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 immerse 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.
October 25th, 2015
New Tufts PREP Course Offering for Summer 2014
Interprofessional Team Management of Pain (PREP 244; 0.5 credit)
Health care is increasingly delivered by groups of providers with diverse professional training, roles and identities. Lack of coordination and communication between health professionals may lead to adverse patient outcomes and lower patient satisfaction, risk management challenges, and provider dissatisfaction and burnout. This course provides tools to construct effective interprofessional (“IP”) teams to treat pain within models of care such as the medical home, to assess how well these teams are functioning, and to analyze and repair their dysfunction. Attendees will acquire knowledge and skills for achieving outcomes crucial to patient-centered care, focusing on pain and its treatment.
Led by seasoned IP clinician educators from occupational therapy and medicine, joined by fellow educators from the nursing and pharmacy professions, this innovative course will present methods to analyze and optimize team function. Attendees will examine how teams function as small groups, and identify how to shape cohesive functional groups. Participants will also develop skills to turn typical threats to team function from destructive forces to constructive and/or creative elements.
Pain is the most common reason for patients to seek medical care. By the conclusion of this course, participants will be able to analyze, optimize, and if circumstances require create de novo the team-based processes and policies that shape effective and efficient care of patients with pain. Applying these principles to optimize IP team management of pain will impact upon patient satisfaction, quality measures and potentially, and quality-based payment. In keeping with the PREP’s approach of training the trainers, attendees will be equipped to assume leadership roles in the assessment and treatment of pain within multiple organizational models including the medical home.
Dates & Location
· The 2014 course will take place from Thursday May 29 through July 2.
· Onsite class sessions will take place on Thursday evening, May 29 from 4-7 PM and Friday May 30 from 9AM- 5PM. [Dinner Thursday and lunch Friday plus snacks are included.]
· Online synchronous videoconferencing for case discussions and team problem-solving continue at 5:30-7:30 PM Wednesdays on June 11, June 18, June 25 and July 2.
To learn more about our Summer 2014 courses visit: publichealth.tufts.edu/Academics/MS-Pain-Research-Education-and-Policy/Programs-of-Study/Blended-Learning. To register for non-credit enrollment click “Register now for a course” at the end of the first paragraph on that web page. Non-credit enrollment is meant for those who want the experience of this course without receiving a grade, nor submitting homework or other assignments. Course cost for non-credit enrollees is $1,130 ($905 if paid before April 29, 2014).
Current Tufts graduate students may enroll in the course through the Integrated Student Information System (iSIS) and will be responsible for pre-course readings and 2 papers. The standard fee per graduate credit will apply. Prospective applicants wishing to earn credit graduate credit towards a future Tufts degree should follow this link: publichealth.tufts.edu/Admissions/Apply-to-PHPD-Programs/MS-in-Pain-Research-Education-and-Policy .
Contact the co-course director, Dan Carr at firstname.lastname@example.org with any questions.
April 15th, 2014
by Pamela Katz Ressler, MS-PREP, RN, HN-BC, Adjunct Faculty, PREP-Aired blog moderator and administrator, Pain Research Education and Policy Program, Tufts University School of Medicine
On June 29, 2011, the Institute of Medicine (IOM) released a report addressing the issue of pain in the United States and called for “a cultural transformation in the way pain is viewed and treated” (IOM report p. 3). The 313-page report entitled: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, examines the enormity of the burden of pain from many measures. Chronic pain affects at least 116 million U.S. adults and the financial cost of pain to society, measured in 2010 dollars, is estimated to range between $560 and $635 billion annually. In comparing these staggering numbers to other chronic diseases, the cost of pain is greater than the cost of heart disease, cancer and diabetes combined.
The authors of the IOM report base their recommendations for change and transformation of pain on nine underlying principles:
- A moral imperitive
- Chronic pain can be a disease in itself
- Value of comprehensive treatment
- Need for interdisciplinary approaches
- Importance of prevention
- Wider use of existing knowledge
- Conundrum of opioids
- Roles of patients and clinicians
- Value of a public health and community-based approach
The IOM report highlights the importance of education in the multidisciplinary nature of pain issues and includes it as a key action item in the proposed blueprint for transformation of pain in our society. On the topic of professional education IOM report recommends:
- Expansion and redesign of education programs to transform the understanding of pain
- Improving the curriculum and education for health care professionals around the issue of pain
- Increasing the number of health professionals with advanced expertise in pain care
We, at the Tufts Pain Research Education and Policy program (PREP), applaud the IOM for increasing awareness of the enormous burden of pain in our society by issuing the report: “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research“. We are also extremely proud that the Tufts PREP program has been providing the type of comprehensive pain curriculum proposed by the IOM report for over a decade, since 1999, and remains the first and only multidisciplinary postgraduate program of its kind in the United States.
Your comments and thoughts on the IOM report are welcome; please click here to read a full, unabridged online version of “Relieving Pain in America: A blueprint for Transforming Prevention, Care, Education and Research”.
July 5th, 2011
by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED blog moderator
Untreated or under-treated pain causes needless suffering and negatively affects the quality of life. That is why the management of pain remains a critical area of health care and why the concept is addressed throughout the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements.
We congratulate the Tufts University School of Medicine’s Pain Research, Education and Policy Programs co-founder, Daniel Carr, MD, FABPM for providing the forward to the newly published second edition of Approaches to Pain Management: An Essential Guide for Clinical Leaders
Approaches to Pain Management: An Essential Guide for Clinical Leaders, published by the Joint Commission Resources, provides an overview of pain assessment and management, identifies what the standards require regarding the treatment of patients with pain, and offers guidance on making pain management an integral part of care services. Dr. Carr, an internationally recognized expert in pain management, provides both perspective and vision on the complex nature of pain.
The majority of the book is devoted to the best practices of health care institutions that have adopted focused pain programs. This updated guide also incorporates a global view of pain management, additional organizational best practices—including some from non-U.S. institutions. Other features include the following:
- Summaries of every Joint Commission and Joint Commission International pain assessment and management requirement across all health care settings
- Strategies for identifying and using evidence-based medicine resources for pain management
- Expanded case study chapters from clinical leaders describing how their organizations developed and implemented their pain management activities
- Techniques and ideas for understanding and meeting pain-related standards
- Guidance on committing an organization to pain management improvements
For more information about the newly released edition of Approaches to Pain Management: An Essential Guide for Clinical Leaders, click here
November 29th, 2010
By Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP graduate student and PREP-AIRED blog moderator
You may see a new face if you are on the Tufts University School of Medicine campus in Boston these days. Wendy Williams, BSN, M.Ed, is in a new role with the Pain Research, Education and Policy Programs at Tufts University School of Medicine, focusing on program development and administration. I recently had the opportunity to sit down with Wendy to ask her a few questions about herself and her visions for the PREP programs.
Welcome Wendy…Can you tell us a bit about yourself?
I just arrived at Tufts from spending 8 years at Northeastern University in the School of Nursing working to ensure high quality clinical nursing education placements for both the undergrad/pre-licensure students and the advanced practice students seeking both clinical and non-clinical nursing master’s degrees. My own clinical nursing background centers around oncology and HIV/AIDS. I spent wonderful years at both Dana Farber Cancer Institute, during the time they had inpatient units, and at Harvard Community Health Plan/Harvard Vanguard with other highly skilled nurses on the HIV/AIDS Resource Team.I married a great guy back in 1996 who had a couple of sweet little boys who are now terrific college age young men, studying here in Boston. My husband, Jeff, and I live in Framingham with our 3-legged cat, Punky, and hairless dog, Diddy.
What interests you about the PREP programs?
The concern for under-treated pain and pain management are steady threads that ran throughout my own clinical practice. Ensuring adequate pain management is a strong cornerstone of quality nursing care and practice, so the PREP programs of study are very attractive to me and tie together much of what I value. The chance to work collaboratively with the three program leaders (who are also physicians), Dr. Dan Carr and Dr. Richard Glickman-Simon and Dr. Ylisabyth Bradshaw, is an opportunity I want to leverage.I have long sought ways to be a force behind strengthening linkages between medicine and nursing and other health care disciplines to encourage both multidisciplinary and interdisciplinary approaches to health care. The PREP programs present an ideal setting to have broad-based conversations around the area of pain issues. Also, my own master’s degree is in education, specializing in adult and organizational learning, so . the opportunity to develop a program of study and optimize learning for students globally is a really strong draw for me to be here at Tufts working with the PREP programs.
What do you see as the strengths and challenges of the PREP program?
A real strength of the PREP programs is its unique position in masters level education that delves deeply into the many physical/clinical, social and scientific aspects of pain. There is not a population of people, worldwide, that is not impacted by pain issues. Also, the fact that the PREP programs are not solely clinically based creates a rich learning environment for many types of students… clinicians seeking to be subject matter experts in pain issues learn side by side with non-clinicians who may be seeing the PREP programs as a way to become well-informed advocates for pain issues. After about a month in this role, I see two challenges to the PREP programs that I would like to positively impact. One challenge is getting more and more people in the greater Boston area to know about this great set of programs and to become students in the program. I happen to know one graduate of the program, Hallie Greenberg, a nurse from the Brigham & Women’s Hospital, and know that there are so many others that would be really inspired to become proficient in this area. The other challenge is understanding and communicating to others clear linkages between getting one of the certificates and/or the master’s degree and a specific career enhancement. There seems to be a certain pioneering element to encouraging students to go for the certificates or the degree as a natural next step in career growth.
What are your hopes and vision for the PREP program?
I hope that PREP grows steadily, both in numbers and in innovative educational initiatives, and sustainably with input from all communities of interest: students and alumni and staff and our steering committee and faculty and leaders in pain issues globally. I would love to speak with students and alumni and gain their insights on how we can best lead the way in pain research, education and policy. I welcome calls, 617 636-0815, emails email@example.com, or simply stop by my office in the M&V building, Room 142A. I’d love to meet you.
November 15th, 2010
By Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP student and PREP-AIRED blog moderator
Thank you to 2010 MS-PREP alumna, Nancy Mitchell, for sending along a recent update to the Cochrane Library and the Cochrane Database of Systemic Reviews addressing acupuncture and tension-type headaches. In a previous Cochrane Review (2001), acupuncture was found to be inconclusive as a treatment for tension-type headaches. However an updated 2009 Cochrane Review on acupuncture and tension-type headaches, which included 11 randomly controlled trials, concluded that acupuncture may be a valuable treatment option for patients suffering from frequent tension-type headaches.
The Cochrane Review stated: “We reviewed 11 trials which investigated whether acupuncture is effective in the prophylaxis of tension-type headache. Two large trials investigating whether adding acupuncture to basic care (which usually involves only treating unbearable pain with pain killers) found that those patients who received acupuncture had fewer headaches. Forty-seven percent of patients receiving acupuncture reported a decrease in the number of headache days by at least 50%, compared to 16% of patients in the control groups. Six trials compared true acupuncture with inadequate or ‘fake’ acupuncture interventions in which needles were either inserted at incorrect points or did not penetrate the skin. Overall, these trials found slightly better effects in the patients receiving the true acupuncture intervention. Fifty percent of patients receiving true acupuncture reported a decrease of the number of headache days by at least 50%, compared to 41% of patients in the groups receiving inadequate or ‘fake’ acupuncture. Three of the four trials in which acupuncture was compared to physiotherapy, massage or relaxation had important methodological shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes with the latter therapies. In conclusion, the available evidence suggests that acupuncture could be a valuable option for patients suffering from frequent tension-type headache.”
Cochrane Reviews are an integral part of evidence based medicine. It is important to include both allopathic and integrative medicine studies in the rigorous review process to further our knowledge of effective strategies to treat and manage chronic pain conditions.
May 23rd, 2010
by Pamela Katz Ressler, RN, BSN, HN-BC, MS-PREP student and PREP-AIRED blog moderator
One of the aspects of the Pain Research Education and Policy program at Tufts University Medical School that I find so enriching is the diversity of the students, faculty and alumni. The interdisciplinary nature of the program, as well as the international mix of the students helps to create a global community of pain management experts and an ever expanding network of colleagues. I was able to use my Tufts PREP program connections recently by networking with MS-PREP alum Anne Colyn in Luxembourg where she is now living. We had an interesting discussion of the role of integrative modalities of pain management in Europe.
April 1st, 2010
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.
March 1st, 2009
by Ylisabyth (Libby) Bradshaw, D.O., M.S.,FACEP, Academic Director of the Pain Research, Education and Policy program at Tufts University School of Medicine
Does it matter whether pain is a disease or a symptom?
For people living and suffering with pain, such a question may seem irrelevant. Perhaps like splitting hairs.
“Just make the pain better.”
“I don’t care what category you put it in!”
“Don’t just talk about it. Do something! Anything to relieve this agony.”
Why would it matter whether and how medical professionals want to categorize pain?
Symptoms are defined as subjective experience; diseases are defined in objective terms, with specified causes, or associated signs and symptoms.
People with pain certainly have a personal, internal experience of pain. And, aside from asking a person to describe and rank the intensity of their own pain, there’s no medical test for determining the type of pain or its severity.
The predominant medical view for centuries has been that pain is a symptom, and viewed as an entirely subjective experience by an individual. Physiologically, pain has been seen as simply the transmission through nerves of information about damage or potential damage to parts of the body.
After all, when pain is caused by something inside the body – a ruptured disk, nerve disease, or compression from an expanding tumor – it seems that something is irritating or pressing on a nerve, which is then communicated, allowing us to feel pain. Pain is a classic symptom, it would seem.
And pain could hardly be expected to be a disease when it’s caused by forces from outside the body – a fall, an automobile crash, or even surgery; it seems completely straightforward – and easy to understand when nerves are compressed, crushed, or cut – pain is the symptom.
Yet, accumulating evidence in neuroscience says pain is more complicated. No matter what initiates pain – from traumatic forces to specific neurological disorders – if conditions continue, and the pain signal is maintained, specific bodily changes occur.
Measurable now in research labs, such characteristic, physiological alterations, arising from actively transmitting information about pain, can unfortunately become sustained biochemical changes. Ordinarily, our bodies reverse this process when the initial circumstances causing pain are relieved. Yet, too often these changes become irreversible, and permanent, resulting in chronic pain.
Two imperfect examples from our material world – Once cement is mixed and sets up, it becomes a new substance. Once glue is used, it can bind to a substance, and be impossible to remove. The science of pain is still discovering answers, and resolving uncertainties. OK, our brains and nerves are not comparable to cement, glue, or jello. Yet it is clear, signals about definite or potential tissue injury turn on many biochemical processes that transmit information about pain through our nerves. Over time, these can become irreversible changes. Pain, then, is beyond being merely a symptom.
Please join this initial discussion on the Pain Research, Education and Policy blog at Tufts University School of Medicine, and include your thoughts regarding, “Is pain a symptom or a disease?”
If pain is more than a symptom, does that make it a disease?
Common definitions of “disease” include impaired functioning*. From your knowledge and experience, how do pain conditions have impaired functioning?
We look forward to interesting exchanges from students, faculty, practitioners, alumni and members of the general public committed to improving the conditions treatment and prevention of individuals across all ages with acute and chronic pain problems.
* Disease –
“a condition of the living animal …[or one of its parts] that impairs normal functioning and is typically manifested by distinguishing signs and symptoms” MeriamWebster
“an impairment of the normal state of the living animal … or one of its parts that interrupts or modifies the performance of the vital functions, [and] is typically manifested by distinguishing signs and symptoms…” Medline
February 22nd, 2009
The PREP program’s small classes and collaborative learning experiences lead to wonderful , long lasting connections between students, faculty and alumni. PREP students, faculty, staff and alumni joined together at a local Boston restaurant on February 13, 2009 to celebrate three new PREP graduates, Anne Colyn, Jess Gerber, and Marie Belle Francia, and wish them well on their new career adventures.
MS-PREP 2008 graduates Marie Belle Francia, Anne Colyn, and PREP academic director Libby Bradshaw
MS-PREP 2008 graduate Jess Gerber, PREP student Gretchen Kindstedt, MS-PREP 2008 graduate Anne Colyn
PREP student Sherry Brink, MS-PREP 2008 graduate Marie Belle Francia, former PREP program director Jeanne Connolly, PREP student Cindy Rodman
February 14th, 2009