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Thread: The Politics of Pain

  1. #1

    The Politics of Pain

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    The founding father of pain medicine was John J. Bonica, an Italian-born American anesthesiologist whose intimacy with the topic stemmed in part from the 14 years he spent moonlighting as a professional wrestler.

    During World War II, Bonica was chief of anesthesia of an Army hospital filled with soldiers injured in the Pacific theater. The patients he saw theremany suffering from neurological disorders and post-amputation syndromes like phantom limbconvinced him that the medical understanding of pain was woefully inadequate.

    At the time, pain was understood solely as a symptom. To treat it, doctors thought, one need only treat the underlying illness. According to Marcia Meldrum, a UCLA historian of medicine, "Pain was somethingto doctorsthat could tell you where the disease was, and it was often thought of as an indication that the body was fighting disease."

    This understanding was fed by larger public attitudes about pain, says Meldrum. "There was wide cultural support for the idea that the endurance of pain was a virtue, both in the context of childbirth and in the context of disease."

    But in not taking pain seriously, Bonica argued, doctors were consigning their patients to undue suffering. They were also drastically oversimplifying the phenomenon itself. In fact, pain can outlive its original stimulus, so that curing the underlying disease doesn't bring any relief. In other cases, like phantom limb, the neurological system will just start broadcasting false pain signals, to excruciating effect.

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    Medically speaking, then, pain has come to be understood not as the character-building crucible of old but as a dangerous medical problem. As a result, doctors have started to look to stronger measures to treat itincluding so-called opioid analgesics like morphine and oxycodone (the active ingredient in Oxycontin). According to Portenoy, such drugs are "by far the most reliable and the most powerful analgesics available to humankind."

    While morphine was the wonder drug of the 1800s, for most of the 20th century doctors prescribed such drugs sparingly, partly out of addiction concerns and partly from fear of prosecution. In the three decades after the 1914 passage of the Harrison Act, the nation's first drug law, 25,000 doctors were arrested for prescribing opiates.
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  2. #2
    Thanks Raven, it is interesting how many pain docs gained the interest in war, like Mitchell. I think all who knew him loved John Bonica. For me he is St. John and he was better than anyone gives him credit for. He was a real doctor.

    lyHis epidural has probably done more good for mankind than anyone since Morton invented anesthesia. THere is, however, a caution in John's life in my opinion. It was his use of the stellate ganglion nerve block, which is now largely not done. If someone as smart and caring as Bonica can convince himself he is helping when he is not, then it is a lesson for every pain therapist. Docs must not be so caring and charming that the patient is too embarassed to confess that the pain was not better. This is rather common in pain medicine, I believe. I just finished reading a book by a neurosurgeon who called himself an opponent of Bonica because he did not believe peripheral input continued to be part of central pain and John did. Then, this neurosurgeon proceeds to say he thinks psychotherapy is the best thing for central pain, although he is honest enough to state that this is not based on any statistics. The neurosurgeon seemed to doubt Dejerine Roussy at some level because autopsies showed some patients with CP had lesions elsewhere in the brain than the thalamus. Of course, we all know from reading the posts that CP patients are different, NOT the same. This neurosurgeon also admitted that patients who had cordotomy for pain often developed a "dysesthetic burning" which he could not treat with opioids. He seems right about much but way off on other things. Even the intelligent ones seem able to miss the mark. That is why we need to speak out and be straight with our doctors, no matter how much we love them and dont' want to alienate them.. John may have been a little off the mark on ganglion blocks, but at least he never thought psychotherapy would cure central pain. Science is the process of disproving what was once accepted by most as true. Therefore it pays for all to be humble and not try to override the patient, which is what saying their pain is psychiatric is doing. I know that many claim pain who may or may not have it, and that this must be annoying to docs but the doctor should be able to recognize the true case from life style adjustments. I say this as someone who loved Dr. Bonica and who was immeasurably helped by him. I must still recognize that somehow he gained an opinion of ganglion blocks that is no longer accepted. We, and our docs continue to need something to measure pain.

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