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Alaina Woodford

Week 2 thought piece:

For me, the most interesting part of the reading History of Pain

Concepts and Theories was the constant evolution of pain theories.

The question, where do we feel pain? brings a lot of humanity to

even our most distant ancient ancestors. Hearts were long considered

the center of sensation, and we still today instinctively say that our

hearts hurt, or are broken. Despite our new knowledge, we dont say

that our brains hurt when were sad. I feel this contributes to our

evolving notions of where is pain? Pain cant be at the location of the

pain itself, or phantom limb pain wouldnt exist. Therefore, it has to be

made up in the brain, right? So why do our brains locate pain where

they do? Do we only feel our heart hurt because we have a cultural

concept of hearts as feeling centers? What if we thought our livers

were our emotional centerswould we feel pain there instead?

Week 3 thought piece:

I get the feeling my mind is going to be blown a lot in this class,

because so far, its being blown by concepts alone, much less specific

awesome details. While reading the Central Pain piece by Boivie, I

read that central pain can often be associated with different quality of

pain, and I had to stop reading because I had so many thoughts. What
causes pain to feel like tearing or burning, compression or expansion?

Are there different types of pain signals? And if pain is chronic, and the

cause cant be found, something has gone wrong not only in sending a

pain signal at all, but likely a specific pain signalsharp or dull, throb

or staband why was that particular signal sent?

Week 4 thought piece:

In addition to quality of pain, I found the readings on intensity of

pain to be very engaging to me. This is because I have my own history

of chronic pain, and reading about its symptoms is like hearing your

own story from somebody else. One quote in particular struck me:

[E]ven if the pain is of low or moderate intensity, patients assess the

pain as severe because it causes much suffering due to its irritating

character and constant presence. It explains so muchmy personal

ability to measure pain was useless with chronic pain, because

something mildly irritating became intensely frustrating depending not

on the pain intensity, but the amount of time Id had to deal with it.

Week 5 thought piece:

Im interested in the shift away from paternalistic physicians

decision-making on behalf of the patient. The cooperative relationship

described in Ballantyne & Fleischers paper certainly seems more

moderate and agreeable than either extreme. And the fascinating


question posed by the same authorswhether prescribing opioids to

drive up patient satisfaction metrics is justifiedcould put

philosophers in a tizzy for years (and probably already has). The

seeming medical agreement that it is better for a person to live with

pain than drug addiction is morally debatable, to say the least. For

example, how debilitating would the pain have to be to outweigh the

patients family history of drug addiction? And how much depends on

the patients ability to work uncompromised by pain? For example, a

two-parent family may be able to function with one disabled parent,

whereas a single mother suffering from the same debilitating pain may

not have another way to provide for her children, and may therefore

more urgently need palliation for her pain.

I understand but disagree with the assumption that because the

clinician doesnt suffer from pain, they are better- or more logically-

equipped to make the decision about whether their patient should

receive opioids. I think the all-encompassing nature of pain cannot be

spoken to by someone who is not experiencing that pain. The biological

urgency to relieve the pain by any means is, as my computer

programmer father would say, a feature, not a bug. That is, the total

overriding of all other factors in favor of pain relief may not be a fault

in logic at all, and especially not one worth handing the decision over

to an unbiased other party. In this case, the bias of excruciating pain

might be absolutely crucial to making a decision that affects ones


ability to cope with that pain. Is it simply out of the question that

someone could logically choose drug addiction over life with chronic

pain?

Week 7 thought piece:

Im particularly fascinated by socioeconomic factors and their

effects on pain and suffering. As such, the Men, masculinity, and pain

article was interesting to me, especially considering the surprisingly

little amount of research that has been done on the topic. I feel its

worth noting that throughout history, practically every attempt to

define or encompass humanity and nearly every research-based

approach to anything has been modeled on males alone. So

technically, while specific research may not have been done on men

and pain, Im willing to bet that the overwhelming majority of research

has in fact been conducted on men alone, as men are generally

considered the default choice, and women were historically assumed

to be close enough to benefit from male-oriented research.

Week 8 thought piece:

I chose to read Reynolds Prices A Whole New Life: An Illness and

a Healing. I found it beautiful and insightful to the world of pain (and

Im more than a little interested in picking up more of his books after

this).
The form of chronic pain I suffered from varied significantly from

Prices, making his story nearly as fresh as a first-time journey into

chronic pain. For instance, his chronic pain frequently topped the

charts in intensity, receiving adjectives like howling, noisy, and

glaring. My pain, to contrast, was low in intensity but relentless,

leading to constant irritation, plummeting patience, and fits of

frustration. From my personal experience with both acute and chronic

pain, it is the high-level blinding pain that you have no choice but to

accept. In my opinion (arguably supported by Prices book), the purely

disabling nature of high-level pain leads to an up-front surrendering of

ones personal dignity and hopes for a life lived in pursuit of something

other than survival; abandon all hope, ye who enter here. Your focus

isnt being split, because you can do nothing else but stare down the

hard pain or search for relief in sleep. On the other hand, in my own

lower-level chronic pain, I retained enough of my consciousness and

pride to resent the constant assault on my dignity. I had enough of my

former life left that it was slowly and repeatedly stolen away, rather

than swept off all at once.

I was surprised by the comparatively little amount of time Price

spends dwelling on or attempting to describe the pain he experienced.

I suppose theres only so many ways to say completely and totally

debilitating pain, as blinding and awful as it comes. When Price says

that his pain, frequently rated a 9 or 10 on the pain scale, surpasses


the scale altogether and becomes an unbearable 12, I guess thats all

that really needs to be saidtheres not much more than can be laid

out to get a reader to understand that pain if they havent experienced

it themselves.

Fittingly, however, much of his descriptions of pain seemed to

concentrate on what activities he could or could not do as a result of

that pain. Dr. Loeser and Dr. Tauben both emphasized their strategy to

concentrate on the patients ability to perform certain tasks, rather

than on the patients perceived level of pain, as a marker of their

progress. Perhaps instinctively, Price chose the same marker,

describing good days as a certain number of leg lifts, and bad days as

the inability to sit up, roll over on his own, or even lift his head. This,

perhaps, gives us a much deeper insight into a disabled life than any

descriptions of glaring pain could. After all, many of us believe we

know high levels of pain; but far fewer, I believe, have experienced a

life without the ability to move their head of their own volition. This

serves as a concrete marker of the disabling nature of pain, the kind

that expands our own vision of a pain scale from our own vivid life

experiences to replicable and (more) objective standards.

Final paper excerpts:

Alaina Woodford

Chronic pain comorbidities


6/5/16

Chronic pain has many associated comorbidities, or co-occurring

conditions; the specific number varies depending on which doctor you

ask. When visiting our class, Dr. David Tauben named thirteen mostly

physical comorbidities, but I wish to deal with the psychosocial

comorbidities in particular. An article by Davis et al. named SPADE

(sleep disorders, pain, anxiety, depression, and low energy) as the

most prevalent and co-occurring symptoms (388) to be found, and so

those are the conditions Ill be examining today. Any patient with

chronic pain is likely to experience at least one of the comorbidities,

and patients with one of the comorbid conditions are more likely to

develop chronic pain than the general population. Ill be exploring the

link between chronic pain and these four most common comorbidities

in this paper.

Ill begin by showcasing evidence of the quadrangular link

between anxiety, depression, sleep disorders, and low energy. Much of

the association between these four conditions can be construed

through mere common sense, so I will start by parsing out the links on

my own, and then confirming my postulations with statistics and

medical studies.

Firstly, anxiety and depression are known to be highly co-

occurring; anecdotally, I have nearly a dozen friends diagnosed with


both, and zero with only one. The two conditions have several key

symptoms in common, such as a lack of ability to exert control over

ones negative-tending thoughts. Indeed, anxiety and depression make

up two of the most common co-occurring psychiatric conditions: the

SPADE study mentioned above found their co-occurrence to be

somewhere between 75% and 90%.

Low energy is part and parcel with depression; it makes up one

of the latters primary, and perhaps most well-known, symptoms.

Anxiety can also contribute to low energy, as panic attacks or constant

general worrying can leave a patient worn out, with little energy left for

anything else. Anxiety contributes to sleep disorders by making restful

sleep difficult to achieve; racing thoughts and persistent worrying can

keep one from feeling peaceful or safe enough to fall asleep. And

issues with sleep can drain a patients usual reserve of energy, leaving

them fatigued. Low energy can interfere in turn with sleep cycles,

causing a patient to throw off their circadian rhythms by napping

during the day and subsequently getting less restful sleep that night.

Depression, too, can interfere with sleep cycles, as patients may

oversleep to escape the numbness they feel while awake, caused by

their lack of executive function and disinterest in regular activities.

Additionally, depression may also contribute to decreased sleep. The

depression-induced diminished care for ones own future can cause a

patient to purposefully eschew sleep that they need to rest and


function well the next day, as they cannot summon the energy or

executive function needed to take better care of themselves.

Having thoroughly demonstrated the link between these four

psychosocial conditions, I will next address the link between each of

these conditions, separately and jointly, with chronic pain, higher pain

intensity, and hypersensitivity to stimuli. Woolf defines chronic pain as

representing an uncoupling of the clear stimulus response relationship

that defines nociceptive pain. In other words, nociceptive pain

responds directly and appropriately to a noxious stimulus, while

chronic pain has no clear cause-and-effect relationship. This means

that the underlying cause of chronic pain and its comorbidities could

be the same, which would explain their high rate of co-occurrence.

While determining an underlying cause of chronic pain is not the

purpose of this paper, it will be useful to keep in mind as we inspect

the link between chronic pain and its accompanying comorbidities.

The persistent link between chronic pain and its comorbidities

has overwhelming evidence. A scientific article published in SPINE

studied over 100,000 patients with chronic low back pain (CLBP) and

the same number of controls without chronic pain. Psychological

conditions like depression, anxiety, and sleep disorders were found to

be 2.3-, 2.5-, and 3.2-fold higher, respectively (Gore E670) than they

were in the control group. A different study by McBeth and Jones

implicatedstress, anxiety, and depression and coping methods as


important contributing factors to CLBP (McBeth 418). And a study by

Dominick et al. found that patients with two or more physical chronic

pain comorbidities (such as migraines or IBS) had between a 30% and

70% chance of developing anxiety or depression.

Psychosocial conditions like our four studied are more likely to

flare up at a high-stress period in life. For our purposes, chronic pain is

that period: a high-stress and overwhelming change, likely to throw the

patients emotional and psychological state into a rollercoaster.

Depression, anxiety, low energy, and sleep disorders can all result from

this large and negative life change. Several of these symptoms are

evident in Reynolds Prices book, A Whole New Life: An Illness and a

Healing, in which the author recalls the emotional turbulence of his

adjustment to life with chronic pain. Price showed signs of all four

comorbidities; he had low energy and difficulty sleeping, both due to

his chronic pain, and demonstrated depressive symptoms such as

sudden disinterest in socializing and his previous favorite pastimes. A

study by Cyders et al. on somatosensory symptoms found a significant

correlation linking depression with increased pain disability and

severity, which matches Prices experience of extreme pain and

impairment.

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