How Our Culture's Thinking On Pain Has Changed Over The Last Five Decades

NPR's Invisibilia podcast is back for a fifth season. The first episode this season is about pain — and the changing way in which our culture thinks about and treats pain.

AUDIE CORNISH, HOST:

NPR's Invisibilia is back. It's a podcast that explores the invisible forces that shape our lives. And their first episode this season is about pain.

ARI SHAPIRO, HOST:

Over the last five decades, the way our culture thinks about and treats pain has changed dramatically. Today Invisibilia's Alix Spiegel tells us about a little-known event that helped propel that change.

ALIX SPIEGEL, BYLINE: There are parts of this story that you know well and parts you've never heard. The part that you know, have probably heard so much you're almost numb to it is the sad part where people all over the country are dying - casualties of the opioid epidemic.

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UNIDENTIFIED REPORTER #1: Snohomish County recently saw seven opioid overdose deaths in one weekend alone.

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UNIDENTIFIED REPORTER #2: And here in the Sioux Falls area alone, 13 people have died of overdoses.

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UNIDENTIFIED REPORTER #3: Staten Island has seen more than two dozen overdoses in just the past three weeks.

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UNIDENTIFIED REPORTER #4: Seventy deaths in Cuyahoga County...

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UNIDENTIFIED REPORTER #5: With more than 2,000 overdoses expected by year's end...

SPIEGEL: Of course many different factors contributed to this terrible epidemic - aggressive drug companies, pill mills run by unethical doctors. But in the medical community, there are people who make the argument that the opioid epidemic could not have happened if starting in 1995 the medical profession had not been taught to think about and respond to pain in this new and radically different way...

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SPIEGEL: ...Which brings me to a man named James Campbell and the insanely clever idea he had in the shower one day.

JAMES CAMPBELL: I don't recall one lecture about the field of pain in my medical school. Pain was off-topic.

SPIEGEL: James Campbell, the gifted son of a Midwestern electrician, went to medical school in the 1970s when pain was seen as almost irrelevant to the task of being a doctor. Pain was seen as a symptom, not an actual disease or injury. So doctors didn't feel like there was a pressing need to address it. But Dr. Campbell felt this attitude towards pain was wrong. In his practice, he would see patients so crippled by back pain they were unable to leave their house to make a living, cancer patients so shrunken in agony they were unable to engage with their families. And it really bothered him. Why wouldn't they take it more seriously?

KEITH WAILOO: There is a history of regarding pain as predictable and expected as part of life.

SPIEGEL: This is a medical historian from Princeton named Keith Wailoo, and he says this idea that pain was normal started falling out of fashion in the '50s and '60s. See; there was serious political change, the civil rights movement and women's lib, a small but growing sense that society needed to think more seriously about all kinds of experiences that it never took seriously before. So the idea that pain was something to acknowledge, explore and actively address was growing. The problem was that traditionally medicine only focused on things it could measure like blood pressure or temperature. For doctors, if you couldn't measure it, how did you know that it was real?

WAILOO: So it's in this time period that you have the invention of that questionnaire that we all have probably heard at some point. On a scale of 1 to 10, 10 being the worst pain that you've ever had, how would you rate your pain right now?

SPIEGEL: With this simple questionnaire, pain suddenly became a thing that you could count like white blood cells. But even the pain scale didn't do a ton to improve the treatment or status of pain in the medical world.

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SPIEGEL: Then one day in 1995, James Campbell stepped into his bathroom.

CAMPBELL: I think literally I was in the shower on a Sunday morning, and the idea of pain, the fifth vital sign, popped into my head.

SPIEGEL: Pain, the fifth vital sign. Vital signs are the rock stars of the medical world. They're the critical measures that everyone agrees deserves star treatment because they're essential to life. And until the morning James Campbell stepped into his shower, for hundreds of years, there had only been four.

CAMPBELL: Blood pressure and then pulse, temperature and breathing.

SPIEGEL: So if Dr. Campbell could get pain established as the fifth vital sign, pain would go from being a D-list celebrity to basically Beyonce.

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SPIEGEL: The only potential problem with this plan is that pain is not, at least usually, an indication that there is something critically wrong, and Dr. Campbell knew it.

CAMPBELL: Well, strictly speaking, pain wouldn't be a vital sign because a vital sign would be a manifestation of the physiological functioning of the body that's vital to life. So it's vital in the sense of being associated with being alive.

SPIEGEL: But Dr. Campbell still thought elevating the status of pain would do more good than harm. And since in 1995 he was president of a medical organization called the American Pain Society, he used his presidential address to launch a campaign. And the idea caught fire. Over the next few years, lots of groups made pain a priority. For example, the Veterans Health Administration put out a toolkit which taught doctors and nurses exactly how to treat pain as the fifth vital sign.

CAMPBELL: Yeah, it was really amazing 'cause it transformed medicine.

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SPIEGEL: But not in a purely positive way. Some people now argue that these actions and the way that they taught doctors and patients to see pain as a critical problem to be solved led ultimately to the opioid epidemic. After all, when doctors are expected to ask about pain, it's hard not to give pain medications if a patient reports a high score. And several drug companies that made pain pills were quietly funding these initiatives.

In fact, Dr. Campbell set up a pain awareness group that got a decade of financial backing from Purdue Pharma, the maker of OxyContin. In congressional hearings on the opioid crisis, Dr. Campbell called that support generous. But the group's chief executive added that funders do not influence its work.

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SPIEGEL: What is beyond debate, however, is that elevating pain to a vital sign meant that pain got a lot more attention than it ever had before, and that bothers some in the medical world.

DAVID SHERRY: This whole pain thing has just become a juggernaut that has been hard to stop because now it's the fifth vital sign.

SPIEGEL: This is Dr. David Sherry, a pain specialist at Children's Hospital in Philadelphia. And he told me that from his perspective, recasting pain as a vital sign fundamentally changed the way both doctors and patients think about and therefore respond to pain. He believes patients have become counterproductively conscious of pain and doctors counterproductively ready to treat it.

SHERRY: How's your pain? How's your pain? How's your pain? So we're focusing on your pain all the time. And if they have no pain, you still have to be asked, and they have to say zero.

SPIEGEL: This makes no sense to David Sherry. He thinks it would be healthier for everybody to move more towards the old way we saw pain - as a difficult but predictable and expected part of life.

SHERRY: I think it is the lot of all mankind to - and womankind - to suffer. I think that that's just part of being human. I think there's some suffering that people just need to live through.

SPIEGEL: Alix Spiegel, NPR.

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