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pain in the a

Pub: Sydney Morning Herald

Pubdate: 13-Feb-2010

Edition: First

Section: Spectrum

Subsection: The Essay

Page: 12

Wordcount: 2471

A sore point with modern medicine


Elizabeth Farrelly

Chronic pain is Australia’s forgotten disease, despite its huge economic and personal toll. It’s time to do something about it, argues Elizabeth Farrelly.

PAIN is something most of us spend quite a lot of time avoiding. Indeed, pain-avoidance can seem the primary goal of existence. But it’s also true that pain – the idea of pain – excites and attracts us, and not just in boutique activities such as extreme sports or S&M sex. Violent movies energise us, partly via imagined pain. And as any sub-editor knows, a headline worded “Woman’s agonising death” will sell 10 times more papers than just “Woman’s death”.

Why the contradiction? Is this just chimp stuff, avoiding our own pain and ghouling over other people’s? What is pain, anyway? Is mental pain different from the physical sort? And how have we mythologised it? Does pain have any intrinsic value or is it, like tonsils, essentially superfluous? What, in short, does pain mean?

At an evolutionary level, pain’s purpose is clear. It helps us avoid damage. People who feel no pain – a rare condition known as congenital analgesia – typically experience ongoing damage from birth. Congenital analgesia can imply insensitivity to pain (not feeling it) or indifference to pain (feeling it but not being impelled to respond). Either way, it affects only a few hundred people on the planet but those who are affected (sometimes two or three siblings in a family) have a reduced life expectancy.

Occasionally, at least in fiction, such painlessness can be advantageous. Stieg Larsson’s giant thug Ronald Niedermann is rendered virtually insuperable by his combination of vast strength and zero pain – until the elfin Salander eventually defeats him by nailing his feet to the floor. (This echoes the real-life case of a child who could not remove his shoe and eventually, after much twisting and tugging, discovered the reason: a nail had pierced both shoe and foot, fixing them together without his knowledge.)

In reality, however, people without pain are generally disadvantaged, aggravating damage by running on broken ankles, failing to wash acid from skin or – as in the case of one child – walking off a roof to impress friends. It is common among lepers, who feel no pain in the affected limb or body part, to worsen their disability through unnoticed damage.

At this basic, survival level, then, pain has a clear damage-reduction function. Beyond that, though, we’d sooner not feel it – at all, ever. At the dentist or in childbirth, few of us choose to feel pain that has become optional and an enormous branch of medicine is devoted to pain – its study, management and relief. Or so we thought.

Next month’s National Pain Summit in Canberra will gather 130 organisations to address two core facts. Some 3.2 million Australians suffer chronic pain (this is probably under-reported) and the annual cost to the economy, as estimated by Access Economics, is $34.3 billion.

Professor Michael Cousins, director of the University of Sydney’s Pain Management Research Institute at Royal North Shore Hospital and summit chairman, hopes it will ratify a national pain strategy, raise awareness of pain as a disease in its own right and raise funding from levels that are “shockingly inadequate”. Although 20 per cent of us suffer chronic pain (30 per cent in older age groups), most miss out on available treatments.

So pain is absolutely still with us. And yet our lives are vastly less painful than almost any lives in history. My own children – largely unsmacked and blissfully unaware of the dental dread once associated with the “murder house” – have experienced so little pain that just removing a sticking plaster becomes a major life incident. I cannot convince them that they may be exaggerating because, among their peers, this is normal. So perhaps a pain-free human future is, for the first time ever, plausible.

The philosopher David Pearce’s Hedonistic Imperative website ( is devoted to this concept. “Over the next thousand years or so, the biological substrates of suffering will be eradicated completely. ‘Physical’ and ‘mental’ pain alike are destined to disappear into evolutionary history. The biochemistry of everyday discontents will be genetically phased out, too. Malaise will be replaced by the biochemistry of bliss.”

Is he right? Would it, if he were, be a good thing? Given that modern history is a story of the tossing-out of babies with bathwater, can we seriously expect to jettison pain altogether without some hidden cost? Is there (beyond that base survival level) such a thing as good pain?

Most medics, including Michael Cousins, say no. Pain, beyond that basic damage-warning function, isn’t just not good. Pain is actively, hugely destructive.

And yet it is clear that, as society becomes less pain-prone and increasingly pleasure-capable, self-punishment regimes such as exercise addiction, yoga, boot camps and extreme sports proliferate. The familiar mottos – from Jane Fonda’s “no pain no gain” to the athlete’s “breaking the pain barrier” ideal and the US marines’ “pain is just weakness leaving your body” – all represent not just a stoical “putting up with” pain but a welcoming of it. Bring it on. Almost as if pain is something we need.

This sense of pain as ennobler is familiar from history. In the Mandan Indians’ Okipa ceremony, witnessed by George Catlin in 1835, warriors proved their physical and spiritual prowess through an ordeal that included three days of fasting without sleep, peeling of the chest skin (while smiling), suspension until fainting from wooden skewers inserted behind the chest muscles, amputation of both little fingers and, to finish, a quick sprint round the village square.

Aboriginal initiation rites presuppose a similar ennoblement-by-ordeal and pain rituals, on a much smaller scale, are still enacted by school children interested in seeing who can stand the longest Chinese burn. Even the current tattooing fad has something of this pain-fetishism about it.

The history of torture, ghastly as it is, is interesting here, because of the illogical presumption that pain would produce truth – when most of us know we’d say anything at all, confess to anything at all, to stop even mild but persistent pain.

For the mediaevals, pain and truth were closely linked. Today, most of us scoff at this idea of pain as an ennobler, treating it like a primitive rationalisation we’ve outgrown. Mortifiers of the flesh – such as Silas, The Da Vinci Code’s albino monk – we regard as freaks. Even recent revelations that Pope Jean Paul II engaged in regular self-flagellation make us think he was weirder than we knew, not that we should perhaps follow suit.

The traditional idea that corporal punishment benefits children we also see as risible and antediluvian at best; at worst a hypocritical excuse for adult-on-child sadism. Some countries even ban smacking (New Zealand’s Prime Minister, John Key, has refused to overturn that country’s anti-smack statute, despite an overwhelming, 80 per cent referendum result supporting the parent’s right to smack).

Perhaps, though, the good-pain/bad-pain distinction is all about choice and duration. After all, there are big differences between a spot of self-flagellation and, say, rheumatoid arthritis: will, for a start, and brevity. Short-lived, self-inflicted pain is altogether different from pain that is persistent and imposed.

But that’s not the view espoused by the religions that have shaped human history. C.S. Lewis’s book The Problem of Pain addresses the atheist’s argument that a world in which “creatures cause pain by being born, and live by inflicting pain, and in pain they mostly die” makes a kind and omnipotent God an impossibility. This is a version of moral philosophy’s age-old “problem of evil”. Indeed, Lewis defines pain as “sterilised or disinfected evil” – yet, he says, pain is good.

Etymologically, pain means punishment; in particular for that old original sin that had us ejected from the garden. Lewis argues that punishment – retributive pain – is essential to justice. Without retributive pain (incarceration, for example, or smacking), we have no feeling of fairness.

Pain is not good in itself, says Lewis: what’s good is the sufferer’s submission to a higher will, be it God or society, and the spectator’s compassion.

This may sound sophistical but Lewis’s arguments are compelling, echoing the Gnostic intuition that dualisms such as good and evil, pleasure and pain are as necessary to our wellbeing as the light and darkness with which they are so often equated.

The Jewish Kabbalah, too, sees purpose in pain. Says Rabbi Michael Berg: “Many times [pain] comes to cleanse negativity of previous incarnations … it comes to help us expand our vessel and therefore our capacity to experience Light … Pain helps us break the negative shells (klipot) that conceal the Light within us from truly being expressed.”

Buddhism has a slightly different take, distinguishing carefully between pain and suffering. Pain is inevitable but suffering is optional. Suffering is how we choose to experience pain.

Theravadin monk Bhikku Bodhi says that his severe, chronic head pain has helped him “develop patience, courage, determination, equanimity, and compassion”. When he stops worrying about or struggling mentally with the pain, it becomes more tolerable. Contemplation helps him observe the pain dispassionately, without attaching to it.

This brings us to a paradox, or knot of paradoxes. Modern medicine must reject any ideas of the goodness or inevitability of pain because of the contradiction with the Hippocratic Oath. (Although, it must be noted, all these religions exhort their followers to alleviate pain and suffering whenever possible.) And yet the shift from pain as spiritual trophy (as for the Mandan) to pain as pathology contributes to pain’s stigma. Hidden, under-reported and under-discussed, it is deprived of the funding it so desperately needs.

Orthodox medicine, seeing pain as symptom, not disease, works to cure the pain by treating the disease. Pain relief is used in passing, as it were, during treatment but the presumption is that removing the cause will end the pain.

Sadly, this is not always so. Even in “normal”, nociceptive or body-damage pain, there is no one-to-one relationship between damage incurred and pain felt. Several studies show that women feel pain more (but receive less treatment) than men, although in childbirth femaleness can lessen pain – partly through hormones such as oxytocin and partly through mind factors, like the sense of birth pain as “good” pain. One study even suggests that African Americans feel pain more intensely than other Americans, suggesting that pain may be privilege-related (we know that pre-op anxiety greatly increases post-operative pain).

But when pain becomes chronic (persisting past the healing of tissue damage), it may be neuropathic in origin, stemming from nerve damage or (where no cause is apparent) nerve dysfunction. In complex regional pain syndrome, for example, an area of the body becomes excruciatingly sensitised, often after nerve injury or simple immobilisation (such as a broken arm). Erythromelalgia sufferers experience often lifelong burning in their feet and to those with allodynia, an innocuous stimulus (such as touching skin or feeling air) can feel like daggers.

Such pain is notoriously difficult to treat and made all the more intolerable by traditional medicine’s tendency to dismiss it as “psychosomatic”, which to many people feels like “just buck up and get on with it” advice.

And yet that is often the worst approach, partly because – scientists have recently found – untreated pain is often dangerous in itself, capable of triggering heart attacks or strokes but also of transitioning into chronic pain, which is much, much harder to treat.

The gateway theory of pain dates from the 1960s but underpins most current thinking. It’s not just a metaphor. Pain signals actually flow and if the stimulus continues, or if pain is under-treated, molecular gates that would normally close after acute pain can get stuck open, letting pain “flood” the body.

There is also a phenomenon known as “wind-up”, where nerve pathways respond to under-treated pain by becoming hyperactive, mobilising and manufacturing extra transmitter and receptor molecules to increase pain and draw attention to their plight.

Analgesics, then, must interrupt some stage of this process, and the chemistry is complex. But one interesting factor, says Cousins, is that two of the highest risk factors in predicting which acute-pain patients will transition to chronic pain are psychosocial: irrational fear of re-injury and the quality of the person’s relationship with their immediate superior at work.

This sort of evidence, and the fact that depression and chronic pain are often comorbid and show largely identical brain activity and neuroplastic changes, lead most pain specialists to say no, there’s no difference between mental pain and physical pain. In fact, they invert the Buddhist distinction: what happens at the point of damage is just noxious nerve stimulus, or “nociception”. Pain (like the Buddhist “suffering”) is what happens in your brain.

So all pain is mental pain – chronic pain, says Cousins, is a “complex biopsychosocial phenomenon” – and all pain patients should see, inter alia, a psych. (Remember little Sophie Delezio’s experience of blowing her pain away in bubbles; cognitive behaviour therapy can help.)

For anyone suffering it, pain is absolutely an issue (as the huge black market in the synthetic opioid oxycodone, to which Heath Ledger was supposedly addicted, attests). Surprisingly, though, pain is not really an issue for drug companies, governments or medicos in general.

Many new pain-killing drugs, for example, have come into analgesic use by accident. Tricyclic antidepressants such as amitriptyline and anti-epileptics like gabapentin are both effective for different kinds of neuropathic pain but, being unsubsidised for these new purposes, can be prohibitively expensive.

Another bizarre omission is that pain is not generally recorded on a patient’s bed chart. This no doubt reflects perceived difficulties in reliable measurement but dozens of studies now show that a simple one-to-10 patient rating is usually very reliable, and Cousins would like to see pain habitually charted as the “fifth vital sign”.

Militating against such change, though, is the fact that pain is only scantly taught. A recent Canadian study showed that vet school graduates averaged six times (98 hours) the pain training of medical graduates, who averaged 16 hours and sometimes recorded zero specific pain teaching. Similar attitudes pertain here.

So Australia, a world leader in pain thinking, has just 269 pain specialists. For a working interdisciplinary system, says Cousins, we’d need at least twice that and a co-ordinated primary care approach. Although the good news is that our capacity to help chronic pain patients is up to 80 per cent – from 10 per cent 40 years ago – the bad is that fewer than 10 per cent actually get that help, with waiting times up to three years.

Every one of the millions of Australians dogged, silenced, house-bound, bedridden or prematurely aged by persistent pain will hope next month’s summit will start to turn this around.

The National Pain Summit will be held on March 11 at Parliament House in Canberra.


PHOTO: Illustration: Fiona Lawrence


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