability to do it and its attainment was encouraged those quoted
by Friends. The higher education was for girls as above]
well as for boys, as we may judge from reading the [Sidenote:
journal kept by Sally Wister (or Wistar), a Quaker Education an
girl of the days of the Revolution.[107] She attended asset; but apt to
be perverted]
the school kept by Anthony Benezet,[108] which
was one of the highest class, moral and literary, and patronized by
the best classes of the citizens. Extracts from her Journal indicate
that her education had not been limited to the mere rudiments, but
that she enjoyed also an elementary knowledge, at least, of Latin
and French.[109] This sort of education was clearly not uncommon
among Friends and it was not the object of opposition on their part. It
must, however, be kept in mind that the Quakers never confused
education necessarily with true Christianity.[110] Religion in this life
and the salvation of one’s soul in the next was a problem which
concerned the poor as well as the rich, the untutored as well as the
learned. How could the demands be greater for one than the other;
the same tests had to be met and passed by all, the educated one
received no favors though more might be expected of him.[111]
Education was looked upon as an asset which might be turned to
great use for Christianity, but the lack of it was never a bar to
Christianity.[112] On the other hand, education might easily become,
according to the Quakers’ views, a definite hindrance to Christianity.
[113]

It would be quite improper in connection with this [Sidenote:

subject to fail to mention the scheme, Utopian in Scheme of
that day, which was conceived in the mind of education
Thomas Budd, for the development of a system of suggested by
Thomas Budd]
education for Pennsylvania and New Jersey. At the
very outset it seems more comprehensive than anything suggested
by any other leader, and in fact it embodied so much that it was quite
beyond the limit of expectation for either of the colonies. Thomas
Budd, though not at first a member of Friends, became convinced of
the justice of their principles and joined the society before the year
1678.[114] He was a man of affairs and became greatly interested in
the colonization of Pennsylvania and New Jersey, whither he soon
came as a colonist himself. At that time it was equally true, as at the
present, that if a scheme or undertaking was to be put through, it
must be made as attractive as possible to the prospector. The
attempt to do this called forth a considerable exercise of individual
initiative, and one result was the educational plan outlined by
Thomas Budd and published in Philadelphia in 1685. The details of
the scheme as outlined are deemed of sufficient interest and
importance to warrant their reproduction here.
[Sidenote:
1. Now it might be well if a law were made by Children to be in
the Governors and General Assemblies of public school
Pennsylvania and New Jersey, that all persons seven
more]
years or

inhabiting the said provinces, do put their

children seven years to the Public School, or longer, if the
parent please.

2. That schools be provided in all towns and [Sidenote: To

cities, and persons of known honesty, skill and receive instruction
understanding be yearly chosen by the in the arts and
sciences and to
Governor and General Assembly, to teach and learn a trade]
instruct boys and girls in all the most useful arts
and sciences that they in their youthful capacities may be
capable to understand, as the learning to read and write true
English and Latin, and other useful speeches and languages,
and fair writing, arithmetic and bookkeeping; the boys to be
taught and instructed in some mystery or trade, as the making
of mathematical instruments, joinery, turnery, the making of
clocks and watches, weaving, shoemaking or any other useful
trade or mystery that the school is capable of teaching; and
the girls to be taught and instructed in spinning of flax and
wool, and knitting of gloves and stockings, sewing, and
making of all sorts of useful needlework, and the making of
straw work, as hats, baskets, etc., or other useful art or
mystery that the school is capable of teaching.

3. That the scholars be kept in the morning [Sidenote: Eight

two hours at reading, writing, bookkeeping, etc., hours per day
and other two hours at work in that art, mystery allotted to studies
and chosen trade]
or trade that he or she most delighteth in, and
then let them have two hours to dine, and for recreation and
in the afternoon two hours at reading, writing, etc., and the
other two hours at work at their several employments.

4. The seventh day of the week the scholars [Sidenote:

may come to school only in the forenoon, and at Regular school
a certain hour in the afternoon let a meeting be work five and
one-half days per
kept by the schoolmasters and their scholars, week; moral
where good instruction and admonition is given instruction on
by the masters to the scholars and thanks Saturday]
returned to the Lord for his mercies and
blessings that are daily received from him, then let a strict
examination be made by the masters, of the conversation of
the scholars in the week past, and let reproof, admonition and
correction be given to the offenders, according to the quantity
and quality of their faults.

5. Let the like meetings be kept by the school [Sidenote: Similar

mistresses, and the girls apart from the boys. arrangement for
By strictly observing this good order our girls educated
separately]
children will be hindered from running into that
excess of riot and wickedness that youth is incident to, and
they will be a comfort to their tender parents.
 6. Let one thousand acres of land be given
and laid out in a good place, to every public [Sidenote: Land
endowment for
school that shall be set up, and the rent or schools]
income of it to go towards the defraying of the
charge of the school.

7. And to the end that the children of the poor [Sidenote: Indians
people, and the children of Indians may have and the poor to be
the like good learning with the children of the educated
cost]
free of

rich people, let them be maintained free of

charge to their parents, out of the profits of the school, arising
by the work of the scholars, by which the poor and the Indians
as well as the rich, will have their children taught, and the
remainder of the profits, if any be to be disposed of in the
building of the schoolhouses and improvements on the
thousand acres of land, which belongs to the school.[115]

The author does not claim to be entirely original [Sidenote: The

in his scheme, having been influenced, he says, by industrial and
a similar thing described by Andrew Yarenton in a commercial
values to be
book, England’s Improvements by Sea and Land. derived are
[116] His chief interest seems to be in the benefit to pointed out]
be derived for the commercial life of the colonies,
and for that reason there is accordingly a great stress on the
industrial education. By this introduction of the industrial schools,
spinning for example, in the larger cities and the preparation of
children at an early age for participation in that great occupation, the
production of linen cloth could be made equal not only to the
domestic demands but also a considerable margin for the foreign
trade.[117] It is pointed out that the colonial consumer pays twice as
much for his purchase as its cost of production in France or
Germany, and that he pays this extra cost into the coffers of the
English merchants. This profit should accrue to the home merchants.
The educational and also the industrial scheme [Sidenote:
is to receive the backing of the colonial Scheme to be
government. It is recommended that laws be
passed for the encouragement of linen encouraged by
manufacturers and that farmers “that keep a plow” the government]
should sow an acre of flax and two of hemp, with [Sidenote:
which to supply the manufacturers.[118] Educational Essential points
urged in the
support by the government was not secured, as is scheme]
amply evidenced by the unsurpassed development
of private and parochial schools of all [Sidenote: The
denominations. The churches were the sponsors lack of
governmental
for education. It is worthy of note, however, that the support; supplied
elements emphasized by Budd, (1) education in the through meetings
arts and sciences for all those capable of it, (2) of Quakers]
industrial education for a trade for every one, (3)
moral and religious training, and (4) equal educational opportunities
for poor and rich or otherwise unfavored classes, are the same as
those urged officially by the Quakers.[119]
Far from receiving governmental support, it was necessary that
the schools be supported by individual or small group enterprise.
The society recognized this, and it is stated in the organization of the
church that the duty of the monthly meeting is to provide for the
subsistence of the poor and for their education.[120] Furthermore it is
recommended that all special bequests of Friends be kept as a
distinct fund for the purpose originally intended by the donor, and
that if expended for any other purpose, it must be again made up by
the quarterly meeting.[121] One of the most frequent uses
designated, judging from the records, seems to have been the
educational.[122]
The reader may have perused the foregoing [Sidenote: Have
pages with more or less interest; a curiosity may Quaker schools
have been aroused concerning the present-day kept pace with the
public?]
attitude of Friends, educationally. Have they
experienced any considerable change? The institutional evidences
of their continued interest are familiar enough to the educationist. But
what is the attitude within the schools: Is instruction stiff and more
formal there than in the public schools, and what can be said of the
progress among the teachers? To answer all of these questions and
similar ones is not the purpose of this present work. And in the
following excerpt, taken from an expression drawn up by a body of
teachers, it is not hoped to find conclusive proof of this or that, but
perhaps it may be taken as a fairly reliable indication of the present
professional attitude.
[Sidenote: The
The teachers’ subjects are not Mathematics, pupil as an
nor Latin, nor Scripture, nor Quakerism—they individual to be
emphasized]
are boys and girls. The information imparted is,
in a sense, a minor matter: the growth of the [Sidenote: Well-
mind that assimilates it is all-important—growth equipped
teachers needed;
in keenness, efficiency and power.... and their
To the Society at large we would put forward academic
freedom
this view that the principles urged above are essential]
deserving of careful consideration in making
any forward move. The quality of the teaching given in our
schools is in a measure in the hands of Friends; they have
raised admirable buildings in many places—these are a small
matter compared with the character of the staff. The freedom
of the teacher, which is an indispensable condition of
excellence is a gift they can grant or withhold. And that we
who are responsible for the term of school life may have the
best chance and the best reward, we would press upon
Friends the need of laying foundations and awakening
interest in the days of childhood, and of turning to best
account the powers of those who go forth from our schools.
[123]

SUMMARY
This chapter treats of the attitude of Friends [Sidenote:
towards education. At the beginning there is Summary of
presented a criticism of S. H. Cox, which is a Cox’s position]
concrete example of the type of criticism referred to
in these pages. Following this there are presented the educational
views of several Friends,—Penn, Barclay, Benezet, Woolman,
Whitehead, Crouch, Tuke, and Thomas Budd, in order that the
reader may judge of the truth or error presented in the criticism. The
chief points made in Cox’s criticism are: (1) hostility of the Quaker
system to classical education, (2) general hostility of the Friends to
colleges and seminaries of learning, and (3) that the “light within”
was sufficient without any education.
From the material next presented it is shown [Sidenote:
that: (1) Penn recommended both practical and Summary of
higher education, (2) useful arts and sciences are points maintained
by certain Quaker
recommended to be taught in public schools, (3) leaders]
the classics were introduced as a part of the
curriculum in the Penn Charter School, and also in other schools
established by the society, (4) Barclay explains that the society holds
a classical education not absolutely necessary for a minister, though
it is useful, (5) the learning of languages is recommended by the
London Yearly Meeting, (6) education is advocated by Benezet as a
religious and social duty; the education of the poor and unfortunate
classes and races is urged; a higher education for schoolmasters is
recommended, (7) Woolman urges the education of Negroes and
Indians as a social duty; the responsibility is placed on the individual,
(8) Crouch states that Hebrew, Greek, and Latin are recognized as
useful and are not opposed when taught for that purpose, (9) Budd,
one of the early Quakers in Pennsylvania, introduced a very
comprehensive and Utopian scheme for (a) industrial education and
(b) higher education, proposing to organize it under the control of the
General Assembly, and (10) indications are that progress, within the
teaching body in Friends’ institutions, is quite comparable with that of
other institutions, though there is no attempt to produce conclusive
evidence either to that effect or the contrary.
 CHAPTER IV
EDUCATION IN PHILADELPHIA[124]

On ye 27th day of October, 1682, arrived before ye Towne

of New Castle from England, William Penn, Esqe., whoo
produced twoo deeds of feofment for this Towne and twelve
myles about itt, and also for ye twoo lower counties, ye
Whoorekills and St. Jones’s—wherefore ye said William Penn
received possession of ye Towne ye 28th of October, 1682.
[125]

It is probable that Penn reached Philadelphia in [Sidenote: The

the latter days of October or the early part of date of Penn’s
coming disputed]
November,[126] though no student of Philadelphia
history has yet been able to settle the question of the day absolutely.
Tradition says he came up the river in an open boat and landed at
the landing on Dock Street near the new tavern, the Blue Anchor,
which had just been erected by George Guest, a Quaker.[127] The
formal ceremony of transferring the territory which had been
arranged between Penn and the Duke of York before leaving
England,[128] was accomplished with the Duke’s commissioners,
Moll and Herman,[129] and the official debut of Pennsylvania in
colonial society was no longer a hope but a reality.
The foundation of the colony’s educational [Sidenote:
institutions had, however, not been delayed till the Education
formalities of “making” a colony were over. provided for in
first Frame of
Education received early consideration in the Government]
Frame of Government which was drawn up from
England by Penn and agreed to on April 25, 1682, before he
prepared to depart for Pennsylvania.[130] In that document it is
clearly set forth that education was the function of the civil authority,
though the intentions of the author were not realized fully for more
than a hundred and fifty years.[131] The same idea is present in each
of the three Frames of Government which were drawn up; the first,
April 25, 1682;[132] the second, April 2, 1683;[133] and the third,
November 7, 1696,[134] under Governor Markham. The instrument
drawn on April 2, 1683, contained in part the following stipulations,
which bear the impression of the Quaker ideal of education.
[Sidenote: The
Tenth. That the Governor and the Provincial provisions]
Council shall erect and order all public schools
and encourage and reward the authors of useful sciences and
laudable inventions in the said provinces and territories
thereof.
Eleventh. That one-third of the Provincial Council residing
with the Governor from time to time shall, with the Governor,
have the care and management of public affairs relating to
peace, justice, treasury and improvement of the province and
territories, and to the good education of the youth, and
sobriety of the manner of the inhabitants therein aforesaid.
[135]

The plan for education as above set forth was [Sidenote: Quaker
not destined to be the one followed consistently for Council provides
more than a century and a half of development, a school]
though throughout the first decades the relations
between the schools of Friends and the governing Council were very
close.[136] It is significant that the first school was actually ordered by
the Council, in keeping with Penn’s provisions. About one year after
Penn’s arrival in Philadelphia the educational problem came to the
attention of the Council and received decided recognition, as the
following witnesses:

The Governor and Provincial Council having taken into their

serious consideration the great necessity there is of a
schoolmaster for the instruction and sober education of the
 youth in the town of Philadelphia, sent for Enock Flower, an
inhabitant of said town, who for twenty years past has been
exercised in that care and employment in England, to whom
having communicated their minds, he embraced it upon the
following terms: to learn to read English 4s by the quarter, to
learn to read and write 6s by the quarter, to learn to read,
write and cast accounts 8s by the quarter; for boarding a
scholar, that is to say, diet, washing, lodging, and schooling,
ten pounds for one whole year.[137]

Thus the first impetus to education in [Sidenote:

Pennsylvania came through properly constituted Additional
governmental authority. The Council records show provisions or
books]
that the interest in educational affairs was
maintained for some time. In the month following a [Sidenote: Charter
law was proposed for making several sorts of of 1701 does not
refer to education
books for the use of persons in the province, and as did the former
also recommended that care be taken about ones]
“Learning and Instruction of youth, to witt: a school
in the arts and sciences.”[138] This interest in, and the close relation
of the Council to, education were not long continued however; for
this there is no satisfactory explanation, though it is very clear that
the attitude on the part of the government did change.[139] This
change is evidenced in the policy as outlined by the Charter of 1701,
in which there is no reference made to education or the responsibility
of the Governor or Council therefor.[140] To the writer it seems that
the withdrawal of the Council from any very active participation in the
affairs of education may have been due to two reasons: first, the
willingness evinced by private interests to establish schools and thus
take over to themselves the duties of educators (evidenced by the
establishment of Keith’s school by Friends in 1689 without the
assistance or advice of the Council);[141] and second, the urgent
details of establishing a new government, which occupied their first
attention.
 If further proof of the withdrawal of the colonial government from
the active establishment of schools, and of the fact that they did
accept and recognize the assistance of private agencies is desired, it
is to be found in various acts of legislation of the first half century.
Specific instances of such permissive legislation were the acts of
May 28, 1715,[142] and also of February 6, 1730-1.[143] This
legislation is chiefly concerned with granting privileges to purchase
and hold land and erect buildings for the use of institutions stated
therein, among which schools are mentioned. In this connection the
statute of 1715, which evidences the facts stated above, is quoted.

Be it enacted by Charles Gookin, Esq., by the royal

approbation Lieutenant-Governor, under William Penn, Esq.,
Proprietary and Governor-in-Chief of the Province of
Pennsylvania, by and with the advice and consent of the
freemen of the said provinces in General Assembly met, and
by the authority of the same, that it shall and may be lawful to
and for all religious societies or assemblies and
congregations of Protestants, within this province, to
purchase any lands or tenements for burying grounds, and for
erecting houses of religious worship, schools and hospitals;
and by trustees, or otherwise, as they shall think fit, to receive
and take grants or conveyances for the same, for any estate
whatsoever, to and for the use or uses aforesaid, to be holden
of the lord of the fee by the accustomed rents and services.
And be it further enacted by the authority aforesaid, that all
sales, gifts or grants made to any of the said societies, or to
any person or persons in trust for them, or any of them, for or
concerning any lands, tenements or hereditaments within this
province, for and in any estate whatsoever, to and for the use
and uses aforesaid, shall be and are by this Act ratified and
confirmed according to the tenor and true meaning thereof,
and of the parties concerned therein. And where any gifts,
legacies or bequests have been or shall be made by any
person or persons to the poor of any of the said respective
religious societies, or to or for the use or service of any
meeting or congregation of the said respective societies, the
 same gifts and bequests shall be employed only to those
charitable uses, or to the use of those respective societies or
meetings, or to the poor people to whom the same are or
shall be given or intended to be given or granted, according to
what may be collected to be the true intent and meaning of
the respective donors or grantors.

On “11th month, 9th, 1682,” the Friends met and [Sidenote: The
enacted business relating chiefly to the sick, a first meeting of
meeting house, purchase of books and such other record]
details of importance, but made no reference to [Sidenote: The
schools or the education of youth.[144] This probable length of
Flower’s tenure
remained true for all meetings till 1689,[145] the as teacher]
chief part of business in the meantime having to do
with either (1) strictly religious affairs or (2) raising money for the
poor and the orphans. The absence of any remarks or any plans for
schools from 1682 to 1689 is more easily understood when it is
recalled that the school under Enock Flower was set up in 1683.[146]
There is no evidence to prove definitely that Flower continued as
schoolmaster during the whole of this time, but (1) the absence of
any record of change, (2) no record of schools kept by the Friends
Meeting, (3) the fact that he was a teacher of long experience
(twenty years) and probably as satisfactory as any to be found, and
(4) the absence of keen competition on the part of neighboring
places to draw him away, would lead one to believe it probable that
he remained there for the greater part of the period at least.
In 1689 Friends determined to establish a school, designed to
meet the demands of rich and of poor,[147] which does not seem at
all strange since they were known to have been supporting their poor
and the orphans by subscriptions since their first establishment.[148]
The transaction of the business relating thereto was performed in the
monthly meeting and referred to the quarterly meeting (higher) for its
approval. The following extract from the records of the meeting gives
the result of their decision: