Each year, I get excited as the beginning of our seminar on multidisciplinary approaches to pain draws near. I teach this undergraduate honors seminar with my friend and colleague, John Loeser, of UW’s Department of Neurological Surgery, and also Anesthesiology and Pain Medicine. John is my “mentor” in pain–as one of the true founders of scientific and clinical approaches to pain, he has been a true inspiration.
We approach pain, especially chronic pain, as a phenomenon that is a multidimensional experience. By this, I mean that chronic pain is as much social and psychological as it is biological. It is depicted scientifically, but also in the rich depths of the arts, of literature, of behavioral and depth psychology. We can understand the epidemiologic approaches to pain, and clinical approaches. but unless we can understand the personal meaning of the experience of pain, perhaps we understand little.
Acute pain is a symptom and a warning: it serves an adaptive function, and is a symptom of tissue damage. Persistent pain, however, alters brain structure, brain physiology, and neurologic processes. In other words, it alters the very structure of the nervous system. Chronic pain seems to develop a life of its own, and serves no adaptive function. It becomes a disease unto itself. Approximately 100 million Americans report that they experience chronic pain at any one time. It is the top cause of disability adjusted life years globally.
Treatments are improving, but they are far from satisfactory in that treatment failures are common. The approaches that seem best–and data bear this out–are multidisciplinary approaches to pain treatment. These typically involve a combination of medication (esp tricyclic and SNRI antidepressants), antieptilectic medications (esp gabapentin and pregabalin), cognitive-behavioral therapy, relaxation, visualization and mindfulness meditation, and “graded”, or gradual, increases in physical activity, geared to the individual and to not exacerbating underlying pathology.
These mutldisciplinary programs have the best outcomes, and it is not surprising. Unfortunately, because they are few and far between, much of the population in the US does not have access to them. This is compounded by the fact that clinicians typically have poor understanding of pain, its underlying mechanisms, and its optimal treatments. The average medical school curriculum has less than one half day devoted to pain. Knowledge of how to treat acute pain is more common than knowledge of how to treat chronic pain–a much more complex phenomenon–a psychosocial phenomenon. It is more than acute pain that lasts longer than usual.
Narrative medicine–understanding the story, the narrative behind each patient’s experience–is helpful in understanding the subjective experiences of those who are caught in the cycles of chronic pain. We read one novel and one personal narrative: Philip Roth’s The Anatomy Lesson, and Reynolds Price’s A Whole New World. The former deals with a protagonist with a chronic pain problem that comes to dominate his life, and the latter is written by an author and novelist recounting his own experience with a devastatingly painful spinal tumor. Both books are eloquent narratives by 2 of the country’s greatest writers.
I can understand my excitement as we approach the beginning of the pain seminar. We expose the students to something that transcends easy diagnostic categories, and that remains mysterious, and frequently dreaded. While there are epidemiology courses on cardiovascular, cancer, and infectious disease epidemiology, or neuroepidemiology, or psychiatric epidemiology, we know of no course on pain epidemiology.
Thus, as we approach the beginning of our pain course–the only such course that we have been able to find in the US–there is good reason for our excitement. If we can get a few students to think about pain in novel ways, or to enter clinical or research careers with foci in pain, our efforts will be successful.