PAINWeek 2012 Conference Keynote Address: The Realities of Pain as a Public Health and Social Issue

LAS VEGAS, NV Daniel B. Carr, MD, of Tufts University School of Medicine delivered a keynote address titled “Have We Been Backwards, Upside Down, or Both?” at the opening session for PAINWeek 2012. He advocated teaching about pain by emphasizing the reality of pain as population-based, inter-subjective, and with an important moral dimension, rather than beginning by focusing on nociceptors and the biochemistry of pain. This perspective will allow students to face difficult interactions in the clinic.

Dr. Carr began by citing Buddha, who taught that we are what we think; all we are arises with our thoughts; and with our thoughts we make the world. Dr. Carr explained how our perceptions of our world construct our reality. Normal consciousness constructs a continuous narrative. Pain narratives are strongly shaped by context, which includes culture and social interactions.

The International Association for the Study of Pain has defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Dr. Carr suggested that by framing pain this way, pain research and education have moved toward impersonal reductionism. Loeser's bottom-up “onion” model of pain, where the sensation begins with nociception, and then moves to pain, suffering, and pain behavior, builds pain up from minor to major, and may be misleading.

Dr. Carr explained the relationship between pain and consciousness, defining consciousness as an “emergent” neuronal property, where emergent refers to a property that occurs when elements are put together that transcend what any one of those elements could achieve alone. He stated pain is currently viewed as a network of brain structures that employ nociception, other inputs, and memories to actively construct a continually evolving internal model of reality. However, the intensity of pain is not strongly or directly dictated by nociception. Other inputs, such as meaning and memory, actively evolve a continually evolving, internal model of reality.

Dr. Carr used the example of a cathedral being built from a pile of bricks. While bricks are relevant to a cathedral, they do not explain the purpose of a cathedral. He stated that this concept is important for explaining why the notion that understanding pain has a start with a biochemical basis may be flawed. The areas of the brain that light up when someone is experiencing pain are the same areas that light up when watching someone else experiencing pain — pain is primarily a social phenomena. He explained that social interaction, which is most widely used and has no side effects, is the perfect analgesia. When a child bumps his head and is crying, the mother will nurture the child, and the pain goes away in the vast majority of incidents. Social inclusion is critical in the process of pain, and pain is linked with stigma or humiliation.

Dr. Carr stated that pain can be considered a public health issue because it is preventable, population-wide, related to socioeconomic status, related to human rights encompassing varying inequalities, and proposes that it is a moral imperative to transform thinking.

Dr. Carr envisions educational changes as pain is addressed as a public health issue. Today, most texts on pain begin with the biology, mention the psychological aspects, and barely touch on the social aspects of pain. Dr. Carr feels that the sociological and psychological aspects of pain should be introduced first. The study of pain should be informed by social neuroscience, which is the study of neural mechanisms that subserve social processes and behaviors. Pain should be taught in a population-based context that considers social, cultural, environmental, and economic factors, rather than merely as an impersonal, microlevel biochemical mechanism.