Tell Me Where it Hurts: The Soft Science of Pain Assessment

Creek_EarlyMorning

“Doctors put drugs of which they know little into bodies of which they know less for diseases of which they know nothing at all.”
- Voltaire

Pain management by healers has been a primary focus for millennia. From the neat holes made in the skulls of Pharoah's citizens by trephining, to the medieval routine of leech application and blood-letting, medical advancement has long been driven by experimentation around treating symptoms of pain. We do not fully understand what makes some patients respond to pain-inducing stimuli with extreme reported discomfort, while others seem to tolerate pain more efficiently. Pain perception is inherently subjective, and due in part to the variance of self-reported treatment outcomes, the best measure of efficacy is still a physician asking “does this make you feel better?”

Pain perception is inherently subjective, and due in part to the variance of self-reported treatment outcomes, the best measure of efficacy is still a physician asking “does this make you feel better?”

Medical practitioners generally designate pain as either acute, where the cause will be solved quickly; or chronic, where the cause may be obscure and the duration long-term. Some of the most effective acute pain management is the use of nerve blocks for local anesthetic elective surgical procedures. To watch one’s own finger being sutured painlessly with digital Xylocaine injection, for instance, is a categorically surreal experience.

Extending this particular treatment to dental, whole limb, ocular and even epidural and spinal anesthesia (as used in much of obstetrics, orthopedics, and general surgery), has improved safety and comfort for billions worldwide. However, there is no diagnostic tool that represents the effectiveness of this anaesthetic with more accuracy than patient reporting.

Chronic pain management is subjective for the sufferer, often compounded by fear, fatigue, and disposition. Conversely, younger and more athletic patients with hypothetically higher endorphin levels are seemingly more resilient to painful stimuli. This subjectivity points to a wide spectrum of potential pain modulation response, as pain scoring is inherently limited by being self-reported. It is this fact that leads to polarization between practitioners who value the scientific basis of medicine with peer reviewed evidence versus those who believe that reducing suffering is their primary purpose.

In medical practice, chronic pain management is a tight, repetitious battle between empathy for the sufferer (Scylla) and the degradation of the patient due to opiate addiction (Charybdis).
The legal prescription of narcotics has more than doubled in the last 20 yrs. Although there are numerous anecdotal reports of successful substitution of opiates in favour of Cannabinoids for chronic pain, the biochemical and pharmacological research has been minimal in comparison.

Our extensive knowledge of the lethal and addictive side effects of opiates will continue to guide prescribers for now. The alternative of prescribing non pharmaceutical, minimally researched, uncontrolled inhalants, is currently too problematic for the majority of conservative safety minded medical practitioners.

"I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel." - Hippocratic Corpus