Every practitioner of pain medicine knows the complexities of treating chronic pain. Quantitative research helps provide answers to biomedical questions, and we have good validated psychometric measures for quantitating psychosocial dimensions, but these fall far short of illuminating the full dimensions of the pain experience. The complex psychosocial contributions for understanding pain's pathology and the therapeutic effects of various treatments cannot be underestimated. These elements of human pain are subjective and “qualitative.” Yet the field of qualitative research is nascent, challenging to conduct and controversial in its interpretation. Ever mindful of the challenges, Zheng and colleagues, within this issue, present us with “Chaos to Hope: A Narrative of Healing,” a fascinating account of the journeys experienced by people in chronic non-cancer pain and, in particular, the effect, for good or ill, of taking opioids to relieve that pain . It is a valiant effort.
The pain narratives are insightful and probably generalizable. They are also troubling because they suggest to us what we may be doing wrong. The authors describe the human effects of real-world pain that go beyond a pain intensity or other traditional quantitative assessment. An overriding theme is the need to be supported, believed, and not alone. Man is a social species, and we live and thrive for community. When ill, it is the community that we look toward for physical and emotional context and restoration. Places of worship have served this role for millennia, but so have families, friends, and other communities. A person in pain needs and deserves this support from the professional health care community.
A reasonable hypothesis is that connectedness is a key element of the primordial biological process. Zheng and colleagues define this connectedness as dependent on three key relationships: person in pain, and his or her society; person in pain and provider; and primary provider and the expert provider community.
It seems that in addition to the need to be believed, a sense of hope is essential for healing. Our “cure it” and “fix it” culture both inside and outside the medical community fails people in pain because the pain experience is more than a transaction of neurotransmitters with action potentials to be blocked or modulated, and cure is very rare (at least in chronic pain). Life's experiences, aspirations, and emotional needs are essential considerations to treating the whole person. People with pain must feel cared for and loved. These are integral components of healing in contrast with being fixed like a flat tire.
Our current health care system is the antithesis of one that lends itself easily to healing and caring for people in pain. This is manifest, for instance, in the regulatory expectations of opioid agreements, mandatory urine drug testing, and prescription database monitoring, which—while yielding important safeguards, data for effective management of adverse events, and some quantitative information—reflect regulating care rather than giving care. In such a forensic and strictly mandated environment, healing is unlikely, and healers are reduced to policemen and technicians. The person in pain often feels empty, alone, and hopeless, even paranoid and left with suicidal ideations as Zheng et al. discuss. Quantitative measures cannot yield the same type or quality of information told to us in these stories.
As would-be healers, not mere technicians, we must grapple with the tough issues. The Centers for Disease Control and Prevention reports an epidemic of opioid misuse and mortality , while the Institute of Medicine reports an epidemic of pain . How can control measures aimed at these two epidemics be reconciled? Perhaps another very real epidemic consists of loneliness, despair, isolation, and alienation.
More than 15 years ago, Rachel Naomi Remen, MD, suggested something similar in her pioneering work, “Kitchen Table Wisdom,” suggesting that physicians take a more natural and humanistic therapeutic approach to suffering, born from her experience of caring for people dying from cancer . In the book's foreword, Dean Ornish, MD, president and founder of the non-profit Preventive Medicine Research Institute in Sausalito, CA, USA, beautifully described the value of the qualitative elements of healing:
“When our hearts begin to open, we are able to feel it, like opening the window shade and letting in the sunshine that's been there all along, waiting patiently to be allowed inside” .
Just as music evokes an emotion based on an individual's life experience, the same can be said of the effect of pain on the individual. The sound from bowing a violin, picking a harp, or manually changing the volume and velocity of air through a wind instrument can be explained by mathematics, but the experience of receiving the sound is processed in areas of the brain where it will be qualitatively analyzed and valued. The quintessential qualitative role of a minstrel is to produce an emotive experience. Similarly, the qualitative end goal of practicing pain medicine is to heal.
As clinicians and researchers, we need to re-examine our approach to healing. A health care system that forces physicians to judge and police their patients' behavior when prescribing opioids for pain may be actually contributing to their illness rather than healing them. In some instances, the only real thing a clinician can do for a patient is to give them hope by treating the whole person, not just the physical body.
Stories of people who struggle with pain and the challenges of opioid therapy remind us that it is not the instruments of our profession or even how we play them that matters but how they are received.