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A new paradigm of pain

Author explores changing attitudes, approaches to chronic pain

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A 2009 report by the nonprofit Mayday Fund found that chronic pain afflicts more than 70 million Americans and costs the economy $100 billion per year. Chronic pain plagued writer Melanie Thernstrom for years, motivating her to seek out the true nature of her problem. Her investigation resulted in a new book, The Pain Chronicles, in which she rigorously examines the evolving notions of pain throughout human history. Stanford Medicine News caught up with her during her recent book tour.

Why is pain so hard to describe?

A: Well, pain sits right at this juncture between biology and culture. On the one hand, it’s a very private experience. It draws on the meaning-making parts of the brain and brings all kinds of memories and associations into it. But it is also a universal experience because we all have a similar nervous system. It’s not really like anything else, so it’s hard to find the words to describe it.

What does pain tell us about a time, culture or society?

A: Because pain is a subjective experience, a perception generated by the brain, it has enormous flexibility of meaning. It is stamped by the context in which it occurs, but it is also stamped by the social era. In ancient times, pain was a spiritual signifier coming from the realm of demons and deities. In the 19th century there was a shift to the belief that pain was simply a biological phenomenon that indicated tissue damage. Today we have a paradigm that in some way reconciles both the ancient one and the 19th-century one.

What happened to change this paradigm of “the gods are angry”?

A: With the discovery of anesthesia, pain was seen as something that could be controlled by man. That helped cement the view of pain as a biological phenomenon. However there were limitations to that view that were evident in things like phantom limb pain— if you cut off someone’s hand, they will still experience pain as coming from the hand, though it’s really being generated by the part of the brain that maps the missing limb.

What happens in the body to change from acute pain to chronic pain?

A: Some of the worst forms of chronic pain originate only in the nervous system. In many cases the person had an injury and the injury healed, but the nervous system undergoes changes and the system revs up so that it becomes increasingly more sensitive over time.

So pain begets pain?

A: Pain begets pain. There also is some evidence that chronic pain atrophies the gray matter of the brain—the parts that are associated with cognition. Pain atrophies the so-called “thinking parts” of the brain twice as quickly as normal aging does.

In your book, you write about the way in which primary care physicians and patients talk about pain in very different ways.

A: I think we are in the midst of a paradigm shift about pain. The specialists know that chronic pain is a disease, but that understanding has not really seeped into the medical community at large. Again and again I interviewed patients who had the experience of going to their primary care physician and saying, for example, they have crippling back pain. And the doctor does an exam and says, “I think your back looks fine.” Maybe they do an MRI and they say, “I don’t see any problem.” The implication is that you must not have pain.

That it is all in your head.

A: Right. The MRIs are not going to show problems in the nervous system and the brain, where the pain actually is. In the lab, there is a lot of work being done in functional brain imaging studies of people in pain and people under pain stimulus, so that we can actually see what pain looks like in the brain. But that is not available in the doctor’s office.

What most excites you about the future of treatment for pain?

A: The most exciting directions of pain research are in the genetics of pain and the genes that make some people more vulnerable. I think that one day there will be a clinical test and you will be able to find out whether you are vulnerable. That would be very valuable to know.

The other big direction—and this is work in which Sean Mackey, MD, PhD (director of the Stanford Pain Center), is really a world leader—is using imaging to identify the mechanisms in the brain generating pain and learning how to activate the system to dampen it.

To hear the full podcast, go to stan.md/bg1hmD. Learn more about Mackey’s research in chronic pain at paincenter.stanford.edu.

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