For all that modern medicine has learned about disease and treatment, it’s alleviating pain that still lies at the heart of the profession. And in recent years, the notion of treating “pain” as its own entity has been rising to the forefront in medicine. Pain management now has its own journals, conferences, clinics, and specialists, and pain relief is sometimes referred to as a human right.
In September, a coalition that includes the FDA, the CDC, and the NIH is expected to release a long-awaited “National Pain Strategy.”
But as pain rises on the agenda for clinicians and patients, research is uncovering some unsettling facts about how it really affects people. First, not everyone experiences pain similarly
It’s also clear that not everyone’s pain receives equal attention. A robust and growing body of evidence suggests that the groups who suffer the most also receive less effective treatment for that suffering.
Pain, it appears, is distributed with a kind of inequality distinct from the other inequalities in American health care—one with its own contours, its own logic, and its own disturbing history. And because chronic pain, in particular, often lacks a discrete location in the body, it leaves both diagnosis and treatment almost completely up to a doctor’s own judgment, which brings in a range of subtle prejudices that psychologists and other scholars are only beginning to understand.
the emerging research on pain, suggest that pain mirrors existing prejudices in society in ways that medicine is only beginning to grapple with. There’s no quick route to solving the problem of pain care, and its thorniness suggests that doctors must first face the steep challenge of understanding both the history and psychology of a problem that medicine, often, would rather not talk about.
There was little mainstream medical interest in the question of pain until the 1970s, when researchers began looking into pain itself, not just pain as a byproduct of various conditions. The field of pain management got its own medical society in 1983, and by then it was starting to become clear that not every pain patient was treated the same
Women still receive less effective pain treatments, even though they are significantly likelier than men to experience pain.
With chronic pain in particular, convincing doctors to take pain seriously can be difficult. “With childbirth, we don’t say to the woman, ‘Oh, you’re making up the pain, stop being such a wuss,’” said Judy Foreman, a former health reporter for the Globe and the author of the recent book “A Nation in Pain: Healing Our Biggest Health Problem.” “With chronic pain, the pain can be way worse than childbirth, and you don’t know if it’s going to go away, and people don’t believe you.”
Black pain patients are less likely than white patients to receive pain medication; when they do receive it, they receive less. Studies of post-operative care have repeatedly found white patients receiving higher doses of opioids than minorities. The same is true for chronic pain.
Pain is a special case, even within the tilted playing field of American health care. One reason is its inherent, even radical, subjectivity. Western medicine is founded on objectivity: When a patient says something is wrong, doctors look for a discrete problem that can be tested and correlated to a diagnosis. Pain, by contrast, is defined by what the patient feels.
Chronic pain in particular often doesn’t have a discrete material location, or an identifiable cause.
This leaves its sufferers vulnerable to skepticism, prejudice, and “accusations of malingering,” he said. It doesn’t help that many pain medications are addictive, and some people really do feign pain to scrounge their next prescription.
Because pain has such a strong psychological component, finding objective tools to diagnose it is not a simple proposition. Research emerging in the last few years has suggested that certain types of pain create a distinct signature in the brain, and even that sensitivity to pain might be connected to brain structure. But the idea of a practical and affordable tool for measuring all kinds of patient pain is a distant dream at best. And that leaves pain susceptible to doctors’ prejudices, including unconscious ones. What it comes down to is: Do they trust their patient’s account of their own pain?
It is easy to forget, amid tales of chronic pain, that the story of pain relief since those dark days is a genuinely triumphant one: Modern painkillers are often quite cheap and effective, and the stronger ones can make serious pain almost magically endurable. But ironically, advancements in medicine may have made it harder to deal with the pain that remains
Patients still talk about their pain—particularly online—but doctors do not listen like they used to, she suggests: Modern pain management is “moving the subjective experience of pain further towards the periphery of medical discourse.”
As awareness of the undertreatment problem spreads, there’s hope that it will start to change how pain is greeted by hospitals and doctors’ offices.
Some see psychology offering tools for change.
asking subjects in pain-perception experiments to briefly pause to consider the other person’s perspective drastically reduces racial bias
Just as pain has become its own field of medicine, the rise of pain as its own cause may be what catalyzes change.
Our best hope is for pain patients to get very active,” Foreman said. Sometimes the only reasonable response to pain is to scream a bit louder.