The Spiritual, Societal, and Historical Milieu Influencing Pain Perception

Note: this is my first blog posts as a PRF-NAPS correspondent for the 2019 North American Pain School. Can also find the blog post at https://www.painresearchforum.org/forums/discussion/118414-2019-prf-naps-correspondents-blog.

He fought down an aching shiver, stared at the lightless void where his hand seemed to remain of its own volition. Memory of pain inhibited every movement. Reason told him he would withdraw a blackened stump from that box.

"Do it!" she snapped.

He jerked his hand from the box, stared at it astonished. Not a mark. No sign of agony on the flesh. He held up the hand, turned it, flexed the fingers.

"Pain by nerve induction," she said. (Herbert, Dune, 9)

I love science fiction. It can often inform science and give a glimpse into how our endless drive for knowledge could shape the world around us. Unlike many animals, humans have an enormous capacity to control our response to noxious, or painful, stimuli. I will often end talks with a note about the Pain Box from Herbert's science fiction classic Dune [1], which illustrates this point brilliantly while emphasizing other important aspects of pain. The idea of artificially inducing pain highlighted in the above Dune quote has become more wide-spread---as it is masterfully portrayed with the potentially negative consequences in Black Mirror's "Black Museum" episode. However, this idea of pain induction, instead of reduction, potentially being useful also points toward a broader discussion that I look forward to having at North American Pain School (NAPS) 2019 related to this year's "Biggest Neglected Problems in Pain Research" theme: what pain perspectives, management, and research are we overlooking by a focus on eliminating patient pain that is Western-centric in outlook? This theme will be touched on more in the future, but here I will briefly highlight introductory thoughts on two areas: understanding societal and spiritual influences on pain perception along with different historical and non-Western perspectives on pain.

Currently my views of pain are formed from a mix of personal experiences and my basic science, systems neuroscience research into nervous system function [2] using calcium imaging techniques during my PhD in Prof. Mark Schnitzer's lab [3]. These views have and will benefit from interactions with physicians, patients, and others. Looking over the North American Pain School 2019 program [4], I am encouraged by the Patient partners and "Ask-A-Patient" sessions. These should provide great opportunities, beyond discussions with those that work in a more clinical setting, to ask about both systematic and anecdotal perspectives on how pain perception varies across those of different socioeconomic and spiritual backgrounds.

The interaction between spiritual views and pain often reminds me of a conversation with a friend who had studied both medicine and theology. He noted that one goal as a physician would be to improve the broader community and spiritual life of patients, both to improve patient outcomes, such as in palliative care settings, as well as to give those at the end of life a more comfortable passage to the next. This view of the interaction of spirituality and pain, the biopsychospiritual model, has been reported on previously and research suggests that certain types of prayer or spirituality can help with pain management [5-7]. While we are unlikely to turn patients into Thích Quảng Đức, a Buddhist monk who famously endured self-immolated by fire, there is an opportunity to discuss in a more comprehensive fashion how greater interactions between clinicians, churches, and other spiritual communities can improve pain management.

Beyond the spiritual is the societal influence on pain. Societal factors are known to play a role in pain perception and reporting [8] and has informed biopsychosocial models of pain [9]. We currently live in an increasingly urbanized society [10] that limits many people's access to nature [11], losing out on the many associated health benefits. While effective pain management in the clinic is important, this should be complemented by incorporating the wider context of how other aspects of modern life---such as constant agitation due to car and other noises; stress caused by dreary architecture and living spaces along with jobs, advertising, etc.; and lack of deep community connections and support owing to a variety of causes---interact to prevent proper healing, e.g. via stress-induced alterations in body function [9]. For example, within urban planning landmark works such as The Death and Life of Great American Cities [12] and the idea of walkable cities [13] have paved the way toward better understanding the interaction between living spaces, community, and wellbeing that have helped guide redesigning existing and new urban landscapes to improve population health. Throughout NAPS 2019, I would be interested in what faculty and NAPsters would consider to be an appropriate way for pain researchers to interface with government officials, urban planners and architects, community organizers, spiritual leaders, and others to look into ways local and regional communities can integrate ideas from multiple fields to help improve pain management, with additional benefits to other health outcomes. This will be increasingly important as the population ages and larger, planned living spaces are developed.

Lastly, a historical and cross-cultural perspective of the general populace's view and experience of pain can help see whether other avenues of treatment are being missed. For example, during the Middle Ages in Europe, the view of death was different than it is now [14-15]. Death was ever-present and this has led to the claim that people back then were better able to cope with death than we are able to today. Great review articles have been written about the changing intellectual and scientific views on pain throughout the ages [16]. However, these should be complemented by more non-academic/clinical histories of evolving cultural perspectives on pain. In addition, more discussion in Western academic institutions should involve how non-Western cultures view, study, and experience pain. Cross-cultural perspectives have been studied before, such as the painful procedures women of the Dugum Dani tribe in New Guinea undergo that are considered natural and thus apparently do not cause as much suffering as might be assumed [17]. A discussion I had with a research scientist who had done acupuncture to reduce back pain highlights this point: they initially went in very skeptical and dismissive of the practice (there are many valid reasons for this [18]), but after experiencing it gained a new perspective, commenting on how their acupuncturist mentioned that in the East any pain during the procedure is not avoided, but embraced. These are only segments of a broader tapestry highlighting differing views of pain across space and time that may prove useful for devising new, holistic pain management strategies.

I am super excited to discuss these thoughts at NAPS 2019 and get perspectives on how we are and can better integrate spiritual, societal, and historical-cultural perspectives into pain research and management. I look forward to sharing the insightful discussions as a PRF-NAPS correspondent (keep updated @syscarut)! Montebello here we come!

References

1. Herbert, F., & Schoenherr, J. (1965). Dune.

2. Quiroga, R. Q., & Panzeri, S. (2009). Extracting information from neuronal populations: information theory and decoding approaches. Nature Reviews Neuroscience, 10(3), 173.

3. Corder, G., Ahanonu, B., Grewe, B. F., Wang, D., Schnitzer, M. J., & Scherrer, G. (2019). An amygdalar neural ensemble that encodes the unpleasantness of pain. Science, 363(6424), 276-281.

4. Mogil, J. (9 June 2019). North American Pain School 2019 Program. Retrieved 16 June 2019 from https://northamericanpainschool.com/wp-content/uploads/2019/06/NAPS_program_2019.pdf.

5. Weinstein, F., Kapenstein, T., Penn, E., & Richeimer, S. H. (2014). Spirituality assessment and interventions in pain medicine. Practical Pain Management, 14(5).

6. Siddall, P. J., Lovell, M., & MacLeod, R. (2015). Spirituality: what is its role in pain medicine?. Pain Medicine, 16(1), 51-60.

7. Dedeli, O., & Kaptan, G. (2013). Spirituality and religion in pain and pain management. Health psychology research, 1(3).

8. Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. https://doi.org/10.17226/13172.

9. Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological bulletin, 133(4), 581.

10. United Nations. (2018). 2018 revision of world urbanization prospects.

11. Cox, D. T., Hudson, H. L., Shanahan, D. F., Fuller, R. A., & Gaston, K. J. (2017). The rarity of direct experiences of nature in an urban population. Landscape and Urban Planning, 160, 79-84.

12. Jacobs, J. (1961). The Death and Life of Great American Cities. New York: Random House.

13. Southworth, M. (2005). Designing the walkable city. Journal of urban planning and development, 131(4), 246-257.

14. Historyextra. (7 October 2013). People in the Middle Ages coped better with death than we do. Retrieved 16 June 2019 from https://www.historyextra.com/period/medieval/people-in-the-middle-ages-coped-better-with-death-than-we-do/

15. Bovey, A. (30 April 2015). Death and the afterlife. Retrieved 16 June 2019 from https://www.bl.uk/the-middle-ages/articles/death-and-the-afterlife-how-dying-affected-the-living.

16. Perl, E. R. (2007). Ideas about pain, a historical view. Nature Reviews Neuroscience, 8(1), 71.

17. Free, M. M. (2002, April). Cross-cultural conceptions of pain and pain control. In Baylor University Medical Center Proceedings (Vol. 15, No. 2, pp. 143-145). Taylor & Francis.

18. Ingraham, P. (13 June 2018). Does Acupuncture Work for Pain? Retrieved 17 June 2019 from https://www.painscience.com/articles/acupuncture-for-pain.php.

Biafra Ahanonu, PhD | Postdoctoral Scholar, Stanford University, Stanford, CA, USA