Pain into Process: A PREP Graduate’s Before and After Look at Taking Her Own Medicine

Guest blogger: Felice Indindoli, MS-PREP 2015, MAc 2015, Tufts University School of Medicine, Pain Research, Education and Policy Program

Raring to go! That’s me. Upon entering the MS-PREP program I made quick work of getting a grant and press pass to fly out to the PainWeek Conference, 2013, in Las Vegas. It comes with my territory; jump with both feet or don’t jump (it hurts more when you leave a limb behind) and it was time to iFelice Bochman Indindolimmerse myself in the goings-on in the world of pain research.

My prior ventures into pain research and theories about pain were mainly on the literary side. Great writers have said great things about the human experience of pain with full realization that cosmic irony applies; language fails us in the face of pain. From the point of view of narrative, this is a massive conundrum. A lot can be said about that, or nothing.

Off I went to PainWeek with an editor’s sense of story development. I was eager to report on the conference. And, as someone not new to the learning process, I wanted to discover just what I’d gotten myself into pursuing both research and clinical degrees in pain management.

Kid in a candy store. That was me at the conference. But, in wrangling with the mountain of new material I had to absorb, fascinating though it was, I found myself in an odd place: speechless. Looking back, it was an apt response (or lack thereof and still appropriate) in the face of so much new information. Odd how it seemed to parallel what I knew from literature about the language of pain, the metaphors and analogies all refer to the evaporation of meaning in language. Words mean nothing. Or, given a state of pain, one has no words at all.

I left the conference with my memory and laptop stuffed with information about pain research. The second year of my acupuncture program was already in session and I’d just missed a cool week of class and lab to attend the conference. As I started to unpack what I’d learned, the writing process turned swiftly from thinking about what I had learned to, “what was I thinking?” in taking on a full week of pain research. Ouch…no pun intended.

Some of the most thought provoking talks at the conference were subjects I would soon tackle in PREP classes, under the tutelage of highly experienced teachers and mentors, which proved essential to my gradual understanding of the landslide of pain information I had subjected myself to…willingly, I might add. The following topics were of particular interest:
• Learning to Unlearn: How Coaching is Changing the Pain Management Landscape
• When Does Acute Pain Become Chronic?
• The Complexity Model: A Novel Approach towards Improving the Treatment of Chronic Pain
• Glia and Chronic Pain
• Teaching the Five Pain Coping Skills
• The Mad Woman in the Attic: Pain and Personality Disorders
• Chronic Pain in Children: Are they a Population at Risk?
• Drug Diversion VS Pain Management: Finding a Balance
• Opioid-Induced Hyperalgesia: Clinical Implications for Pain Practitioners
• Rational Polypharmacy
• Interview with an anesthesiologist and researcher working on a new drug NKTR-181 (now in phase 3 trials): taking the likeability out of pain medication via slow rate of entry
• Living on the Edge: Depression, Pain, and Suicide

The above lists only a handful of the talks I attended during the week-long conference. But, hopping from bullet to bullet, this list traces my learning curve in the PREP program. Pain topics in 2013 have not fallen off the table in 2015; they remain relevant.

What did I know before I started the PREP program? As I mentioned, reading about the human experience of pain from the literary side only goes so far in the understanding of that experience from the clinical side, the pragmatics of what it means to diagnose, treat, and manage pain. What I did not know before the PREP program is that each time one approaches a patient with a pain dilemma, one immediately steps into a minefield of several other issues. The ripple effect was new to me. Pain isn’t separate from anything—it’s a cause and an effect. I began to understand this concept during the PainWeek conference and it was hugely motivating. I was also starting to see patients as an assistant and then intern in my acupuncture training—the “ah-ha!” light bulbs were going off everywhere. Almost too many to manage. For a newbie, the deep-dive into pain research, education and policy brought me to a place of near blindness. Education shines a very bright light on the unknown…you do the math.

The 12 bullets listed above weren’t just talks I attended at the conference; they represent opening lectures in my education on pain. Concepts in ethics and culture that I knew from literary references were turned, virtually overnight, into case studies on the impact society and our ability to listen to medical narrative have on the pain patient. Haruki Murakami, in his book 1Q84, says, “I can bear any pain as long as it has meaning.” For a healthcare practitioner, this is the hallmark of bearing witness: enter Social and Ethical Aspects of Pain, PREP 232, with Pam Ressler and Dr. Libby Bradshaw. This was the class in which I discovered my capstone topic (though I didn’t know it at the time). I remember admitting to Pam that my topic was messy, disorganized, big holes in the research, more questions than answers and that perhaps I shouldn’t “go there.” Her answer was, “perhaps you should.”

Topics on pharmacy and medicine that had been the subject of my pre-med studies, an interest in the history of medicine, and web content on parenting, were addressed in detail in Neuroanatomy and Neurochemistry of Pain, PREP 230, and Introduction to Clinical Pain Problems, PREP 234, with Dr. Dan Carr, Ewan McNichol, and Dr. Steve Scrivani. We examine the physical, the empirical while understanding that the experience and expression of pain do not survive our granular look at the specifics; in fact, they seem to evaporate. More neurons, less person. More person, less neurons. Either way, we may try to get our hands on the shadow of pain left by a scar and chase it into a corner so we might label it, manage it, or at the very least identify it with nothing to use as a benchmark or basis of comparison. We understand that Palahniuk’s words in his nightmarish Diary, “We have no scar to show for happiness,” underscore the horror inherent in grappling with pain; happiness will not be found hiding under the scar or by following the pain once its neurological pathway is established–it’s somewhere else. Where, you ask? Cue the psyche.

On matters existential and psychiatric, I would point to Shakespeare for a juicy literary explanation that undoubtedly summed up a world of hurt in verse. This resonates with other literary critics, such as Elaine Scarry in her book, The Body in Pain. She suggests, “Whatever pain achieves, it achieves in part through its unsharability, and it ensures this unsharability through its resistance to language. [She continues] “English,” writes Virginia Woolf, “which can express the thoughts of Hamlet and the tragedy of Lear has no words for the shiver or the headache.” … Physical pain does not simply resist language but actively destroys it.” For all her insight into Virginia Woolf and the human body as a political map, Scarry didn’t make patients more real to me than evaluating them in Dr. Kulich’s class, Psychological Approaches to Pain Management, PREP 238. That mangled language left in the wake of pain can be even more difficult to interpret in those patients who struggle with disorder, in and of itself, applied not only to their expression of pain but also to their thought processes and mental health. I remember the talk given at PainWeek, The Madwoman in the Attic: Pain and Personality Disorders, which borrowed its title from the landmark text written by Gilbert and Gubar, with the intention of infusing a ruthlessly unfunny topic with some sense of humor.

Of drug diversion, complexity models, and clinical trials, I can’t say I have a good literary reference. I was enlightened, however (and not without some degree of pain) by two epidemiology and biostatistics classes, Professor Mark Woodin’s Principles of Epidemiology, PH 201, and Professor Janet Forrester’s Epi-Bio: Reading Medical Literature, HCOMM 502. I can return to the PainWeek slide presentation on NKTR-181 and make sense of the visual display of the quantitative analysis. This feels like a different type of accomplishment to me, like looking under the hood of a car and knowing what to do. At the same time, one needs to be able to reverse-engineer the information; take the information, understand it scientifically, express it and then turn it back into information accessible to a lay audience, perhaps a patient. Alia Bucciarelli was instrumental in helping me further hone my writing and editorial skills by using them to address scientific and medical information in a semester-long directed study in Advanced Writing for Medicine, PREP 400. We took the research from my capstone project and turned it around for parents of adolescent girls with chronic abdominal pain. It’s not a short journey from a systematic search in PubMed, to articles on pediatric abdominal pain, to interpreting the stats and overarching epidemiological issues, to analysis and back again but writing this time 5 truly cogent bullet points for parents in need of reliable information.

For the PainWeek talks that focused on educational issues and touched on healthcare policy, I was able to lean into some literary insights on pain. The discussions about children and chronic pain research as well as the pitfalls of trying to teach adult chronic pain patients coping skills, I would later learn in Dr. Srdjan’s Nedeljkovic’s class on Public Policy, Legislative, and Forensic Issues in Pain, PREP 235, were both examples of those minefields I mentioned earlier. Children and pain research, adults and coping skills to manage reliance on medication—instant ethics dilemmas served up with a side of forensics. For literary references, there are two that I like. One is from C.S. Lewis in his book, The Problem of Pain. He says, “Pain insists upon being attended to. God whispers to us in our pleasures, speaks in our consciences, but shouts in our pains. It is his megaphone to rouse a deaf world.” What can we do, what are we supposed to do when roused in this way for the sake of children who are sick and in pain? More concerning is what happens when we do nothing. Of all of the PREP classes I took, it was in this class that I found myself dumbfounded more often than not in the face of policies that both help and hurt, the clever maneuvering of legal language that sometimes, always, or never (you chose) lives up to the actions it purports to protect or expose. But, one must understand these things in order to navigate the minefield of pain issues in a given case—it’s never just one patient, with one problem, somehow in a vacuum. For discussions about pain and education in general, I will end with my favorite literary author on pain, Alphonse Daudet. His book, In the Land of Pain, written in the late 19th Century while suffering the final stages of tertiary syphilis, is a simple yet brilliant collection of the writer’s thoughts and feelings. It brings us back to the significance of language in the study of pain. Daudet asks, “Are words actually any use to describe what pain really feels like? Words only come when everything is over, then things have calmed down. They refer only to memory, and are either powerless or untruthful.”

This is the essence of what I learned both at the PainWeek Conference and in the PREP program: the value of listening. It’s the golden rule of pain management. Learn how to do it and why. Policy or poetry? You tell me. Actually, I’ll let my patients do the talking.

Add comment October 25th, 2015

Military Leads the Way in Acupuncture for PTSD

by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED blog moderator
With an estimated 17 percent of U.S. miliary personnel returning from Iraq and Afghanistan with symptoms of PTSD or Post Traumatic Stress Disorder (Archives of General Psychiatry), the military is now leading the way in integration of western and eastern models of care into the healthcare system. Use of acupuncture, meditation, yoga, and tai chi are currently being utilized in conjuntion with allopathic medical and psychological care. A recent article in highlights these integrative efforts.
Click here to read the article.

1 comment June 24th, 2010

NESA Research Seminar Series

New England School of Acupuncture, located at 150 California St, Newton, MA, invites interested student, faculty, and community members to come to a lecture by Helene Langevin, MD, Associate Professor of Neurology, Orthopedics and Rehabilitation at the University of Vermont College of Medicine. She will speak on Monday, April 13 from 2:30-4 PM on “Connective Tissue: Relevance to Chronic Pain & Acupuncture”. Dr Langevin’s research focuses on connective tissue mechanical signal transduction as a mechanism common to acupuncture, manual and movement-based therapies. Her previous studies in humans and animal models have shown that mechanical tissue stimulation during both tissue stretch and acupuncture causes dynamic cellular responses in connective tissue. She is currently investigating how these tissue responses are affected by chronic conditions such as low back pain

Add comment April 8th, 2009

Welcome to the Pain Research, Education & Policy Blog

by Richard Glickman-Simon, MD, Program Director, Pain Research, Education & Policy Programs, Tufts University School of Medicine
Welcome to the Programs in Pain Research, Education and Policy at Tufts University School of Medicine! Our multidisciplinary masters program is the only one of its kind in the United States, and our joint program with the New England School of Acupuncture is the only one in the world. This blog serves as a useful and engaging resource, not just for information about our program, but for timely articles on the latest developments in the field of pain and its management. Contributors include our faculty, alumni and students.
Who are we?
The mission of the Programs in Pain Research Education and Policy (PREP) is to equip our graduates with the knowledge and skills necessary to meaningfully improve the lives of people anywhere suffering from chronic or recurrent pain. Most of our students and recent graduates fall into one of two categories:
• Clinicians working with patients suffering from chronic pain (e.g., nurses, physical therapists, physicians, psychologists) who wish to be more effective on their behalf
• Students training to practice in a field that frequently serves patients in pain (e.g., acupuncture occupational therapy).
However, PREP is also well suited for those engaged in a variety of other professions including clinical research, dentistry, public health, health communication, grass-roots advocacy, legislation and the pharmaceutical industry. Recent college graduates have also enrolled in our program in preparation for medical school or other related fields.
For more information about our two masters programs and certificate program, please visit our program website.
Why do we exist?
PREP was created ten years ago in response to a number of disquieting trends in the world of pain that continue to this day. Mounting research from the biomedical and social sciences clearly demonstrate that, despite their superficial similarities, acute and chronic pain share little in common. Clinicians who manage their chronic pain patients with the same methods they use for acute pain inevitably fail their patients. Acute pain results from tissue damage or other causes of inflammation as a signal to the sufferer that something is amiss and needs attention. Chronic and recurrent pain, however, often occur in the absence of any identifiably persistent cause. (See Is Pain a Disease or Symptom article in this blog.) In fact, it is hard to imagine how such pain could be construed as beneficial in any way. Simply treating chronic pain with long-standing doses of anti-inflammatory (e.g., ibuprofen), narcotic (e.g., morphine) or other analgesic medications may provide a modicum of short-term relief. However, this approach does not address the underlying problem, which is far too complex and multifaceted for any medication (or equally simplistic treatment) to manage alone.
We now know that the experience of chronic pain involves far more than the persistent transmission of noxious stimuli through the nervous system. It is the culmination of a highly elaborate and dynamic process inextricably tied to the sufferer’s cognitive, psychological, social and cultural history. Standard analgesic treatments that downplay or ignore these dimensions of suffering should not be expected to adequately serve anyone in chronic pain. A far more sophisticated approach is required if these patients are to find adequate and sustainable relief. Fortunately, this is now possible. But does it happen?
Modern medicine is quite capable of ameliorating many, if not most, acute problems, including pain. It is can also effectively manage a variety of chronic or recurrent conditions like heart disease, diabetes and peptic ulcers, largely though the use of medications and invasive procedures (e.g., surgery). It is not surprising, therefore, that most clinicians are sufficiently trained to successfully take on these common illnesses. However, for patients presenting in chronic pain, for which there is often no identifiable cause, standard methods are often not up to the task, particularly the kinds of expedient treatments emphasized in clinical training and practice. Under these circumstances, otherwise highly competent clinicians are forced to settle for symptomatic interventions that serve as stopgap measures rather than actual solutions. Many chronic pain patients, therefore, continue to suffer despite their clinician’s best efforts.
• According to data from the National Health and Nutrition Survey conducted from 1999 to 2002, 26% of Americans reported being in pain for more than 24 hours during the prior month, 42% of whom had been suffering with their pain for a year or more.
• In a 2004 survey, 27% of respondents reported low back pain, 15% reported severe headache or migraine, another 15% reported neck pain, and 4.3% reported face or temperomandibular joint (TMJ) pain in the previous three months.
• Also in 2004, 31% of adults reported joint pain (other than neck, back or TMJ) in the past 30 days; among those over 65, the proportion rose to 52%, with 17% of respondents in this age category characterizing the pain as severe.
• In 2003-04, narcotic analgesics were prescribed or provided during 23% of all emergency room visits, and for the period 1999-2002, 4.2% of adults reported using narcotic drugs in the previous month
(Data from Health, United States, 2006 from the Centers for Disease Control and Prevention)
Of course, many of these patients are benefiting from the services they receive from the physicians, nurses, physical therapist, acupuncturists and numerous other professionals providing high quality care. And, the numbers would certainly be even worse without their efforts. But what these and other troubling statistics strongly suggest is that we as a society have a long way to go before the formidable public health problem of persistent pain is brought under control.
Like any social or health problem, additional research has the potential to reduce the enormous burden of suffering from chronic pain. Even the most remarkable advances in research, however, will help no one unless they are translated into action by clinicians, educators, advocates and policymakers. It has become abundantly clear that an overly simplistic, one-dimensional strategy is no match for the complexity and tenacity of chronic pain. Pharmacologic and surgical interventions are often essential, but they are rarely sufficient. What chronic pain sufferers require is a sophisticated, multidimensional strategy worthy of the challenge.
PREP was created for precisely this reason. Our programs encourage students to take on the problem of pain from every conceivable angle: biological, psychological, sociological, cultural, spiritual, ethical and legal. Our graduates emerge with an perspective and expertise few of their colleagues possess. More than anyone else, they have the capacity to meaningfully change the lives of people suffering from chronic pain.
Again, welcome. I hope you find our blog to be an interesting, provocative and enlightening gateway into the rapidly progressing and widely divergent field of pain and its management. I look forward to your comments, suggestions and contributions.

2 comments March 1st, 2009

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