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14 Articles in Volume 9, Issue #7
Anomalous Opiate Detection in Compliance Monitoring
Anticipating Biotechnological Trends in Pain Care
Continuous Lumbar Epidural Infusion of Steroid
Disordered Sacroiliac Joint Pain
Efficacy of Stimulants in Migraineurs with Comorbidities
Hand Tremor with Dental Medicine Implications
Helping Patients Understand the
Non-surgical Spinal Decompression (NSSD)
Pain Management in Nursing Homes and Hospice Care
Patients Who Require Ultra-high Opioid Doses
Relief of Symptoms Associated with Peripheral Neuropathy
Share the Risk Pain Management in a Dedicated Facility
The Multi-disciplinary Pain Medicine Fellowship
Thermal Imaging Guided Laser Therapy: Part 2

Anticipating Biotechnological Trends in Pain Care

Precautionary Purpose and Process

“Slight not what is near through aiming at what is far.”1

Robert Foery, PhD, DABCC/TC

The past decades have evidenced considerable progress in capability and applications of technology in neurosciences. Neurotechnology— the science and devices that allow analysis, understanding, and treatment of the brain and nervous system—has changed the face of both health care and society, at-large. In the former case, the use of new technologies, and novel applications of existing techniques and devices, have allowed heretofore unforeseen ability to depict, assess, and manipulate the neural system in vivo. In the latter case, the information and knowledge gained from the use of these technologies has affected public expectations of the technological type and extent of medical care, as well as an alteration of social conduct.

Pain care reflects this technological turn, as there is increasing reliance and hope resting upon technological innovation to advance research—of both technology itself, and use of the technologies as tools—and to translate this research into clinical therapeutics.2,3 The tools of neurotechnology also conjoin advances made in other disciplines, namely genetics, nanoscience and computation (i.e., cyber-science). Each and all of these offer somewhat unique properties and capabilities that affect multiple dimensions of neural systems. For example, genetic manipulation that provides means to change the expression of particular neural phenotypes over various timeframes (e.g., generationally; within an individual’s lifespan, etc.). Nanotechnology allows articulation and manipulation at the sub-cellular scale, while cyber technology creates almost boundless access to information. Clearly, these technologies may be focused upon neural applications and/or coupled to other technologies that directly engage neurological systems and functions. We posit that taken together, geno-, nano-, neuro-, and cyber-science may converge to constitute something of a ‘singularity’ as described by Ray Kurzweil.4 The fusion of these technologies will likely lead to a paradigm shift that changes what we know, how we know it, and the social attitudes and actions that arise from this new knowledge and capability.5

Effects of Biotechnological Convergence Upon Pain Care

How might this change in the scientific and social order affect the scope and conduct of pain care? Given that (1) an underlying maxim of achieving ‘good’ is the driving force that generates the development and use of technology, at least in health care (albeit implicitly); and (2) pain is construed as an existential loss (i.e., negatively impacting the ‘good’ of life); then the employment of these new technologies toward ameliorating, if not wholly eliminating, pain would be axiomatic.6,7 However, it is important that while striving for good, we remain aware of potential burdens, risks and harms. For example, while progress in the field may be conceptually ‘aimed’ and pulled by profound philosophical and practical questions of the human condition (e.g., pain, suffering, physical degeneration, etc.), in reality, the pace and extent of technological advancement(s) may be ‘pushed’ by other, non-medical agendas (e.g., market forces, sociopolitical imperatives).8 As well, our understanding of the brain-mind remains speculative and the ‘hard problems’ of neuroscience (viz., what is consciousness, the mind, the self?) persist.9

Of course, it could be argued that these very same hard problems compel the development and use of multiple biotechnologies. We agree, however, it is equally important to acknowledge that the rapid pace of technological advancement tends to be greater than that of profound discoveries of the sort that will shed light upon such perdurable questions. So, we are faced with a rapidly expanding technological set that allows access to, and manipulation of, substrates that are not yet fully understood. In light of this, it becomes almost impossible to predict what effects these technologies might have, insofar as their use will incur potentially unforeseen trajectories and outcomes. It is unreasonable to consider impeding technological advancements given the strong and multi-dimensional ‘pushing forces’ that drive such progress. Rather, we call for a dialectical approach that balances technological incentives with responsibility in inquiry, application and consequences.

To be sure, the advancements in neurotechnologies have the potential to generate major ethical, legal, and social issues (ELSI) and so we advocate that these must be considered early, as well as throughout the research and development process. Several neurotechnologies are already available (e.g., neuroimaging, transcranial magnetic stimulation, deep brain stimulation, nano-pharmacology, neurogenetic assessments, neuroprostheses, brain/machine interfaces, etc.) and these give rise to concerns that require immediate consideration.10,11 For example, while neuroimaging provides unprecedented ability to view the living brain, it is important to exercise caution about the actuality of the images, individual differences and basic limitations of the technologies themselves. Thus, given what is known about the structure and function of the brain, pain as a process of networked neural activity and the uniquity of its phenomenal experience, it is unlikely that current iterations of neuroimaging technology will be able to create a wholly objective measure and/or discernment of pain.12,13 Obviously, similar discernment of the lack of pain (e.g., malingering) is equally problematic. But, let’s presume that we accept neuroimaging as a reasonably valid assessment for the presence or absence of pain. How then, should we treat the individual whose neuroimage objectively depicts pain, but who does not subjectively feel or express it? Conversely, how might we treat the patient who complains of pain, but whose neuroimage fails to ‘depict’ brain activity reflective of nociceptive processing?

When considering deep brain stimulation, (either in it’s current form, or as projected to involve implanted micro- and/or nano-devices) it is important to acknowledge the long-term viability of the implant and unintended outcomes that may occur as patterns of neural network activity are altered over time. Many of these same concerns apply to transcranial magnetic stimulation. Ultimately, we must ask whether we are prepared to maintain responsibility for the longitudinal management of any such unforeseen consequences and effects.

Nano-neurotechnologies initiate additional concerns, given that the behavior of materials and systems at the nano scale are not fully known. Thus, when taken together with the unknowns of neural function, the pairing of nano- and neurotechnologies and their employment in neural systems may create compound unknowns that give rise to entirely unanticipated effects.14 Neurogenetics hold promise to elucidate genotypic predispositions to certain types of pain. However, it is not yet possible to manipulate the genome to mitigate these pain syndromes.15 And, even if it were possible—either through genetic or some combination of other technologies—should we?

At face value, one could assume that, given the ‘badness’ of pain, its eradication would represent a viably good, moral end. However, this would also presume that we could first obtain a reliably objective measure/representation of pain from which we could establish a (clinically and socially) relevant threshold that determines the obligation to treat. In the absence of the former, we must still rely upon some level of subjective report and valuation of pain from the patient. This being the case, how should we determine what type and/or severity of pain should be eradicated? Should some pains be left untreated or should all pain be eliminated? Then, of course, we must ask: Who shall receive these treatments and what criteria shall be used to justly distribute these medical ‘goods’?

It is naive to think that market and/or political influences would not be operative in such distribution. Moreover, in light of (1) the ascribed harms of pain, and (2) the predominant principle of non-harm in dictating much of human conduct, how will we treat those who cannot feel pain? Might this create some new medical or social hierarchy? And what of those dispositions to pain conditions that cannot be ameliorated? If the current health care system portends any vision of the future, then we must be wary of policies and plans that discriminate against individuals who are shown by genetic testing to have a ‘predisposition’ to an existing condition.16 Granted, a genetic predisposition does not always predict phenotypic expression and, in the best case scenario, genetic ‘diagnosis’ of a potential pain disorder would instigate an active program of health behaviors and preventive care. But, this is the ideal. Will this care be supported by insurance plans or is it more likely that such diagnoses would lead to higher premiums or inability to obtain insurance?

Merging these technologies with the information revolution would conceptually allow rapid access and retrieval of an almost unlimited amount of medical data. This would allow real-time monitoring of individual patient’s physiological composition (e.g., genotype, expression of particular phenotypes, etc.), and status (e.g., metabolic processes, etc.) that could be used to maximize medical care. Trial and error empiricism would be minimized and any physician would have access to a particular patient’s full medical history and records—as well as current condition—at any time, anywhere in the world. Such ‘stacking’ of information would increase the knowledge base that is usable to personalize treatment. However, the adage among cyber-pundits that “… if it’s stackable, it’s hackable” raises concerns about unauthorized access and use of highly-detailed patient information. This new type of ‘identity theft’ could have profound impact upon insurability, access to care and safety. Furthermore, even if ‘appropriately used,’ that is, not hacked or stolen, it is entirely possible that patient information gained through these (geno- nano- neuro-) technological resources could be used for job discrimination and social stigmatization.

“When considering deep brain stimulation...it is important to acknowledge the long-term viability of the implant and unintended outcomes that may occur as patterns of neural network activity are altered over time.”

Precautionary Process

How then are we to engage technological progress? At the fore is the need to balance potential and problems, as well as public health and personal liberties inclusive of privacy. A simple precautionary principle that would advocate retarding any or all technological advancement or development when the risk exceeds the benefit is not entirely applicable. This is because conditions are risky at the frontier(s) of the known, unknown and potentially unknowable.17 Therefore, risks will always be present and may frequently outnumber known benefits. Many of the risks arise from unexamined gaps in information about mechanism(s), systems and substrates of application and effects.

We opine that the sound and effective use of (geno-, nano- and neuro) technologies in pain care can be facilitated through a process of gap identification, analysis and compensation. Identifying where information is lacking is important to focus research activity and depict where unknowns may occur. Understanding the interaction of factors and outcomes occurs through the process of gap analysis. In the event, any progress will be somewhat problematic and will lead to unforeseen and/or undesirable consequences. The potential for these consequences must be anticipated and ‘gamed’ through proposing different scenarios, elucidating various outcomes and posing and developing militative strategies and tactics to heighten benefits while diminishing potential burdens, risks and harms.18 At each stage, it is important to evaluate not only the direct medical effect(s) of the use(s) of particular technologies but also the ethical, legal and social ramifications that these medical outcomes incur and that the technology itself might foster (e.g., costs, access, distribution, etc.).

“Few, if any, technological developments incur solely beneficial outcomes without risk or negative effect(s). Obviously, the goal is to enhance the benefit and decrease the risk...”

Few, if any, technological developments incur solely beneficial outcomes without risk or negative effect(s). Obviously, the goal is to enhance the benefit and decrease the risk, but it is equally important to consider how such risk(s) can, and should, be minimized. We claim that risks must be assessed for the capacity to be containable, reversible or forgivable. It may be, for example, that the concomitant development of other technologies allows for containment and reversal of particular technological risks and burdens. And, if the overall benefit is capable of achieving a ‘good’ that is acceptable and justifiable to all end-users, then it is probable that particular risks, burdens and even harms will be forgivable.

Conclusion: Social Policy and Responsibility

Technological advancement does not occur amid social stasis. Society and culture change as a consequence of adopting new technologies and, in reciprocity, technologies are developed to accommodate particular socio-cultural needs.19 If we are to employ emerging technologies (either individually or as some singularity) then it is vital to remain sensitive and responsive to social and cultural contexts and values so as to best steer technological development in those ways and toward those ends that are best aligned with the public good. To reiterate, in the ideal, these technologies will be used to promote and sustain profound good. Yet, in reality, it is axiomatic that capricious forces act upon even the best intentions. As Dominique Janicaud has noted, “…the ideal and the real intersect, as do rights and morality, the individual and the collective. At the point where they meet, we find both reflection and political action, just as we always have.”20

Can these technologies change the scope and conduct of pain care? Perhaps. The question is: How? Thus, it is our responsibility to develop guidelines and policies to ensure that these technologies are evaluated, developed and implemented with reflection, insight and moral integrity as means to a good end— not simply as ends unto themselves.

Acknowledgement

This essay was adapted, in part, from the paper “Ethical, Legal and Social Issues in Geno- and Nano-neurotechnology Research and Applications: Confronting the Singularity, Considering the Implications” presented by the authors at the Annual Symposium of Biotechnology and Ethics, NY Polytechnic Institute, Brooklyn, NY, March, 2009, that will be forthcoming in The Journal of Long-term Effects of Medical Implants (2010).

Last updated on: January 6, 2012
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