EDITORIAL

Why We Need Narratives of Healing andQualitative Pain Research

Every practitioner of pain medicine knows the complexi-ties of treating chronic pain. Quantitative research helpsprovide answers to biomedical questions, and we havegood validated psychometric measures for quantitatingpsychosocial dimensions, but these fall far short of illumi-nating the full dimensions of the pain experience. Thecomplex psychosocial contributions for understandingpain’s pathology and the therapeutic effects of varioustreatments cannot be underestimated. These elements ofhuman pain are subjective and “qualitative.” Yet the field ofqualitative research is nascent, challenging to conductand controversial in its interpretation. Ever mindful of thechallenges, Zheng and colleagues, within this issue,present us with “Chaos to Hope: A Narrative of Healing,”a fascinating account of the journeys experienced bypeople in chronic non-cancer pain and, in particular, theeffect, for good or ill, of taking opioids to relieve that pain[1]. It is a valiant effort.

The pain narratives are insightful and probably generaliz-able. They are also troubling because they suggest to uswhat we may be doing wrong. The authors describe thehuman effects of real-world pain that go beyond a painintensity or other traditional quantitative assessment. Anoverriding theme is the need to be supported, believed,and not alone. Man is a social species, and we live andthrive for community. When ill, it is the community that welook toward for physical and emotional context andrestoration. Places of worship have served this role formillennia, but so have families, friends, and other commu-nities. A person in pain needs and deserves this supportfrom the professional health care community.

A reasonable hypothesis is that connectedness is a keyelement of the primordial biological process. Zheng andcolleagues define this connectedness as dependent onthree key relationships: person in pain, and his or hersociety; person in pain and provider; and primary providerand the expert provider community.

It seems that in addition to the need to be believed, asense of hope is essential for healing. Our “cure it” and “fixit” culture both inside and outside the medical communityfails people in pain because the pain experience is morethan a transaction of neurotransmitters with action poten-tials to be blocked or modulated, and cure is very rare (atleast in chronic pain). Life’s experiences, aspirations, andemotional needs are essential considerations to treatingthe whole person. People with pain must feel cared for

and loved. These are integral components of healing incontrast with being fixed like a flat tire.

Our current health care system is the antithesis of one thatlends itself easily to healing and caring for people in pain.This is manifest, for instance, in the regulatory expecta-tions of opioid agreements, mandatory urine drug testing,and prescription database monitoring, which—while yield-ing important safeguards, data for effective managementof adverse events, and some quantitative information—reflect regulating care rather than giving care. In such aforensic and strictly mandated environment, healing isunlikely, and healers are reduced to policemen and tech-nicians. The person in pain often feels empty, alone, andhopeless, even paranoid and left with suicidal ideationsas Zheng et al. discuss. Quantitative measures cannotyield the same type or quality of information told to us inthese stories.

As would-be healers, not mere technicians, we mustgrapple with the tough issues. The Centers for DiseaseControl and Prevention reports an epidemic of opioidmisuse and mortality [2], while the Institute of Medicinereports an epidemic of pain [3]. How can control measuresaimed at these two epidemics be reconciled? Perhapsanother very real epidemic consists of loneliness, despair,isolation, and alienation.

More than 15 years ago, Rachel Naomi Remen, MD,suggested something similar in her pioneering work,“Kitchen Table Wisdom,” suggesting that physicians takea more natural and humanistic therapeutic approach tosuffering, born from her experience of caring for peopledying from cancer [4]. In the book’s foreword, DeanOrnish, MD, president and founder of the non-profit Pre-ventive Medicine Research Institute in Sausalito, CA, USA,beautifully described the value of the qualitative elementsof healing:

“When our hearts begin to open, we are able to feel it, likeopening the window shade and letting in the sunshinethat’s been there all along, waiting patiently to be allowedinside” [4].

Just as music evokes an emotion based on an individual’slife experience, the same can be said of the effect of painon the individual. The sound from bowing a violin, pickinga harp, or manually changing the volume and velocity of airthrough a wind instrument can be explained by math-

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ematics, but the experience of receiving the sound isprocessed in areas of the brain where it will be qualitativelyanalyzed and valued. The quintessential qualitative role ofa minstrel is to produce an emotive experience. Similarly,the qualitative end goal of practicing pain medicine isto heal.

As clinicians and researchers, we need to re-examine ourapproach to healing. A health care system that forcesphysicians to judge and police their patients’ behaviorwhen prescribing opioids for pain may be actually contrib-uting to their illness rather than healing them. In someinstances, the only real thing a clinician can do for apatient is to give them hope by treating the whole person,not just the physical body.

Stories of people who struggle with pain and the chal-lenges of opioid therapy remind us that it is not the instru-ments of our profession or even how we play them thatmatters but how they are received.

LYNN R. WEBSTER, MDPresident, American Academy of Pain Medicine

Medical Director, CRI LifetreeSalt Lake City, Utah, USA

R. NORMAN HARDEN, MDDepartment of Physical Medicine and Rehabilitation

Rehabilitation Institute of ChicagoChicago, Illinois, USA

References1 Zheng Z, Paterson C, Ledgerwood K, et al. Chaos to

hope: A narrative of healing. Pain Med 2013;14(12):1826–38.

2 Office of National Drug Control Policy. Epidemic:Responding to America’s prescription drug abusecrisis. Available at: http://www.whitehouse.gov/sites/default/files/ondcp/issues-content/prescription-drugs/rx_abuse_plan_0.pdf (Accessed August 2013)Released 2011.

3 Institute of Medicine of the National Academies. Reliev-ing pain in America: A blueprint for transforming pre-vention, care, education, and research [report brief].June 2011. Sponsored by the National Institutes ofHealth. Washington, DC; Revised March 2012.

4 Remen RN. Kitchen Table Wisdom 10th Anniversary.1996. New York, NY: Penguin Group (USA) Inc. 2006.

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