The National Uniform Claims Committee recognized interventional pain management as a distinct and separate specialty with the following definition:

“Interventional Pain Management is the discipline of medicine devoted to the diagnosis and treatment of pain and related disorders with the application of interventional techniques in managing sub-acute, chronic, persistent, and
intractable pain, independently or in conjunction with other modalities of treatment.”

On July 31, 2002, The Center for Medicare/Medicaid Services, formerly HCFA (Health Care Finance Administration) established the specialty of interventional pain management. This came about as a result of relentless effort and hard work by The American Society of Interventional Pain Physicians. Prior to the approval and this specialty designation there has been a lot of history.

The history of pain management is intertwined with the history of surgery and anesthesia, with both aimed at controlling pain as an entity. Anesthesiology acts to prevent pain in the form of general anesthesia or local anesthesia blocks before and during surgery. On the other hand, pain management as a discipline involved invasive and noninvasive approaches to treat existing pain, be it acute pain, chronic pain or cancer pain, with the objective of reducing pain, restoring function, and eliminating or minimizing suffering. The earliest documented pain intervention is in the book of Genesis (the Bible) where God put Adam (male) into a deep sleep in order to remove his rib as a template to make Eve (female). People in pre-medieval Europe, Middle East and North Africa used cold and heat applications as well as electric fish to treat local pain. It was also prevalent in that era to link disease and pain to evil spirits., especially when pain sources could not be visibly accounted for. Chinese and other Eastern cultures sought out pain points in the human body and ultimately developed acupuncture therapy and the concept of the meridian, a practice that has lasted over 2000 years. The great Greek philosophers and teachers, Plato and Stratton, as well as other distinguished Egyptians like Herophilus and Eistratus (375 B.C.) all recognized the brain as the site of pain perception and showed its connection to the peripheral nervous system. About 400 years later Galen (ca. 200) revisited his works of the Egyptian anatomists and physiologists on the functional unit of the brain, the spinal cord and peripheral nerves. This is important since the great philosopher, Aristotle, had incorrectly theorized at that time that pain was perceived in the heart. About 1826 the “specificity theory” that established the CNS and PNS (central nervous system and peripheral nervous system) as we know it today was born in Germany by Mueler and about 200 years after Descartes’ descriptions of pain conduction from peripheral damage to the spinal cord then to the brain. At the end of this relatively long period of stagnation in innovation things picked up, and the needle and the syringe (hypodermic injection) was discovered by Rynd (Dublin, Ireland) in 1845 and Pravas (France) in 1853 respectively. Other people credited with hypodermic needle and syringe include Taylor and Washington (USA) in 1839. Soon after, Corning (USA), Cushing (USA), and Wood (UK) demonstrated the utility of the first recognized local anesthesia (cocaine) and nerve block to prevent pain and shock of amputation. It was again was recognized and documented as an anesthetic by Bennett of Scotland. Cocaine and subsequently pure alcohol were used to provide pain block in both anesthesia and cancer pain patients respectively. World War I (1914 to 1918) and World War II (1939 to 1945) provided opportunity to use this new knowledge to treat pain produced by trauma, frostbite, and phantom limb pain as well as the pain of sympathetic medical pain syndromes like causalgias, just as safer local anesthetics were being produced to replace cocaine. It was during the second World War that an Army surgeon by the name of John Bonica started a multidisciplinary approach to pain management on veterans with chronic pain as well as drew attention to the under-treatment of pain in general and chronic pain in particular. His intellectual approach and organized medicine efforts, as well as his 1953 publication of the first comprehensive book in pain management entitled, “The Management of Pain,” led to his universally recognized role in history as the founder of modern pain management. John Bonica had worked in the University of Washington in Seattle after the second World War and his efforts served to inspire the founding of The American Pain Society (APS), and International Association for the Study of Pain (IASP). Today IASP has active chapters in nearly all countries in the world and has served as a major research engine in coordinating activities all across the world as it relates to pain medicine.

Others worthy of mention regarding their contribution in the field of regional blocks and anesthesia include Quincke of Germany, who founded lumbar puncture techniques. August Bier of Germany and Cousins of Australia. Cathelin and Sicard of France, working independently, discovered caudal epidural blocks using cocaine, which was the only available local anesthetic at that time. In 1904 Einhorn of Germany synthesized procaine (Novocain), a safer local anesthetic than cocaine, when it became clear that cocaine was not a perfect local anesthetic. Other pioneers who highlited safety issues in regional anesthesia and pain management included Barker in the UK in 1907, Gray and Parston in the UK, Labat in the USA, Sancetta and Green in the USA.

The publication of the Gate Control theory by Melzack and Wall in 1965 added a new layer of understanding of pain management, on which additional concepts and treatment modalities, as well as understanding of the pathways of pain conduction and modulation have been since developed.

Interventional pain management in the millennium

The name interventional pain management was coined by Steven D. Waldman in an effort to recognize and distinguish the increasing number of pain management physicians to devoted their practice to helping patients in pain by the use of interventional techniques where indicated, as opposed to traditionally relying on pharmacological approaches. An interesting history of this name is best narrated by quoting part of a forward published in the second edition of “Interventional Pain Management,” written by Steven Waldman and Alon P. Winnie:

"…….It’s birth was the result of a request by Dr Alon P Winnie to put together a program to be sponsored by the Dannemiller Memorial Education Foundation to be held in Nice, France, in conjunction with the International Association for the Study of Pain World Congress. The result was a program titled Interventional Pain Management. When I presented the program to Alon for his comments, he asked “What in the world is Interventional Pain Management?” I explained I had coined the term interventional pain management (which I had liberally borrowed from oru radiology colleagues) in an effort to recognize and distinguish the increasing number of pain management physicians who devoted their efforts to help patients in pain by the use of interventional pain management techniques as opposed to limiting their efforts to pharmacological approach. Hence, the subspecialty of pain management was born."

Steven Waldman’s efforts to promote interventional pain management was greatly enhanced by his publication of the first comprehensive textbook devoted to the practice of interventional pain medicine, distinct and separate from the usual text that was a part of clinical anesthesia and regional anesthesia for surgery. The book, “Interventional Pain Management,” by Steven Waldman and Alon Winnie, was published in 1995. Steven Waldman practiced in the Kansas City area. He also founded The Society for Pain Practice Management which served as an educational and clinical forum that helped to guide young Pain Management physicians through the entire clinical and managerial challenges of running a pain management practice. The Society for Pain Practice Management (SPPM) held workshops at locations across the country.

At about the same time, a newsletter that dealt mostly with the problems encountered by interventional pain physicians who at this time were under enormous pressure from health insurance companies and managed care, as well as from The American Society of Anesthesiology (ASA), who unofficially considered anesthesiologists involved in sole practice of interventional pain management as renegades. It soon became clear that pain management physicians needed a national organization. A call was made for the formation of an association of pain management anesthesiologist (AOPMA), whose name subsequently change to The American Society of Interventional Pain Physician (ASIPP). Four interventional pain physicians came together in 1998 with substantial financial commitment to do this. They are Laxmaiah Manchikanti (Kentucky), Vijay Singh (Wisconsin), Cyril Burkitt (Virginia), and Bentley A. Ogoke (Massachusetts). These four members have been since honored as life members as well as permanent members of the Board of Directors for their contributions to ASIPP and interventional pain management. The Society has grown to 2600 members and continues to do so, including pain physicians not only from anesthesiology but also physical medicine & rehabilitation and neurology. ASIPP has since become the true voice of interventional pain medicine. The name was changed from AOPMA in 1999 to The American Society of Interventional Pain Physicians (ASIPP) during the first annual meeting held in Alexandria, a suburb of Washington, D.C. This was in recognition that The American Board of Anesthesiology/Pain Management covers the specialty of neurology, physical medicine and rehabilitation as well as anesthesiology. In December 2000, President Clinton signed into law the congressional mandate to MedPAC that led to the specialty of pain management and due to the exhaustive lobbying efforts of The American Society of Interventional Pain Physicians with the indispensable support of many Congressmen and Congresswomen. Most notable and worthy of mention is Congressman (Honorable) Ed Whitfield (Kentucky), who from the start took up the ASIPP goals personally. Congress asked for and received a review of the 2000 mandates for establishing the specialty designation of Interventional Pain Management separate from anesthesia after the MedPAC hearing in Washington in early 2001. This committee meeting was attended by six members of The American Society of Interventional Pain Physicians, including Bentley A. Ogoke, MD, who testified on behalf of the organization and interventional pain management. MedPAC conducted extensive hearings and study and came out with the report.

During this period in the history of pain management when the hospital pain clinics were shutting down in the New England area from Yale University Medical Center in New Haven, Connecticut to University of Massachusetts Pain Clinic in Worcester, Massachusetts, Dr. Ogoke went to Baystate Medical Center Pain Clinic and obtained a letter from the program head to help explain the fiscal plight of the area hospitals and how patient access had been adversely affected in the New England region due to these forced closures in major pain clinics in the area. This time coincided with the American Society of Interventional Pain Physicians’ efforts directed at obtaining a specialty designation for pain management at the time. ASIPP had been invited for a meeting with the MEDPAC, a functional unit of congress in Washington, D.C., who at that time was mandated by congress under a new bill signed into law by President Clinton to study patient access to Interventional Pain Management as well as practice expense related issues in the proposed specialty. Dr. Ogoke personally delivered the letter from Baystate Medical Center as well as other letters to the MedPAC at the time and pressed the case for improved access of care to pain management under the ASIPP delegation. Multiple presentations by ASIPP succeeded in revealing the barriers to coverage and payment for interventional pain procedures to MedPAC. The final MedPAC Report was favorable. The efforts of ASIPP led to reevaluation of the practice expense rates to hospital outpatient pain clinics as well as ambulatory surgery centers throughout the country in relation to pain management and helped restore the viability of Baystate Medical Center Pain Clinic among others. This is only one of his several visits a year to Washington for lobbying efforts with other ASIPP physicians on behalf of promoting access to the field of pain management since 1999.

The MedPAC report states;

1. The Secretary should evaluate payments for services provided in hospital outpatient departments, ambulatory surgical centers, and physicians’ offices to ensure that financial incentives do not inappropriately affect decisions regarding where care is provided.

2. The Secretary should evaluate payment rates for ambulatory surgical centers (ASCs) using recent charge and cost data from a sample of ASCs. He also should update the list of procedures that are covered when performed in ASCs.

3. The Secretary should recalculate the practice expense payments for interventional pain procedures when data become available on the practice expenses of physicians specializing in pain management.

4. The Secretary should sponsor additional research about the effectiveness of interventional pain services to strengthen the evidence basis for Medicare’s coverage decisions.

In 2001 the specialty of pain management was recognized and designated as Code 72 instead of the specialty of interventional pain management, which the ASIPP fought for. This came as a result of last-minute input by The American Society of Anesthesiology and was a temporary setback for The American Society of Interventional Pain Physicians, but still a leap in the right direction. The continuation of efforts and mobilization of the ASIPP membership in the lobbying process thus highlighting the need for a separate and distinct specialty of interventional pain management. On July 31, 2003 the CMS established the specialty of interventional pain management, designated Code 09.

In the past two decades, substantial advances in understanding and managing chronic pain, acute pain and cancer pain has emerged. Notable among leaders in the field are Alon P. Winnie, MD (USA), Michael Cousins, MD (Australia), Prithvi Raj, MD, Steven Waldman, MD, Phillip Bradenbaugh, MD, John Bonica, MD, Benjamin Covino, MD, among others.

Special appreciation goes to Bert Fellows, MA, clinical psychologist, who has dedicated his practice to the pain patient and was there from the beginning for ASIPP. Mr. Fellows has worked tirelessly as the coordinator for The American Society of Interventional Pain Physicians (ASIPP) and as editor of “The Pain Physician” newsletter since their inception in November 1998, and as editor of “The Pain Physician Journal” from its first issue in October 1999 until April 2002, and continues to serve in the capacity of managing editor. He has also authored more than 30 articles and editorials in the areas of diagnosis and treatment in pain management. He is a member of The American Psychological Association, The American Society of Interventional Pain Physicians, Kentucky Society of Interventional Pain Physicians, and The Society for Comprehensive Energy Psychology.


Bentley A. Ogoke M.D.