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Pain: Is it a Sensation or an Emotion

Pain: Is it a Sensation or an Emotion

     If you combine the opioid use of United States and Canada, together we use one-third of the world supply of narcotics and yet a fifth of us say they suffer from chronic pain. The only noticeable effect of two decades of widespread opioids has been catastrophic harm. More than 50,000 people in North America died from opioid overdoses in 2017 and hundreds of thousands more are addicted to them. It has recently been reported that for the first time we were more likely to die of opioids than of car accidents.

     This has forced many researchers to take a step back and try and discover the true nature of pain and to understand how best to alleviate it.

     The ancient Greeks considered pain a passion—an emotion rather than a sensation like touch or smell. During the Dark Ages in Europe, pain was seen as a punishment for sins, a spiritual and emotional experience alleviated through prayers rather than prescriptions.

     In the 19th century, the secularization of Western Society led to the secularization of pain. It was no longer a passion to be endured but a sensation to be quashed.

     The concept of pain as a purely physical phenomenon reached its peak in the 1990’s when medical organizations such as the American Pain Society and the Department of Veterans Affairs succeeded in having pain designated a “fifth vital sign,” along with blood pressure, temperature, and breathing and heart rates.

     This coincided with the release of long-acting opioids like OxyContin. Doctors believed they now had an effective remedy for their patient’s suffering.

     While opioids do help many patients with acute pain from injuries, surgeries or conditions like cancer, looking back it’s clear that using opioids to treat chronic pain—backaches, sore knees and the like—might well be considered the worst medical mistake of our era. And, we never would have made this mistake if the pharmaceutical manufacturers of these products were honest about their very high addictive qualities.

     Decades of research have shown that opiates provide little to no benefit for chronic non-cancer pain. One recent randomized trial of people with chronic joint and back pain showed that patients using narcotics experienced slightly more pain compared with those using medications like acetaminophen and ibuprofen.

   Why is this? Studies have shown that opioids can reduce patients’ pain thresholds. They can also result in a condition called opioid-induced hyperalgesia, in which people feel more and more pain as they are prescribed higher and higher doses of opioids.

     The conventional thinking about pain as purely a physical stimulus has clearly failed us. Maybe the ancient Greeks knew something we don’t.

     While the expression that suffering is “all in your head” is too often used to diminish others’ agony, the mind does play a very important role in the experience of pain. After a pain signal reaches your brain, it undergoes significant reprocessing.

     How much something hurts can vary depending on factors like your expectations, your mood and how distracted you are. Just seeing someone else in pain can make you feel worse, too. This phenomenon has been demonstrated in studies of both rodents and humans, In other words, pain is contagious and transmittable.

     There is also an incredibly strong association between pain and mental health. Conditions such as depression and anxiety greatly increase the chances of developing chronic pain, while patients who experience pain are at high risk of developing depression and anxiety. This viscous cycle is partly the result of the fact that there is a considerable overlap in the areas of the brain that deal with pain and emotion.

     Additional clues about the fuzzy line between sensation and perception come from pain’s creepy bedfellow; itching.

     The sensation of itching, which is perceived by some of the same skin receptors that are on the lookout for pain, may seem like a purely physical phenomenon, but it’s not. Just seeing someone else scratch, or thinking about feeling ticklish, can make you itchy, too. And, like pain, it is closely linked to mental health issues such as depression and obsessive compulsive disorder.

     That does not necessarily mean there is no physical component to those feelings. There is no doubt that illnesses and injuries cause immense suffering. The question is how severe that suffering is, and how long it lasts. Recent research shows that pain sensitivity varies significantly among people, most likely as a result of genetic differences. There is so much that we still don’t understand about the fundamental biology of pain, and that needs to change.

     In the meantime, there is plenty we can do to address America’s pain epidemic. For too long the pharmaceutical industry has blurred our vision. It was just revealed in court filings that drug companies greatly underplayed the risks of opioids, while billions of dollars in marketing told people that pills were the only answer to their ailments.

     There is a pressing need to increase funding for research into strategies that don’t just involve taking more drugs. Not every person who experiences acute pain goes on to develop chronic pain. We need to learn more about which interventions work to prevent this from happening.

     Pain management should still be emphasized in medical education, but future doctors should be taught that pain is part of the person who suffers from it, not just a separate physical phenomenon. And of course this education should incorporate ways to avoid prescribing opioids for chronic use.

    Progress is already underway, as opioid prescription rates have been dropping since 2012 in Canada and the U.S. But we still have a long way to go. The amount of opioids prescribed per person is three times higher than it was 20 years ago.

     The most important tool physicians need to manage is empathy. If chronic pain is an emotion as well as a sensation, then it is unlikely to be managed without compassion. A 2017 study of doctors in Spain found that those whose patients rated them as empathetic were more effective at relieving their patients’ pain. Physical therapy that doesn’t just manipulate joints but also addresses the context that pain comes in, encourages optimism and builds emotional resilience has been found to be more effective.

     All this takes more time and attention than just prescribing a pill, and unfortunately our health system encourages doctors to see as many patients as possible as quickly as possible. We need to change how physicians are paid in order to give them the time to really talk with patients about their pain.

     A number of years ago I tore a groin muscle playing baseball. I took a month off but I still could not run. I could walk, stand and do anything I wanted except run. That fall I went out to play hockey. The minute I pushed off on the ice, the acute pain was unbearable. I was very frustrated. All winter I did every different exercise except running and then in the spring I was determined to play baseball. I went to the park and stood under a tree. I decided I would run full out as hard and fast as I could and if I fell that was the end of running sports for me. But when I did this there was no pain. I ran another 100 meters and still no pain.  I discovered that I was feeling phantom pain just as person feels pain in an amputated leg. That is when I learned that pain is a lot more than a sensation. It is an emotion as well. [print_link]