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

PainWeek Video features Tufts PREP founder, Dr. Dan Carr

dan carr tufts photoby Pamela Katz Ressler, MS, RN, HN-BC, Faculty, Pain Research Education and Policy program, Tufts University School of Medicine

Dr. Dan Carr, founder and director of the Tufts Pain Research, Education and Policy program was recently featured in a video posted by PainWeek. Dr. Carr has passionately advocated for interprofessional pain education from the inception of the Tufts PREP program. His keynote address from 2012 PainWeek argues that pain is much more than a biophysical model.  Watch Dr. Carr’s 2012 keynote address by clicking here.

Learn more about interprofessional team management of pain by participating in a new course offered by Tufts PREP program this summer (click here).  Dan Carr, MD, FADM and Sharon Schwartzberg, EdD, will be co-directors of this relevant and innovative blended learning course. Learn from the leaders in the field of pain, connect and network with other professionals in Boston for one weekend and then return home to learn online.  For more information about Tufts’ innovative blended learning courses in the Pain Research, Education and Policy Program, click here.

Add comment May 8th, 2013

Pain as a Top-Down Phenomenon: a Bibliography

by Daniel B. Carr, MD, FABPM, FFPMANZCA (Hon.), Director, Pain Research, Education and Policy (PREP) Program, Tufts University School of Medicine

Since its inception in 1999, a single concept has unified PREP’s curriculum and connected its community. This theme is that the study of pain is best accomplished if it is seen as a top-down (i.e., population-based) public health phenomenon as noted in the 2011 IOM Report on Pain.  We are fortunate that PREP has always been situated within the Department of Public Health and Community Medicine and grateful that its Chairs and Deans — Harris Berman and Aviva Must — have shared this view and continually encouraged PREP’s growth.

Advances in pain research and education, particularly as informed by the emerging field of social neuroscience, have made PREP’s vision more and more timely.  Reflecting the broader pain community’s growing awareness of PREP’s distinctive voice, this year I’ve had the privilege of delivering keynote addresses at congresses of the American Pain Society, the Special Interest Group on Pain Education of the International Association for the Study of Pain, and the American Society of Pain Educators’ PAINWeek. The specifics of each talk differed somewhat but all conveyed PREP’s underlying theme.

In response to requests from attendees at these lectures, I have assembled an interim bibliography to allow anyone interested to become better informed about some of the sources that the PREP program draws upon. Reflecting PREP’s interprofessional, eclectic outlook, many are from the humanities and social sciences, complemented by the biomedical literature.  For example, according to the narrator in the novel by Greer, “I do not know what joins the parts of an atom, but it seems what binds one human to another is pain”.

Those who wish to immerse themselves in our curriculum will enroll in a course or one of our certificate or degree programs. Click here to find out more about taking a course.  Following the great success this summer of PREP 233 (End of Life and Palliative Care, directed by Pam Ressler) in a blended onsite-online format, our foundational course PREP 230 is the next of our courses to be offered in this format.  This fall, PREP 230 will begin on September 28.  To reflect exciting advances in the field of pain, we have changed this course’s title from “Neuroanatomy, Neurophysiology and Neuropharmacology of Pain” to “Neuroscience of Pain: from Society to Synapse”.  Click here to learn more about this course.  As in earlier years it will be directed by Steve Scrivani, who has consistently earned high praise for his meticulous running of this course. Besides his own lectures, over the years Steve has assembled a core group of dedicated, expert faculty to provide students with an unparalleled learning experience.

Click here to access bibliography.

Add comment September 5th, 2012

American Society of Pain Educators

by Meridith Lawrence, MS-PREP ’04
Great to see this blog! I wanted to let the PREP community know about an exciting development in the pain education world.
The American Society of Pain Educators(
has recently given the first ever exam for certification to become a pain educator. This is similar to certified diabetes educators (CDE)
and once you meet the criteria and pass the exam you will be able to use the initials CPE after your name.Sixty people took the first exam and most passed.
ASPE also holds a conference every year in Las Vegas called PAINWEEK
in the week right after Labor Day. I have been to the conference twice and it is excellent!
If anyone is intwerested in anything I have mentioned and you have questions please do not hesitate to get in touch with me.
I graduated from the PREP program in 2004 and currently work for the Cambridge Health Alliance as a senior staff pharmacist
in Cambridge,MA. I am able to use my education from the PREP progam every day and that is very gratifying!

Add comment April 26th, 2009

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