This is a bonus addition to a series exploring the intersections between effectively caring for people living with chronic pain and the rise in unintentional poisoning deaths due to prescription painkillers. To read the three-part series, which explores the science of pain management as well as physicians’ and public health workers’ roles in preventing opioid abuse and overdose, click here, here and here.
by Kim Krisberg
“If you really look at how pain affects people and what it means to have pain…you start to view it more as a social phenomenon.”
These are words from Dr. Daniel Carr, a professor of public health, anesthesiology, medicine and molecular physiology and pharmacology at Tufts University. He also directs and co-founded the university’s Pain Research, Education and Policy Program, the only such pain program housed within a school of public health. I had called Carr to discuss the role of public health workers in addressing today’s worrisome prescription drug abuse and unintentional poisoning rate — a trend largely driven and connected to prescription opioids. But in true public health fashion, Carr took the conversation back to the beginning. The time for a population-based approach doesn’t begin with misuse and abuse, he said; it begins, in fact, with how we interpret the contributors to pain in the first place.
Carr told the story of a chronic pain patient he once treated who said she’d gone from “big pain, small life to small pain, big life.” In other words, as her pain shrank, it created room for the rest of her life to flow back in and allowed her to re-engage in the social, vocational and educational networks that we all use to define ourselves. Carr said he believes that chronic pain is inherently linked to isolation and stigmatization, factors that become clearer if viewed through a public health-inspired, population health-based lens.
For example, he asked: What’s one of the most commonly used and safest analgesics? Answer: The safe embrace and kiss from mother to toddler — “it addresses feelings of distress and isolation that in individuals with pain are triggered almost instantly,” Carr said. In a 2009 article he wrote for a publication of the International Association for the Study of Pain (IASP), he discussed the interplay of social and biological, referencing the patient above:
“The warning signal of acute pain is one of many processes that nature has given us to help convey our species’ genetic material across generations. If despite such warning we are hurt, nature provides us with temporary endogenous analgesia to help us escape further harm. Once we successfully escape further acute injury, our bodies draw upon an integrated repertoire of restorative processes that nature has also provided. But if despite these resources we fail to reclaim our place in society, nature liquidates her accumulated investment in our individual wellbeing. For the patient (above), losing her everyday social, family and vocational interactions meant losing what defined her life.”
Carr noted that research examining the parts of our brains that respond to pain strongly shows that pain is very much a social process. And if that’s the case, then it seems only logical that clinicians and their patients would benefit greatly from expanding their frames of reference and taking a cue from public health — “otherwise, we wind up leaving (clinicians) taking care of patients thinking that if they could just work the pharmacology better, things would improve. But that’s an illusion,” Carr said.
“This does not negate the truth at the micro level, but instead the frame of reference is shifted so that the questions it poses and the answers it seeks include the interactions between individuals,” he said. “I would never say that pain is not real…I’m just talking about how we should interpret and study it.”
Regarding the startling rise in opioid-related abuse and death, Carr, who treated patients for 20 years, noted that no one who was initially advocating for expanding treatment options “anticipated there would be this epidemic of misuse and abuse.” However, after talking with Carr, it seems that integrating public health perspectives into pain care could shift prescribing practices and eventually affect the flow of prescription painkillers into the illicit market.
Carr writes in the IASP article: “I cannot think of a better subject than pain as a means to link objective measurement with existential experience, nor a more rewarding way to spend one’s time than in helping pain sufferers.”
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.