Clinical Bioethics: Pain Research
"Our bodies are not one size fits all… this is more true with pain than… ever imagined."1
"…trying to untangle all these factors is a scientific nightmare."2
James Giordano, PhD; Julia Pedroni, PhD
The cover story of a recent issue of Newsweek from which these quotes were taken was dedicated to "The Changing Science of Pain."3 The author, Mary Carmichael paints an accurate picture of the current epidemiology of chronic pain, with particular emphasis on the growing numbers of military wounded who contribute to the demographic and economic toll. The author alludes to many of the pressing issues that have been addressed in this journal, and this column, more specifically. As Carmichael notes "…scientists don’t know why some people develop chronic pain,… pain simply has too many causes."4 Quoting Will Roe, the Executive Director of the American Pain Foundation, Carmichael reports on the "tectonic" inertia in recent research that has sought to investigate both mechanisms of pain and novel approaches to therapeutics.5 Yet, a persistent question is whether the type and nature of pain research is sufficiently developed to allow incisive insight to the problem of pain, the pain patient, and how treatment might best affect this intersection.
In this essay, we suggest that one of the durable outcomes of the Decade of Pain Control and Research should be to study how we study pain, and to revise these approaches so as to create more meaningful, patient-centered therapeutic paradigms.
The Randomized Controlled Trial: Gold Standard or Fool’s Gold?
Throughout the last half century, the randomized controlled trial (RCT) has been construed to be the most effective and efficient method in clinical research.6 Without doubt the RCT has been important in pain research and has yielded abundant information that has deepened our understanding of pain mechanisms and therapeutics. However, as with any methodology, we need to recognize not only its strengths but also the weaknesses that may limit its utility and seek ways to delimit these constraints. To be sure, the RCT is ideal to investigate the effects of an experimental treatment in comparison to a stable control. But it must be remembered that the RCT was derived from the agricultural model in which control was relatively easy to accomplish, and the focal problem being studied was more often than not unidimensional. As this column has attempted to show, pain is not a simple problem, but rather is a complex process of cause(s) and mitigating influences that is uniquely expressed as a phenomenal experience of each person in pain. Therefore the existential impact of pain and suffering must be considered as a focus of any scientific investigation if research is to maintain its epistemic and ethical value. To paraphrase Lao Tse: to know and not to do is not to know. In other words, "what we learn about pain should influence how we study pain, and how we conduct pain studies may then provide insight to new types of knowledge."7
Please refer to the June 2007 issue for the complete text. In the event you need to order a back issue, please click here.