The Value of Pain?

One of the interesting things I learned while researching my book, was the way our conception of pain has changed over time.

Prior to 1900, pain was viewed as an immediate and short-lived response to an injury or illness – the body’s emergency warning system that burned bright and then burned out. Once the injury healed or the illness was cured, (or the body just got used to it, whichever came first), the pain, so the thinking went, disappeared. There was no framework or lexicon for chronic pain, especially in the absence of injury or objectively verifiable disease.

Today, hospitals and clinics are overrun with patients struggling with a growing variety of chronic pain conditions. Indeed the number one cause of Social Security Disability Insurance (SSDI) today is chronic pain. Compare this with the 1980’s, when the leading causes of

disability were heart disease and cancer. Furthermore, pain today need not be caused by an injury or illness. Pain can be its own disease. A growing list of chronic pain conditions has emerged for which there is limited understanding and no obvious medical antecedent: fibromyalgia, complex regional pain syndrome, pelvic pain syndrome, etc.

Another aspect of pain management that has changed in the last 150 years, is the approach to peri-operative pain. As recently as the mid to late 1800’s, pain during surgery was considered salutary, by boosting cardiovascular and immune function and thereby expediting healing.

By the 1950’s, with advances in anesthesia (methods of rendering patients unconscious) and analgesia (methods of eliminating acute pain), especially the growing availability of synthetic and semisynthetic opioids, pain during surgery was no longer considered beneficial. (Of interest, recent reports have shown that patients who receive opioid painkillers during surgery have slowed rates of tissue healing compared to those undergoing the same surgery without opioids, which may be attributable to opioid suppression of the immune system.)

A third way medicine’s conception of pain has changed over time, is pain today is ‘bad’ not merely because it is painful, but also because it is believed to engender future pain, by leaving a neurological scar, so to speak. Such conditions are of-late referred to as ‘centralized pain syndromes’, and localize the source of the pain in the brain, rather than out in the body. As a psychiatrist, I can’t help but note the parallels between centralized pain syndromes and post-traumatic stress disorder, both of which link the acute experience of pain as a potential source of long-lasting pain.

The changes in the past century in the way medicine and society view pain have allowed for a lessening of the burden of suffering for many people with pain; but have also inadvertently contributed to the opioid epidemic, by encouraging doctors to overprescribe opioids for chronic pain, and by making the elimination of all pain the goal of medical treatment. Emerging evidence suggests that opioids are not effective when used long-term for pain (they are very effective for pain short term, i.e. 1-3 days), and may even cause serious adverse health consequences, including making pain worse when used for more than a month.

Anna Lembke, MD, is the chief of addiction medicine and an assistant professor at Stanford University School of Medicine. She is the author of Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.