We live in a country that is in pain. Approximately 20% of Americans suffer from chronic pain. Through lost work and often ineffective treatment, chronic pain costs us $600 billion annually, more than cancer and heart disease combined. The emotional and social toll is uncountable.
Pain is lodged at the crossroads of the two epidemics that have distinguished this decade: opioid addiction and suicide. Pain and its mitigation were the rationale for the profligate (and deceptive) marketing of opioids when prescription pill sales quadrupled between 1999 and 2014. That widespread misuse and addiction followed was, perhaps, not surprising. Physical pain is sometimes at the root of psychic pain; sometimes isolation and despair produce another form of suffering, leading to suicide. Our two epidemics meet at a crisis of pain.
What we know now is that pain starts as a symptom—associated, for example, with arthritis or neuropathy—and for one in five Americans this symptom becomes “chronic,” that is, it lasts for weeks or months or even years. At some point during this period, the symptom becomes its own disease. Chronic pain has its own reliable neurobiology (which we are just beginning to understand), its own brain activation signature, although it cannot be localized in any specific “pain area” like other sensory perceptions such as smell or sight. Still, pain changes the brain’s structure, its neuronal configurations.
Pain’s significance and interference in a person’s life is highly individualized. The experience of chronic pain can be altered by mood, sleep quality, distraction, suggestion, or even anticipation of new pain. Which implies that pain may be exacerbated by social conditions—by violence, by anxiety. Living in poverty increases the odds of living with chronic pain.
Yet pain is argued over. Pain is important in our legal system and is the subject of disputes over payment for disability claims and personal injury suits. The lack of an objective measure of pain means that some who might deserve compensation miss out because they cannot “prove” pain, although we are getting closer to having brain scans presented as legal evidence. Pain is always a subjective experience, but there is a race to make it objective as well;prototype blood tests are also nearing clinical use.
Pain is a threat; it makes us feel helpless. It makes us ruminate and catastrophize. Decreasing avoidable suffering is central to our sense of being healthy. To become or remain pain-free is a nearly universally shared life goal.Assessing and treating pain, chronic pain, coping with its presence and limiting its ruinous effects without misusing opioids or taking one’s own life remains central to the mission of public health and the measure of our empathy.
Warmly,
Michael Stein & Sandro Galea