Tell me about your pain, by which I of course mean: How would you rate your pain on a scale of zero to ten?
This, if you think about it, is a rather absurd question. Okay, a zero means zero pain; this makes sense. And a ten means the worst pain possible — that seems logical, too. But how do I know that what I think is, say, a six is also what you would consider a six? What if my six is your nine, or vice versa? And what if I told you I was at a ten last week, but the pain has somehow gotten worse this week?
There are no hard-and-fast answers to these questions, of course. Pain is subjective. For treating relatively short-term, intense pain — like an athletic injury, or childbirth — reliance on the pain-intensity scale is fine, mostly: If a person feels that their pain is at an eight, then it is. But the scale is also the primary tool physicians use for treating and prescribing medication — often opioids — to the estimated 25.3 million American adults suffering from chronic pain, which, as Drs. Jane C. Ballantyne and Mark D. Sullivan wrote in a New England Journal of Medicine editorial, is not a very useful way to go about caring for patients with chronic pain.
By focusing on the pain itself, Ballantyne and Sullivan write, the rest of the person’s experience is obscured, which means that the psychological issues that can accompany chronic pain — like anxiety or depression — are often left untreated. Beyond that, overreliance on the pain-intensity scale is also potentially dangerous, these two argue, in that this very common approach to patient care may have inadvertently contributed to the nation’s current opioid-addiction epidemic.
In their editorial, Ballantyne and Sullivan trace the recent history of opioids as the go-to treatment for chronic pain. “During the late 1980s and early 1990s,” they write, “it was argued, largely on moral grounds, that opioids should be available for treating chronic pain, and physicians were persuaded that addiction to opioid treatment would be rare.” The idea was borrowed from treatment methods for acute pain and end-of-life pain, which held that “the correct dose of an opioid was whatever dose provided pain relief, as measured by a pain-intensity scale.”
But the feeling associated with acute or end-of-life pain is short-term; it has a clear start and a clear end. Chronic pain isn’t like that. It may begin with an injury, but it can last for a lifetime, though the intensity to which it is felt varies by the day. “For individuals with chronic pain,” Ballantyne and Sullivan write, “especially those who have become dependent on opioids, getting to a lower pain-intensity score often means increasing the dose — which can interfere with the ability to function, decrease quality of life, and may lead to addiction.”
When their editorial was published, it was met with heated criticisms from patients and physicians alike, as the site Pain News Network reported, who — correctly — point out that many of those addicted to opioids are not chronic pain patients. But strictly speaking of chronic pain patients, many argued that the argument presented in the NEJM editorial made it sound like their pain was all “in their heads.” And yet a close look shows that this isn’t what the editorial is arguing — Ballantyne and Sullivan don’t want doctors to stop prescribing opioids, or medications in general, to chronic pain patients. Rather, they believe it should be just one piece of the puzzle in helping people manage their pain — and that a laserlike focus solely on reduction of pain intensity is exactly the wrong way to go about doing that.
“Pain-intensity ratings aren’t necessarily a reflection of tissue damage or sensation intensity in patients with chronic pain,” they write. “The intensity of chronic pain can’t be reliably predicted from the extent or severity of tissue damage, since chronic pain is not determined by nociception.” Nociception refers to the sensory nerve cells that send, essentially, an “ouch” signal to the brain. Interestingly, in chronic patients, the way pain is felt in the brain and body changes over time. “Research in a range of fields — from brain scans to placebo research to virtual reality — is showing that our experience of pain is ultimately created and controlled by the brain,” Jo Marchant, author of Cure: A Journey Into the Science of Mind Over Body, told Science of Us. Actual, physical damage to the body is important, obviously, but it “is neither necessary nor sufficient for us to feel pain,” Marchant said. “Chronic pain, in particular, often persists after the original injury appears to have healed.”
Studies using brain-imaging technology, for example, have shown that a sensation that to the person feels like the same pain migrates in the brain over time. Chronic pain is initially associated with increased activity in the brain’s “pain matrix” regions, but later scans show more activity in the areas of the brain associated with emotion. After a while, the experience of a person’s chronic pain becomes inextricably linked with psychological factors — something that typical pain medications are not intended to treat.
Instead of focusing solely on reducing pain intensity, then, it may be more beneficial for patients to focus on improving their quality of life, said Penney Cowan, executive director of the American Chronic Pain Association. Her organization has created something it calls the quality-of-life scale, to be used as a stand-in for the pain-intensity scale. It assigns meaning to each number, with one being “stayed in bed all day” and ten including things like “go to work/volunteer each day” and “have a social life outside of work.”
Catherine Cartwright, who has suffered chronic back pain ever since an on-the-job injury 15 years ago, has brought the quality-of-life scale to her doctor appointments after many years of frustrated attempts to get her physicians to understand how her pain feels to her. (She has a hunch, though, that “they still like the one-to-ten scale the best — it’s easier for them.”) Through group work facilitated by Cowan’s pain association, she’s found ways to manage her pain in addition to the medication she takes — which, she adds, is vital for her well-being. But just as vital are the pain-coping strategies she’s learned. One of them involved writing a literal letter to her pain, and giving the feeling a literal name. (Hers is named Gertrude.) It’s a way of separating herself from the pain, “instead of internalizing it as a part of you,” she told Science of Us.
Other methods might be as simple as gentle exercise, or mindfulness meditation, or relaxation techniques, Cowan said. The unfortunate truth that often gets lost in physician-patient discussions of pain management is that pain, or some of it, will probably never entirely evaporate. “But the good news is, you can live with it,” she said. “You just have to be taught.”