Pain at its roots

I was privileged this past week to speak at the annual meeting of the American Pain Society. The group is home to a great deal of expertise in pain mechanisms and management. I didn’t think I could tell them much they didn’t already know about any particular such tree, so chose to focus, as is my wont, on a better view of the forest.

I invoked 15 years directing an integrative medicine center to talk about the importance of a holistic perspective. In that clinical model, I worked sideby-side with naturopathic physicians, seeing patients together and conferring in real time. We specialized in treating hard-to-treat patients. More often than not, people came to us after they had been everywhere, and tried everything.

In those situations, the prevailing understanding of “evidence-based” medicine is something of a double-edged sword. On the one hand, it is vitally important to respect science and standards of evidence to guide best, good, and just safe practice. On the other hand, most patients who came to see us, many for chronic pain, had already exhausted the conventional and reliably evidence-based recommendations of all the doctors they had seen before us. We were all but inevitably left with one of two choices: get creative, or say, “sorry, we can’t help you either.”

We chose creativity, but pursued it cautiously, working hard to reconcile unfailing responsiveness to the needs of our patients with responsible use of the available science. We developed, and published a decision guiding framework called CARE — clinical applications of research evidence — that lent some structure to the proposition that evidence is not a yes/no commodity. Evidence varies in quantity and quality. A given treatment might be effective but toxic, or reliably safe but less reliably effective. There might or might not be other suitable treatments left to try, and the patient might or might not have strong preferences.

I pointed out that all five domains — safety, effectiveness, underlying evidence, exclusivity, and patient preference — informed a decision about the next, best treatment to try.

During my 15 years in such trenches, it served me well in my efforts to serve my patients, as did a holistic perspective, something ever more warmly embraced by the so-called “house of medicine,” particularly in light of the nation’s opioid crisis.

Holism, I noted to my colleagues, all too readily devolves into a rather vapid platitude, whereas it should have clear, operational implications. In the case of chronic pain, the most salient of which is this: it is important to treat the person in pain, and not just the pain in the person. People with any given variety of chronic pain may have it in the context of chronic disease, poor diet, poor sleep, depression, stress, loneliness, and more. They have side effects from medications resulting in the need for more medications, with more side effects.

The solution, I suggested, to such a degenerating cascade that might be characterized as “circling the drain,” is a spiral stair in the other direction.

A holistic perspective can be honored by identifying a sequence of issues that need to be addressed, treating pain by starting with attention to sleep, for instance, and then addressing them one at a time. Improving any one aspect of health can help to improve the next, like steps up a spiral stair with vitality at the top. Getting there in one fell swoop by means of holistic magic is elusive; getting there one step at a time is possible as a matter of routine. Increasing attention to such matters is warranted in both clinical practice and research.

I then shifted to my main topic, and the primary focus of my work and career: the opportunity to eliminate the preponderance of human pain at its origins. Robust good health and overall vitality defend vigorously, if not perfectly, against most causes of chronic pain, both physical and psychological.

The National Academy of Medicine, formerly the Institute of Medicine, has reported that 100 million Americans live with some kind of chronic pain. More recent work suggests that figure errs low if anything. For the foreseeable future, then, the experts at the American Pain Society have their work cut out for them. But the best way to predict the future, foreseeable and otherwise, is to create it. The best way to treat chronic pain is to prevent it. The most universally relevant tonic serving that objective is vitality. In that enterprise, lifestyle is the best of medicine, and culture is the best and biggest of spoons to help such medicine go down. With a culture-wide commitment to translating what we have long known about adding years to lives and life to years, we could eradicate much, even most, chronic pain.

My recommendation to my colleagues was that they tend to the trees along the way, even as we commit to that common journey, together, through the forest.