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12 Articles in Volume 9, Issue #1
Atypical Herpetic Reactivation and Chronic Pediatric Pain
Blending Prescription Pain Treatments with Alternative Medicine
Cervical Disc Disease with Referred Pain to TMJ
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1
In My Opinion
Laser Therapy: Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Pain Management in the Elderly
Personality Disorders in Migraineurs
Surgical Implants for Pain Management
Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Trigger Point Ablation and TMJ Syndrome
What a Decade of the Mind Affords the Decade of Pain Control and Research

What a Decade of the Mind Affords the Decade of Pain Control and Research

This retrospective observational study of patients with unresolved wrist pain noted improvements in many quality of life parameters after Hackett-Hemwall dextrose prolotherapy.

“…man consists of mind and body. From this we understand not only that the human mind is united to the body, but also what must be understood by the union of mind and body…”

- Benedictus de Spinoza

Pain, Brains, and Minds

A philosophy of pain and an ethics of pain care are incontrovertibly bound to a definition of pain as both an event of the nervous system, and as an experience of the individual in which that nervous system is embodied.2 Given that ethics both studies and guides the activities of agents in interaction (with each other, and within the milieu of their socio-cultural environments),3 then an authentic neurophilosophy of pain and neuroethics pain care cannot be divorced from a knowledge of the functions and properties of the brain that give rise to cognition, emotion, and behaviors. In other words, considerations of “mind.”

But what is the “mind”? Despite the efforts and progress achieved by the Congressionally–declared Decade of the Brain (DoB; 1990-1999), the “hard questions” of neuroscience persist.4 We continue to ponder the nature of consciousness, reality of the self, viability of experience, and validity of independent action. Still, brain research has pressed on, despite—or perhaps because of —ambiguity in the term and construct of “mind” and, in striving for betterment of the human condition, has sought to unravel the enigma of pain.

Such dedication has been the impetus for, and the focus of, the Decade of Pain Control and Research (DPCR; 2000-2009). But while these investigations have explained mechanisms of pain sensation and the actions and effects of various therapeutics, each and all of these strivings must eventually confront the limitations incurred by the question of how the experience of pain is evoked by and/or arises from the neurological events of nociception or, more simply put, how the brain “makes” the mind. Taken independently or in intersection, the problem of pain with its resultant manifestations and the hard questions of neuroscience engage medicine, philosophy, theology, sociology, ethics, and law.

Posing the Essential Question

The ti esti (i.e.- “what is the essence of it?”) question of both pain and mind remains contingent upon informational gaps between what we know about the brain, and how we interpret the phenomenological experience of the body and world. These gaps have fueled speculation and debate in both meta-physical (“what does it mean to be?”) and practical terms (“do we have free will?”) and incurred profound implications not only for philosophy and ethics but for society at-large.

As one of the sequelae of the DoB, such broad speculation has led to a preponderance of things “neuro”—somewhat sarcastically, what might be referred to as “neuro-ubiquity”—in a number of fields and disciplines. And so we now encounter neuroeconomics, neuromarketing, neuro-law, neuroanthropology, neurotheology, etc. In some way, all of these are relevant and being applied to medicine, in general, and pain medicine, more specifically. In theory, this is valid, at least in part. As I claimed at the beginning of this essay, any realistic discussion or treatment of pain and pain care must be grounded to a contemporary knowledge of what it means to have, and be in pain. But if a neurophilosophy of pain is to be pragmatic and have practical worth, then it must also be aware of, and responsive to, what Matthew Crawford has called the “limits of neuro-talk.”6
In fact, I believe that the “neuro” prefix has become synecdoche—a representation of an entirety through depiction of one of its parts (e.g.- “Wall Street”)—and bespeaks the reductionist/non-reductionist debate as relevant to the fields in which it is applied. So when we consider a neurophilosophy of pain and neuroethics of pain care, axiomatically we enter into this debate and must appreciate what is known, unknown, and as yet un-knowable about the brain-mind. We must recognize that what we know about the brain does not provide sufficient evidence to disregard the mind. That is not to say that we should adopt some dualistic stance. To the contrary, it seems to me that the natural extension of any attempt to explain pain should endeavor to understand the mind, not merely as a folk construct, but as a process of brain function, core of consciousness, and essence of our subjective experience(s).

Decade of the Mind: Toward a Consilient Agenda

This is the focus the Decade of the Mind (DoM)—an agenda proposed in 2007 by my colleagues at Krasnow Institute for Advanced Study at George Mason University, Va.7,8 To date, this undertaking has conjoined scholars from our group at Georgetown University and the Center for Neurotechnology Studies of the Potomac Institute for Policy Studies, Sandia, and Los Alamos National Laboratories, The University of New Mexico, Santa Fe Institute, and the Mind Research Network. By both intent and scope, the project is obviously trans-disciplinary and seeks to generate up to $4 billion in federal subsidy over the next ten years in support of cooperative, consilient research aimed directly at the “hard questions” and problems of brain science.9
Specifically, the DoM seeks to: 1) understand the basis of the brain-mind relationship, and in this way provide bridge(s) across the extant explanatory gaps; 2) develop and use analytic and technological models of mind to further this understanding; 3) employ these models and this knowledge to develop new and novel treatments for a variety of brain-mind disorders, including pain; and 4) facilitate educational paradigms and protocols that utilize brain science not only to augment scholastic learning, but to instill a more comprehensive public awareness of the mind, strengths and limitations of neuroscience and neurotechnology, and the implications and responsibilities that arise from this new information and knowledge.10

Neuroethics, Legal and Social Issues

This latter point speaks to the need to consider the ethical, legal, and social domains impacted by any studies of the brain-mind, and most certainly this relates to pain care as profession and practice. As we approach the DoM, it is important to realize that to date, greater than 98% of federal scientific support has been devoted to research, development, testing and evaluation, while less than 2% has been dedicated to examining the translational validity and value of research, the effects of information gaps on the use of new technologies and techniques on biomedical practice, and/or ethical benefit-risk assessment of research and therapeutics.11 If we are to balance the pros and cons of various investigational methods and translational applications, then we are obligated to create programs of economic support that enthuse 1) reflective governance of how research is conducted, 2) the scope and pace of translation into viable therapeutics, and 3) the development and implementation of guidelines and policies that sustain ethically sound progress.12-15 James Olds, Director of the Krasnow Institute for Advanced Study at George Mason University, and co-chair of the DoM project, has warned that policy formulation needs to be wary of “tripping hazards”—issues and problems that may be initially disregarded or unforeseen due to lack of scrutiny, foresight or hindsight—that subsequently impede advancement and/or outcomes. For sure, we must be aware that such tripping hazards are often entangled in what has already been done and, in this regard, we should be careful not to carry forward the mistakes of DPCR so as to avoid being felled by them in the future activities of the DoM.

As a first step in this process, I have proposed a risk and ethical management paradigm that involves: 1) adopting a precautionary stance that acknowledges that the status quo entails progress; 2) engaging personnel that are perceptive to the nature of such progress and the problems that can occur at the boundaries of the known and unknown; 3) making predictions about whether the problems that could arise are containable, retrievable, reversible, or forgivable, and from this, 4) developing policies to guide research and its translation into practices that uphold the public good.16 In other words, as we move from DPCR into DoM, we must address the unique questions, challenges, and opportunities that this program may face and bring forth.

The Work Ahead: Challenges and Opportunities

These tentative possibilities could impact many of the key areas important to pain care, including the scope and nature of research, development and application of new technologies, and the use (or misuse) of pharmacology and genomics. As well, technological models of mind and progressive iterations of human-machine interfaces might make subjective experience accessible to others, allowing objective validation of the first-person experience of pain, and thereby making moot many of the persistent difficulties of pain assessment. However, an equal challenge is exercising sufficient restraint against making premature or overly expansive conclusions about the potential benefits or applications of mind-based technologies.17 For example, current attempts at utilizing fMRI to detect malingering18 are difficult to justify given what we currently know about brain function, mental processes, and the limitations of neuroimaging.

But perhaps one of the greatest challenges is one shared by DPCR, namely how might these efforts be broad enough to instill a global translational effect. As we have shown, the call for global pain care must confront both socio-cultural diversity, and the geno- and pheno-typic—as well as existential—individuality of persons who are nested within environment(s).19,20 To be sure, these factors equally apply to any studies of the brain-mind, as will issues incurred by socio-economic and/or political constraints upon research and the distribution of clinical and social benefits. To effectively meet these challenges, DoM must be an internationalized effort and the forthcoming conferences—to be held September 2009 in Berlin and tentatively China in 2010—are directed at generating this level of participation on the world-stage. As the director of the Berlin DoM meeting, Michael Alan Schwartz has noted that any efforts toward using brain-mind science to reduce pain and suffering, enhance flourishing, and create better lives in the future must occur through “pluralogue” to bring diverse voices to the table so as not to be exclusionary or parochial. I agree with Dr. Schwartz and am optimistic that the DoM will take up the torch where the DoB and DPCR have left off and, in so doing, illuminate new insights to the mind, better understanding of the brain, and more innovative, effective pain care.

Acknowledgements

Many thanks to my collaborators in the Decade of the Mind and Neuroethics, Legal, and Social Issues project(s) for their tireless work in advancing these endeavors, making DoM a reality, and bringing these concepts to fruition. Special thanks to Drs. James Albus, Vince Clark, Kevin FitzGerald, Chris Forsythe, John George, M. Layne Kalbfleisch, Gar Kenyon, Christof Koch, Jeff Krichmar, Jay McClellan, Jim Olds, Ed Pellegrino, Wendy Shaneyfelt, Michael Shulman, and John Wagner; and gratitude to Kelly Burns, Christine Chavez, Kevin Dixon, Gaye Garrison, Dr. Alexis Jeanotte, Sherry Loveless, Annie Marquez, Dr. Dennis McBride, Jeanette Orona, Sandhya Rajan, Dr. Leah Reeves, Michael Swetnam and Kathryn Schiller for their support and dedication to these projects.

For more information on the Decade of the Mind, visit www.DOM-4.com.

Last updated on: January 5, 2012
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