Sezione Medicina

from Leadership Medica n. 10/2000

These days hospitals with no pain are talked about by many (especially the ‘in vogue’ politicians) with undue emphasis and wide smiles, though without ever explaining to citizens what this pleasing phrase, almost magical and miracle-like, actually means. John Bonica (an Italo-American anesthetist who founded a pain clinic in the 1950s) taught us what ought to be meant by a hospital without pain.
It is a hospital that has the means to carry out pain therapy, be it acute or chronic, in an organized and routine way.
In other terms, a hospital that offers, in addition to its anesthesia and reanimation service, a pain diagnosis and treatment service too. In this sense, there is no pain in that hospital, since it is promptly dealt with, reduced and eliminated.
John Bonica set up his first pain-free hospital in the 1950s at the University of Washington, Seattle. This splendid structure from then on represented a reference point and ideal example for the whole world.
At the end of the Fifties and together with the neurosurgeon Professor Papo (then at Milan’s Policlinico and subsequently Neurosurgical Department Chief in Ancona), we proposed that the Administration of the Istituti Clinici di Perfezionamento (ICP) establish a Pain Therapy service alongside its Anesthesia service.
The idea covered the treatment of both acute pain (postoperative and childbirth) and the chronic type (neuralgic, cephalic and rheumatic pains) and the pain from cancer.
In pratice, it proposed the establishing of a pain-free hospital based on the John Bonica model.
The Administration good-naturedly but firmly suggested we withdraw our proposal. In this way the ICP lost a great historic opportunity to be among the first pain-free hospitals in the world.
Many years had to pass before our dreams about pain therapy organization would begin to come true. In 1976, ten physicians (including myself), responding to the invitation and solicitation that Bonica sent from the United States, founded the Associazione Italiana di Studi sul Dolore, the Italian chapter of the IASP (International Association for the Study of Pain).
Soon after, organized and presided over by John Bonica, Paolo Procacci and Carlo Alberto Pagni, the first World Congress on Pain was held in Florence. If I remember rightly, there were about a hundred participants.
To testify to the clamorous development that the interest in pain therapy has undergone throughout the world, more than 7,000 registered for the IX World Congress on pain held in Vienna in 1998! Italy is a country where pain therapy problems have always found space and attention. Suffice to think of the Florence school with Lunedei and Galletti, the clever pioneers of the physiopathology and diagnosis of major algesic syndromes, or the one in Turin, with Dogliotti and Ciocatto, to whom a great deal is owed for the progress of spinal and peripheral block therapy. And then much has been achieved in the universities like Trieste with Mocavero, Verona with Ischia, Chieti with Vecchiet, Padua with Giròn, to quote just some examples. In 1982, the University of Milan instituted the first Chair of Physiopathology and Therapy of Pain, and I came along from the Faculty of Medicine and Surgery to direct it. Moreover, in 1983, the ICP accepted a generous donation from the Bergamasco and Visconti di Modrone families, who wanted to erect the first University-Hospital centre for pain therapy.
The “Padiglione Maria e Pier Ettore Bergamasco” ward block, of which I assumed the direction, arose in 1985 at Via della Commenda 19, Milan. With my collaborators, all anesthetists, we treated thousands of patients every year.
But what is the situation for pain therapy services within the Italian Hospital Institutions? Put another way, in our country - where more than twenty million people suffer chronic pain and where there are thousands of surgical operations and childbirth deliveries daily - how many pain management hospitals are there currently, i.e. hospitals in which an acute and chronic pain therapy is institutionalized and offered routinely? It is not easy to say it, but certainly very few. Pain therapy is traditionally entrusted to the anesthetists, who in many hospital structures dedicate time to this discipline on their personal impassioned initiatives, often outside their service hours and without being paid.
In 1985, the Venetia Region (the first in Italy), on an initiative by Prof. Giampiero Giron, instituted the Pain Therapy Service in its hospitals. De facto it was the pain-free hospital. This example was successfully followed in various other Regions including Liguria and Emilia-Romagna. And in Lombardy, the Region that set the example? Prof. Giuliano Pradella, then President of ‘Anestesisti Lombardi’, said in an interview: “among the negative examples (also because of political instability), we find Lombardy, where legislative evasion impedes extremely useful projects like the establishing of pain therapy services in its hospitals. Suffice to think that in Lombardy one and a half million people can need analgesic therapies each year”.
Costantino Benedetti (a pupil of Bonica and currently Professor of Anesthesia at Ohio State University) writes that “when acute pain is not suitably dealt with, a growing vicious cycle of anxiety, fear and stress is formed that can lead to insomnia, passivity and immobility, which in their turn augment the patient’s algesic perception.
Chest or upper abdominal pain will impede the patient from breathing normally or coughing.
The incidence of pulmonary complications is reported as being between 20% and 60%. Pain in the lower limbs or pelvis interferes with deambulation, predisposing patients to venous thrombosis and thus the risk of pulmonary embolia”. In the pain-free hospital the operated patient in the post-op period should not in any way feel pain.
Benedetti writes again concerning acute post-op pain [1996]: “Acute post-operative pain should be treated for two fundamental reasons: the first is humanitarian, to diminish the patient’s suffering; the second is clinical, to cut the complications and recovery time”. The pain-free hospital is therefore set on adopting and systematically applying therapeutic rules that may be defined as ethical as well as scientific. In many countries, including the United States, the pain-free hospital model has been applied for years. Many such hospitals have a medical and nursing team engaged with acute pain, while a second team deals with the treatment of non-oncological chronic pain, and a third team is involved with cancer pain treatment.
Pain therapy ought also to be extended nationally, setting up pain therapy outpatient clinics and Day Hospitals within the hospital structures, entrusted to the anesthetists, to whom the citizen could turn to for the diagnosis and treatment of chronic pain. For some time now, SIAARTI (Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva) have been moving in this direction, establishing annual courses on how one should organize and run a pain-free hospital.
To institutionalize the pain therapy service in every hospital is thus a great welfare battle having a scientific and (above all) ethical content.
The person that has to be hospitalized whether for an operation or to give birth would undergo it with much more serenity and tranquillity knowing that there is a guaranteed complete protection from pain. The ideal situation would be that all the Italian hospital structures, and not just some enlightened examples, would become such. It is only an organizational problem and therefore of the good will on the part of the hospital administrators and Regional Health Councillorships. A service that the citizen in the year 2000 has a full right to. It appears that the politicians have finally understood.

Mario Tiengo
Professor of Physiopathology and Pain Relief
University of Milan

(traduzione Dr. Aldo Magliocco - Milano)