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9 Articles in Volume 9, Issue #2
Acupuncture for Fibromyalgia
Brain Atrophy with Chronic Pain: A Call for Enhanced Treatment
Evaluating Function/Impairment of Low Back Pain Using SEMG
Medication-induced Xerostomia Secondary to Pain Management
Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3)
Reducing Pain and Anxiety During Reduction of a Fracture
Successful Treatment of Intractable Pain
Treating Chronic Pain by Patient Empowerment
Treatment of Scapulohumeral Periarthritis and Post-traumatic Joint Pain

Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3)

Program, Purpose and Process

Progress: An Ongoing Process of Reflection, Analysis and Action

One of the outstanding questions of the Decade of the Mind Project (DoM) is how this incentive for cutting edge research will benefit the human and/or global condition. Without doubt, a number of answers are possible and many of these are contained within the mission statement of the project (www.dom-4.com). Previously, I have described how one goal-area for understanding the brain-mind is to generate better knowledge of pain and suffering and, from this, develop improved strategies and tactics of pain assessment and therapeutics.1 I’ve claimed that for this to be successful, we will need to take a reflective pause and look back upon our work thus far (inclusive of that assumed under the aegis of the Decade of Pain Control and Research, Decade of the Brain, and Human Genome Project) and be frankly critical of successes, failures, potential, and problems. This cannot be a myopic or unilateral effort, rather it must acknowledge that we are working at the frontiers and boundaries of the unknown, recognize that the results of this work can—and likely will—be globally manifest and take into account the plurality of society and culture(s) that could be affected by these outcomes.

In the former regard, only a consilient effort of the sciences and humanities can accommodate the philosophical, technical, and social richness of the tasks at hand and, in the latter, a more world-wide effort is needed if we are to truly instantiate a think-tank milieu that generates meaningful application(s) in socially relevant contexts. This is upheld by the fact that the DoM project is trans-disciplinary and international (viz. conjoining scholars, researchers, clinicians and public in Europe and Asia over the next several years). It is toward these consilient, international ends that I am now in Germany working with my colleagues Drs. Gerhard Höver, Heike Baranzke, and Hans-Werner Ingensiep (among others) at the Universities of Bonn and Essen. Our working group is a collaborative involving the natural sciences, medicine, philosophy, and ethics. We are focused upon the problem(s) of pain and pain care and the development of a neurophilosophy and ethics that can substantively meet the challenge(s) of engaging brain-mind studies to create a pain medicine that affords moral and practical good.

Identifying Problems

As a first step, we have begun to identify and analyze the difficulties inherent to pain care—both historically and currently. Perhaps the problem(s) that define contemporary pain medicine as profession and practice could be reduced to a three-fold concept:

There is controversy in the literature about whether tolerance to pain relief develops. In my clinical practice, which includes many patients treated with opioids for up to 15 years, quite a few have been on stable doses of opioids for years. Other opioid-prescribing clinicians have observed the same thing. Unfortunately there is a dearth of outcome reports in the medical literature. Recently, Tennant3 reported on a series of cases in his practice in whom long-term opioid doses were stable. When patients report increased pain after months or years of opioid treatment, their physician frequently attributes this to the development of tolerance to the pain-relieving effect of the opioids. But, remember, tolerance to all the other effects of opioids develops within days! What is much more likely is that the patient’s disease has progressed or that a new pain-producing problem has appeared.

1. problems of understanding
2. problems of translation
3. problems of articulation

In the first case—despite considerable progress into studying the mechanisms of pain, analgesic drugs and therapeutic interventions—we still must confront the “ti esti” (i.e., what is it?) question of pain. When we do, we encounter the “hard questions” of neuroscience which directly or indirectly underlie many of the hard problems of pain medicine.2

In this way, several of the first-fold issues and dilemmas instantiate those second-fold problems, that involves the translation of what we know about brains, minds and “selves” into a reasonably comprehensive system of pain care. This is a paradigmatic problem. I’ve stated previously, and re-iterate again, that pain medicine must be defined by the understanding of pain and its manifestations in the painient individual.3-8 To do this dictates that pain research must:

“Beginning with a low dose of an immediate-release opioid and increasing as needed is a good way to determine the patient’s opioid requirement. My recommendation at that point is to convert to a similar dose of a sustained-release opioid product...”

1) be inter-disciplinary;
2) study the mechanistic aspects of pain, and how these affect and are affected by bio-psychosocial dimensions of patients’ life worlds;
3) obtain a finer-grained perspective of the common as well as individually unique aspects (and effects) of pain; and
4) be equally devoted to both studying “how we study” pain, and revising these approaches in acknowledgement of information and knowledge gained, to date.9-11

Certainly this is an expansive agenda and, given the need to consider problems and issues in pain medicine in light of an appreciation of pain as a brain-mind event, then it too, requires a fuller understanding of embodied selves and their embeddedness in environments, society, and cultures.

To be sure, one of these cultures is that of medicine itself.12 For pain medicine to “work” it must not only develop a normative basis for profession, but must enact these norms in and across a number of clinical domains. Thus, the third articulative problem of pain medicine necessitates resolution through the development of a structure for the profession that entails different types of practice(s)—each and all of which are dedicated and enabled to employ the right knowledge, technologies, and skills in those ways that uphold the primacy of the pain patient’s best interest.13

Given identification of these problems, the goal is to bridge evidence and knowledge gaps such that information gained in response to the first problem, and developed in response to the second, is used in the third. Here we see how the enactment of the therapeutic dimension(s) of pain medicine can, and should, compel and ultimately sustain moral responsibility as an individual and public good. The premise is that this relationship is reciprocal: ethical obligations (i.e., to conduct pain research to empower right and good pain care) dictate the need to generate and provide right and good therapeutic action(s) and any and all therapeutic actions have moral potential and import.

“The promises of pain care are intrinsic to the profession. The structure of the profession entails obligation and responsibilities to certain intentions and actions.”

Premises for Resolution: Upholding a Compound Fiduciary

First, a multi-fold fiduciary reveals the responsibility of research—i.e., science—to society. Simply put, how can and will new knowledge be used in ways that better the condition of humanity (and its dominions)? To begin to answer this question we must use science in the literal sense, as scientia—knowledge, broadly construed to be inclusive of epistemologic constructs (i.e., of ways of knowing, awareness of these doctrines, and patterns of knowledge and understanding)—and of specific foci of, and approaches to, research (i.e., natural sciences, social sciences, and humanities studies) about pain and its effects.

Second, given 1) that the goals of any research enterprise are not simply “knowledge for its own sake” but at least in some way, the desire for knowledge that can be applied toward some practical purpose, and 2) that the ultimate application of pain research is in pain care, then the obligation of science to medicine becomes evident. The terms of this obligation necessitate a working definition of medicine, and for this I refer to the science(s), skills and art of curing, healing and caring for those made vulnerable by the predicament of disease, injury and/or illness.14,15

Two inter-related considerations are vital to this definition, and its specific importance to pain medicine. First is that this construct embodies a variety of approaches and is not simply focal to, or respective of, the curative model. Axiomatically, healing and care (i.e., both “concern”/regard, and sustained provision of clinical ministrations) are part, if not the basis, of medicine as a profession.16,17 Therefore, irrespective of a pain practitioner’s particular clinical orientation or specialization, the foundational obligation is one of care for the person who is made vulnerable by the condition of being a patient and from this arise the desire and goals of bringing about a healing action that is both technically right, and morally “good” for this particular patient. How such care is enacted—and what “healing actions” are needed—depends upon the type, scope, and manifestations of the patient’s pain.18

This instantiates both 1) the second consideration, namely that the authenticity of pain medicine as a profession is made possible by dedication to care that is enacted (albeit in somewhat different ways) in its constituent clinical specialties and sub-specialties—all of which must recognize the subjectivity of pain, and the existential illness that it can evoke; and 2) the third fiduciary of medicine to the patient and public.

The “Promise” of Pain Care

Taken together, these fiduciaries bespeak what Gerhard Höver refers to as the “promise” of pain medicine (inclusive of palliative care).9-21;see also 22 The concept of “promise” is based upon the Latin term to “put forth” (pro-mettere), and is related to the notion and act of profession (viz. from the Latin: profiteri) as a public declaration of skill and knowledge that invites trust of those who seek the goods provided by the practice(s).23 The promises of pain care are intrinsic to the profession. The structure of the profession entails obligation and responsibilities to certain intentions and actions. Thus, the declaration of what one “is” (e.g., “a pain physician” or “pain specialist”) is a communication of what one “puts forth” to both “be” and “do.”24,25

Clearly, this relation is evident in medicine, in general, and takes on particular therapeutic and moral gravitas in pain medicine, as it explicates that the pain physician 1) has knowledge about pain as disease and illness, 2) possesses skills and abilities that enable this knowledge to be incorporated into diagnostic and therapeutic process, and 3) will use these domains of knowledge and capability in those ways that are contextual to the experience of pain in specific patient(s)—and do so in ways that are intellectually and morally consistent with the affirmations, goals, and ends that are entailed by participation in profession and enactment in practice. Recall that here practice refers to an exchange of good as defined by the needs and purposes of those in the relationship.26 For pain medicine, such good, at first blush, would be pain relief and that is certainly important. But what this relief means—to both an individual patient, and to the nature of care—is somewhat more complicated and reflects the fiduciary nature of the professional and practice. In other words, the validity of its promise.

The Promise in Practice

The promise of pain care entails a larger, more multi-dimensional responsibility. Each and all of the inherent domains of knowledge that are essential to medical practice—regardless of discipline—are engaged, so as to allow a theoretical, applied, experiential and contextual understanding of pain (as object), and its expression and effects in the person who is the pain patient. But this is simply the first step. It serves as the basis for both diagnosis and evaluation of how the pathological process manifests illness in the patient’s lifeworld. It is vital to note that the thoroughness of this first step can, and often should, involve the use of those technologies that provide the most time- and cost-efficient approach to categorizing and framing the disorder.27,28 But the first-person nature of the pain experience and its manifestations also mandate that the clinician engage a particular inter-subjectivity so as to best assess how the pathology creates needs that must be met in the therapeutic relationship.29,30

This is the pedestal upon which Pellegrino’s critical inquiry of the clinical encounter can be built: “What is wrong with this patient?” “What can be done?” and “What should be done to effect a right and good healing action?”31 The first two questions reflect the theoretically intellectual domains of pain care, while the third involves a more applied contextualization and therefore must obtain some greater sense of who and what this pain patient is, in the bio-psychosocial sense. From this point, the values, goals, and needs of the patient—as relative and relevant to clinical intervention—must be accorded so as to determine the nature and trajectories of care.

Often, the obvious goal of pain relief may, in fact, not be wholly possible. Intractable pain is a reality of several pain conditions. However, it is important to recall that the “intractability” of pain need not imply that treatment and/or management is untenable.32 We argue that persistent, chronic pain need not devolve into maldynia. The pars malus (i.e., “badness”) of maldynia refers to the lack of purpose for, and denigrative effect upon the person in pain.33 Therefore, for those with intractable pain, the clinical goals are not only to attempt to reduce pain to tolerable levels, but to accomplish this within the larger aim(s) of working with the patient to re-constitute the life that has been de-constructed by pain. Obviously, this necessitates developing an understanding for how pain has incurred such effects, and what values and goals are vital for this patient to re-claim so as to be lifted, in as many ways possible, from the existential burden(s) pain has incurred.34,35

This is actually a point of departure that speaks to Stanley Reiser’s claim that “…medicine begins where technology leaves off.”36 To re-iterate, the claim is not that technology does not comport with medicine, but rather that technological protocols and capabilities often do not, nor cannot, determine the type and quality of care to be rendered. This determination necessitates the knowledge, insight, creativity, and both intellectual and moral judgment that constitute practical wisdom (i.e., phronesis, or prudence). Hans Werner Ingensiep37,38 and I 39,40 have opined that the task ahead is to affirm both Hans Lenk’s identification of the “technological imperative”41 and Hans Jonas’ caveat that technology is a worldview.42 One must recognize that the status quo is one of progress and employ critical reflection and prudence to 1) develop and implement more creative approaches and uses for new and novel technologies and techniques, 2) develop protocols and guidelines for research and use, and 3) utilize these approaches in ways that maximize the good—of both biotechnology and pain medicine—as a multi-cultural endeavor. Without doubt this presents both challenge(s) and opportunities for research and practice(s).

A Paradigm for Pain Care on the World-Stage: Importance of an Ethics of Responsibility

In the main, the challenges are determining what needs to be studied, how such study can and should be undertaken, and what and how research findings should best be translated into care to meet the needs of those in pain. We argue that such challenges must be met through the use of normative and applied ethics that are built upon core responsibilities intrinsic to pain medicine—in both research and practice. As Heike Baranzke 43,44 has noted, there is a centrifugal quality to these responsibilities that reflects an understanding of the nature of the human condition (i.e., neuroscientific, and neuroanthropological perspectives of the brain, mind and self, pain, etc), recognition of self-responsibility, and acknowledgement that responsibilities to others are asymmetrical. The latter are based, in part, upon both self-other relationships and vulnerabilities incurred by such relationships (e.g., inequalities of knowledge, power, and the differential effects of pain, illness, etc.).45

Roger Scruton’s contention is that any approach to improving the human condition (and pain medicine certainly seeks this end) must first reflect upon, and seek to understand, the nature and essence of what it means to “be” human and/or any other painient being46 not only historically but—as Roland Benedikter, Kevin FitzGerald, and I have claimed—in terms that are relevant to both our present circumstance(s) and future possibilities.47 The goal, therefore, is to engage this knowledge to develop a meta-construct of pain and pain medicine that reflects and contains neuroscientific, (neuro)philosophical, and (neuro)ethical domains, and then employ this construct as a basis for ongoing internationalized efforts in research, education, and translation into practice.

“A first step seeks to examine the history of pain and pain care so as to take measure of the interactive effects and dynamics of knowledge, societies, and culture(s) in determining the scope, aims, capabilities, and limitations of treating those in pain.”

A Program Within a Project—N3P3: Purpose, Potential and Invitation

This is the mission of the Program in Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3). Working within the larger agenda of the DoM Project, N3P3 focuses ongoing efforts in the sciences, technology, and humanities upon the problem of pain, the potential of pain care (inclusive of palliative medicine), and engage knowledge gained from these projects toward informing and developing ethically sound and socially effective policies for research and therapeutics. By design and intent, it is inter- and trans-disciplinary, international, and iterative. A first step seeks to examine the history of pain and pain care so as to take measure of the interactive effects and dynamics of knowledge, societies, and culture(s) in determining the scope, aims, capabilities, and limitations of treating those in pain. This is not simply an exercise in nostalgia; rather it seeks to critically evaluate both how these socio-scientific interactions have established the basis of the profession and practice(s) of pain care, and use this historicity to analyze the current state-of-the field and its capabilities as an individual and social good. In other words, the first part of this program will attempt to define the meaning of pain and dimensions of pain care to date.

This will serve as the groundwork upon which to develop and funnel a component of the energies and activities of the DoM project upon the problem of pain and the potential for improving pain care. To do this requires a deeper and more analytic examination of the human condition and the ways that this nature and expression is affected by, and affects, pain and its meanings. To be sure, this work must acknowledge the occurrence of pain across the lifespan, identify and examine the various contingencies when pain occurs in the fetus, neonate, child, adult and aged—as well as when death is imminent—and employ this knowledge to develop improved methods, protocols, and paradigms of diagnosis, treatment, and management.

For such paradigmatic change(s) to occur, we argue that administrative, legal, and financial support must be established and in place (not necessarily in that particular order). If a global pain care is to be realized, then the social structure(s) of the increasingly pluralized world-culture must be acknowledged, accommodated, and incorporated into any/all plans and guidelines for pain care.48 Market forces must be addressed and it is possible that a major thrust of the social front of N3P3 will be to negotiate economic changes that allow multi-disciplinary pain care that is sensitive and responsive to bio-political constraints upon individual and social groups.49 Policies must be built to address and accommodate the issues and problems that confront profession, practice, and the persons served. The calculus of circumstance(s), agents, intents, outcomes, and consequence(s) is vital for any reflection and/or deliberation upon—and actions toward—policy formulations that uphold moral responsibility of pain care, as well as medicine, more broadly.

At present, the cornerstones of this project involve the domestic efforts of our group at: Georgetown, the Center for Neurotechnology Studies of the Potomac Institute for Policy Studies; Drs. Mark Boswell and Gabor Racz at the Messer-Racz International Pain Center of Texas Tech University, Lubbock, Texas. This project includes overseas collaboration with: Prof. Dr. Höver, Drs. Baranzke, and Schaeffer of Universität Bonn, Prof. Dr Ingensiep of Universität Essen, Germany; Prof. Roger Scruton of the Center for Philosophical Psychology of the Institute for Psychological Sciences (USA and Oxford, UK); and Prof. Dr. Roland Benedikter of the Free University of Bozen-Bolzano, Italy and University of Vienna, Austria. As is evident, the approach is diverse and oriented to provide different lenses, perspectives, and voices to the pluralog. In seeking to illustrate historicity, develop canon, and influence profession and practice through policy, this collaboration is equally diverse in funding, with support dedicated to scientific, humanities, and social dimensions of the program and its constituent efforts.

Through a progressive series of workshops, seminars, feasibility studies, and publications, N3P3 is intended to work in partnership with DoM to create a nexus for the exchange of ideas; identification and analysis of evidence and practice gaps; development of new methods of inquiry, protocols for study and practice; and guidelines and policies that enable articulation. From the research core, we hope to conjoin the growing participation of scholars, clinicians, and administrators whose interests and passions are aligned with the scope and aims described herein. Throughout the coming year, this column will serve as a forum for describing new studies, reporting outcomes and implications, raising questions and, as always, stands as an invitation to others to enter the discussion and facilitate meaningful dialectic. Our hope (and vision) is that a rising tide will raise all ships, as it takes a diversified armada to chart the course and safely, prudently, and effectively sail to distant and promising horizons.

Acknowledgments

This essay was adapted from the chapter: Prolegomenon: Philosophy, ethics and policy in and for pain medicine (Giordano J, Boswell MV). In: Giordano J, Boswell MV. (eds.) Pain Medicine: Philosophy, Ethics and Policy. Linton Atlantic Press. Tennessee and Oxford; currently in press.

Thanks to Prof. Dr. Gerhard Höver, Dr. Heike Baranzke, and Dr. Andrea Schaefer of Universität Bonn, Germany, and to Prof. Dr. Hans Werner Ingensiep, Universität Essen, Germany, for their ongoing collaboration in this program.

This work was funded, in part, by the Laurance S. Rockefeller Trust, and Friedrich Wilhelms’ Rheinisches Universität Bonn, Germany, in support of a Visiting Professorship at Rheinisches Universität Bonn; by the Nour Foundation; an American Academy of Pain Medicine National Visiting Professorship (Texas Tech University Health Sciences’ Center, Lubbock TX); and by funding from the Institute of Psychological Sciences/Center for Philosophical Psychology Blackfriar’s Hall, Oxford for a Visiting Professorship in Philosophy and Neuroethics.

Last updated on: December 13, 2011
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