Analgesic culture: can reframing pain make it go away?


We’ve all got a story about pain. Maybe it’s that time you broke your arm skating, or the time you finished the game on a twisted ankle, or the 10 hours of labour without an epidural. Maybe your story of pain is a story of violence, the injury and trauma of an assault. Maybe it’s a story of terror. Or it’s heartbreak, the seemingly endless depths of grief and despair after a loss. Whatever it is, (almost) all of us have experienced what we call pain and we’re not in a hurry to experience it again.

But have you ever tried to define that pain? When you’re telling the story, how do you explain the pain? Do you try to quantify the injury – how many broken bones, the size of the bruise, the amount of blood? Or do you describe the cause – the type of cancerous cells, the crowning baby, the sharp knife? But what if there was no obvious cause? And how do you communicate the intensity? Is it a searing or scalding burn, a throbbing or dull pressure, a pounding or stabbing headache? Is it worse than a bee sting, but not as bad as a dog bite?

When we say “pain”, we tend not to be specific, other than to say where it hurts (and even “where” can be hard to pinpoint). We say a root canal is painful, as is a cut finger, as is chemotherapy, as is arthritis, as is muscle ache, as is eating hot peppers, as is a broken heart, yet these experiences are wildly different from one another. Their single link is that we use this one astonishingly flexible but utterly insufficient word to describe them all. The more we question this, the more we are confronted by the fact that pain is complex, hard to describe and even harder to understand.

Pain is a big concept. It is constructed not only from anatomical structures and neurochemical phenomena, but also where we are, who we’re with, the reason we’re there, our previous experiences with pain, what we expect to feel and what we want. How we react in this moment and how we think about it in retrospect determine whether it will become part of the rush or the trauma. It is shaped by our genetic material, the physical environment in which we are born and raised, and our personal morals and values, which in turn are forged in and framed by the culture, religion and politics of our time.

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And right now, we are suffering from the symptoms of a socially dysfunctional relationship with pain. Pain is complex phenomenon, yet the way we treat it is not. We have more ways to pharmacologically manage pain, but opioids and over-the-counter analgesics often cause more problems than they solve. The increasing availability of ever more powerful drugs means that more and more, we expect to be pain-free. And when we aren’t, this has serious consequences for our health and happiness. The irony is that the more we try to suppress pain, the more we feel it.

It’s not just the drugs that promise to deliver this pain-free existence. Powerful forces – from big pharmaceutical companies to Instagram to the relentless narrative of consumerism – tell us that we can feel good, that we deserve to feel good and that we should feel good all the time.

In an article for the British Psychological Society blog, Christopher Eccleston, director of the Centre for Pain Research at the University of Bath, wrote: ‘The 21st-century world we live in can be characterised as an ‘analgesic culture’, one in which we work to avoid pain and distress. When the avoidance of pain fails our first thoughts are that any pain should be short-lived, diagnostically relevant, treatable and a cause for empathy, sympathy or social assistance.” When we experience pain that doesn’t meet that criteria, that pain hurts more; the flaw in our relationship with pain is based on our expectation that we shouldn’t have to suffer it.

In the 1980s, Harvard psychiatrist Arthur Barsky warned that America was becoming a nation more sensitive to pain and offered some convincing data to back up his claim. He noted that where community surveys from the 1920s found respondents had 0.82 episodes of serious illness a year, by the 1980s this had increased to 2.12 episodes. Even after accounting for increases in awareness and life expectancy, the differences were significant. Americans were objectively healthier, yet they said they felt worse. His argument – and he was not the first or last to make it – was that our tolerance for discomfort decreased as our expectation to be comfortable increased.

In our defence, this wasn’t an entirely unreasonable expectation – after all, during the 20th century, we developed treatments and vaccines for many acute and infectious illnesses, came up with new pharmacological ways to address pain, our life expectancy doubled, and the safety of our homes and workplaces increased. But as hard as pain is to define, it’s equally difficult to reduce completely – not even the strongest opioids can reliably do it. This mismatch between expectation and reality has darkened our perception of the pain we’re in and has made it feel worse.

More than 30 years later, the trends Barsky observed appear to have grown. In 2017, the US National Bureau of Economic Research, published an article analysing survey data from 2011. It showed that Americans reported aches and pains more often than any other nation. According to the survey, 34.1% of Americans reported feeling physical pain “often” or “very often”. Australia, at 31.7%, was closely followed by the UK, at 29.4%.

At the same time, the US spends more money on healthcare than any other nation, about $11,172 per person in 2018. But again, Americans say they feel worse. Speaking to The Atlantic about the data, Barsky suggested Americans assume all aches and pains can and should be treatable, and that it would therefore be intolerable to suffer them. “Curable pain is unbearable pain,” he told the magazine. ‘It’s when you think you shouldn’t have to suffer it, that there should be some solution out there, that it becomes even more intolerable.”

As we adjust our lives around avoidance and suppression, we internalise the message that we cannot handle pain. And when we limit our chances to get hurt, we fail to learn that we can get back up again. This has serious, demonstrable consequences for our ability to deal with both the physical and emotional pain that life will inevitably throw at us, and fuels a paradigm in which we don’t believe we have control over pain without the aid of drugs, surgery or medical intervention.

Our reliance on drugs and surgery is an unintended consequence of the incredible advances in medicine. The dominance of the biomedical model of the human body helped foster those advances, but it has left us with a big blind spot when it comes to understanding and managing pain. This model considers the human body as made up of constituent parts that can be assessed and repaired – just find the broken bit and fix it. Treating the human body like a car can be useful, but this ignores the role of emotion and cognitive processing in the generation and management of pain. It also means that many of us still think some kinds of pain are more “real” than others, and it’s the reason that when someone says “It’s all in your head”, it’s not typically meant kindly.

The invented divide between “emotional” and “physical” pain is the biggest misconception we need to unlearn. Our emotional states have a demonstrable impact on our physical state and vice versa

. The artificial division of mind and body also means potential pathways for easing pain have been ignored. For example, a 2013 study published in the journal Pain found that when the meaning of a painful experience was reframed from detrimental to beneficial, participants exhibited a much higher tolerance. But what was more interesting was the fact that this increased tolerance seemed to have been aided by the co-activation of the opioid and cannabinoid systems, our endogenous painkillers. How we think about painful experiences has measurable neurobiological effects that change how we feel pain.

In one example, swearing can lessen the perception of pain. Of course, as relieving as a well-timed expletive can be in the short term, we can’t swear our way to a better relationship with pain. That’s going to take a lot more work.

This is an edited extract from Ouch! Why Pain Hurts, and Why it Doesn’t Have To by Margee Kerr and Linda Rodriguez McRobbie, published by Bloomsbury Sigma at £18.99. To order a copy for £16.52 for to guardianbookshop.com



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