In The Politics of Pain Medicine: A Rhetorical-Ontological Inquiry, S. Scott Graham offers a rich and detailed exploration of the medical rhetoric surrounding pain medicine. Graham chronicles the work of interdisciplinary pain management specialists to found a new science of pain and a new approach to pain medicine grounded in a more comprehensive biospychosocial model. His insightful analysis demonstrates how these materials ultimately shape the healthcare community’s understanding of what pain medicine is, how the medicine should be practiced and regulated, and how practitioner-patient relationships are best managed. It is a fascinating, novel examination of one of the most vexing issues in contemporary medicine.
© 2015 The University of Chicago Press
Special thanks to The University of Chicago Press for allowing me to publish this excerpt from the book here.
At ten feet high and four feet square, artist Mark Collen’s Hey Doc, Have You Figured It Out Yet? suggests a nearly insolvable puzzle. Beyond its impressive size, the work includes a dizzying array of complex medical images including X-rays, sonograms, and CT scans. These images are repeated around the circumference of five different, yet connected cylinders that offer the promise, but not the realization, of alignment. Read against the above epigraph (the artist’s statement), the “frustration” is palpable, the repetition monotonous. Constructed in a style reminiscent of a “cryptex,” this sculpture represents the extreme difficulty confronted both by clinicians who study pain and patients who seek relief. The very idea of a cryptex was invented by Dan Brown for his internationally best- selling The Da Vinci Code. An amalgam of cryptology, the study and practice of hiding information, and codex, a bound collection of scrolls (information), a cryptex is a secret store of information that can only be accessed through careful and diligent code breaking. In Brown’s narrative, Robert Langdon (professor of symbology and Da Vinci Code protagonist) must use all his intellectual acumen to break the cryptex’s code and retrieve the hidden information— all while avoiding (and sometimes confronting) a complex array of agendas stemming from secret organizations and powerful institutions.
With this in mind, the cryptex is a remarkably apropos metaphor for the plight of not only the pain patient but also the pain clinician. Pain is a greatly vexing constellation of phenomena for contemporary medicine. In many cases, the causes are unknown; in others, the causes are manifold. Furthermore, treatment options are often a veritable nightmare of multidisciplinary multiplicity. The education and training of physicians tells them that the secrets they seek lie in the code of the human body. In medical school, residency, and state- required continuing medical education, they have learned that, eventually, science will prevail. It will crack any code. It will solve any puzzle, if only through continued scrutiny and the agency of ever more sophisticated technologies. Yet at the same time, the question of pain persists. Recognizing this dilemma, clinicians over the past century have published numerous works on pain with suggestive titles like The Mystery of Pain (Hinton, 1914), The Puzzle of Pain (Melzack, 1973), The Challenge of Pain (Melzack & Wall, 1982), and “The Complexity of Pain” (Stevens, 1999). These titles are but a few of the thousands of theoretical treatises, research studies, and clinical trials that have addressed the mysteries of pain. And, certainly, researchers and clinicians studying pain have made great strides throughout medical history. Nevertheless, the cryptex that contains the secrets of pain remains largely unsolved. Clinicians who treat pain routinely grapple with challenging philosophical issues that go to the core of Western science while working in a highly regulated environment. Pain defies modernist categorization.
Indeed, pain’s challenge to modernity has been well recognized in social scientific and humanistic studies of health and medicine. Cultural theorist David B. Morris (1991), sociologists Gillian Bendelow and Simon Williams (1995), and historian Roselyn Rey (1993) have each identified a strong tension among various conceptions of pain. Specifically, they note how latent Cartesian dualism underscoring disciplinary paradigms has resulted in individual health- care practitioners who have either a physiological or a psychological understanding of pain. Morris’s work here is especially informative. It is not only representative of the general thrust of the explosion of nonclinical pain scholarship in the early 1990s; it is also widely considered the authoritative work on the topic. Indeed, as of this writing, The Culture of Pain boasts over 600 citations indexed on Google Scholar. Morris’s book is noteworthy for identifying what he dubs “the myth of two pains”:
Modern culture rests upon an underlying belief so strong that it grips us with the force of a founding myth. Call it the Myth of Two Pains. We live in an era when many people believe— as a basic, unexamined foundation of thought—that pain comes divided into separate types: physical and mental. These two types of pain, so the myth goes, are as different as land and sea. You feel physical pain if your arm breaks, and you feel mental pain if your heart breaks. Between these two different events we seem to imagine a gulf so wide and deep that it might as well be filled by a sea that is impossible to navigate. (p. 9)
Morris’s analysis is a thoughtful and thoroughgoing enactment of postmodern cultural criticism. It keenly examines how medical science, clinical practice, and the larger cultural formations that surrounded them in the late 1980s and early 1990s replicate the binaries of modernity, specifically the mind/body dichotomy. And while this was superb scholarship for its time, medicine and cultural studies have both come a long way since 1991.
Contemporary pain medicine is no longer binary; it has become multiple. Research and clinical practice in pain management exists at a nexus of massive multidisciplinarity with treatment options from at least twenty different medical subspecialties ranging from neurology and rheumatology to psychology and physical therapy. Furthermore, pain scientists and physicians had begun to recognize, even before Morris, Bendelow and Williams, and Rey were writing, the pernicious effects of Cartesian dualisms in pain science. Indeed, as psychological researchers John C. Liebeskind and Linda A. Paul note in Annual Review of Psychology in 1977:
While it is often useful to distinguish between various aspects of pain experience [e.g. “sensory discriminative” versus “motivational- affective” components], other dichotomous terms used in an attempt to specify the origin of pain (“physiological” verses “psychological,” “organic” versus “functional”) connote a Cartesian dualism and should have been discarded long ago. The use of such terms promotes an unfortunate division of pain patients into those seen to have “real” versus those seen to have “imagined” pain and may lead to inappropriate or insufficient treatment offered to the latter. (p. 42)
Since this time, pain medicine has seen the emergence of a wide variety of groups of clinicians working at local, national, and international levels who are dedicated to a nonbinary, nonreductive approach to solving the pain cryptex. Would- be agentive organizations of pain management clinicians have been striving to change the way practitioners think about and treat pain. I would argue that this coalition of groups is working to foster what Bruno Latour (1991) has famously called a “nonmodern” science— that is, one that rejects and bridges the mind/body duality. Certainly, the most popular term for the new and integrated approach to pain highlights its efforts at nonmodernity: the biopsychosocial model. Indeed, the multiple resonances between the biopsychosocial model and Latourian notions of nonmodernity are so strong that it is worth quoting at length from the opening pages of one of the founding works of biopsychosocial theory, McDaniel, Hepworth and Doherty’s (1992) Medical Family Therapy:
Once upon a time, when the problems people brought to a therapist’s office could be neatly divided into psychosocial and physical domains, many therapists persuaded themselves that they dealt only with the psychosocial part of life. These therapists did not pursue an understanding of the place of medical illness in the patient’s personal and family life because physical health problems were the province of other professionals. Patients with medical problems many have received compassion and support from these therapists but not comprehensive therapy. And few therapists actively collaborated with physicians and other health professionals in the treatment of patients. It is as if patients and families checked their bodies at the door of the therapist’s office. The days of innocence are over. We now know that human life is a seamless cloth spun from biological, psychological, social, and cultural threads; that patients and families come with bodies as well as minds, feelings, interaction patterns, and belief systems; that there are no biological problems without psychosocial implications, and no psychosocial problems without biological implications. Like it or not, therapists are dealing with biological problems, and physicians are dealing with psychosocial problems. The only choice is whether to do integrated treatment well or do it poorly. (pp. 1– 2, emphasis added).
While the biopsychosocial model was something of a flash in the pan for its intended audience of mainstream psychiatrists, it has increasingly become a cornerstone of cross- disciplinary approaches to pain. Advocates of this nonmodern approach have been actively working to transform the multidisciplinary nexus of pain science in accordance with the biopsychosocial model. In establishing this new and nonreductive approach, these practitioners hope to usher in a new era of multidisciplinarity that would result in more effective and holistic treatment for those in pain. Given these changes in th scientific and clinical landscape, a fresh exploration of pain is certainly warranted.
Subsequently, The Politics of Pain Medicine chronicles my exploration of various efforts to calibrate the wide variety of disciplinary practices that, when taken as a whole, authorize a biopsychosocial approach to pain. “Calibration” is philosopher Annmarie Mol’s (2002) term for efforts to integrate conflicting approaches to medical care. My exploration of multidisciplinary pain medicine will focus on the calibrating efforts at local, disciplinary, and federal levels, exploring along the way the Midwest Pain Group (MPG), the American Academy of Pain Management (AAPM), and the International Association for the Study of Pain (IASP), the disciplines of pathology, radiology, and diagnostics, as well as the Food and Drug Administration (FDA) and their interfaces with and situation within medical disciplines and regulatory bodies. The MPG was a collaborative educational initiative, advocacy effort, and referral network for clinicians from more than twenty different disciplines and subspecialties in a midsize Midwestern city. What began as a multidisciplinary journal club evolved quickly into a series of interdependent efforts by more than one hundred members to transform the way pain management was practiced in the region and the state. The AAPM is the premier national organization for multidisciplinary pain management. It offers credentialing, educational, and advocacy efforts nationally in the United States. The IASP is, as the name suggests, the largest and most well-known international organization of multidisciplinary pain specialists. It too provides credentialing, educational, and advocacy services, but on the world stage. Much of the first half The Politics of Pain Medicine is focused on the MPG. Yet this exploration necessarily extends beyond the MPG and into the territories of the AAPM, the IASP, medical disciplines, and federal regulatory agencies.
Efforts to calibrate the many forms of scientific and clinical practice needed to authorize a biopsychosocial approach to pain are nothing if not ambitions. In fact, many members of the MPG, AAPM, and the IASP hope that their efforts will help pave the way for a new approach to medicine in general. Indeed as one interview subject from the MPG argued, “My honest opinion is that we are not going to solve the problem [of pain], or many of the problems in health care, until we get a new model of the mind- body connection. . . . I think somebody’s going to put it together. They could be the Freud of the new, of the current, age” (Landau, ethnographic interview). Finding the Freud of the new era and fostering a change of this magnitude will be no easy task. As the subsequent chapters will elucidate, this process is vexed by challenges that (1) lie at the very core of scientific legitimacy, (2) threaten the reimbursement mechanisms of medical subspecialties, and (3) may destabilize the power structures of Western medicine. In establishing a new approach to pain, clinicians, educators, researchers, and regulators must address these difficulties. They must first overcome strong multidisciplinary conflict. Secondly, they must also foster substantive change in pain theory. And finally, the MPG, the AAPM, and the IASP must refashion the economic and regulatory structures of Western medicine so as to support the new model. Obviously, overcoming disciplinary conflict and fostering revolutionary change are no easy tasks. Neither is establishing socioeconomic and/or regulatory change. Nevertheless, these are the tasks the subjects of my research have embraced, and these are the processes The Politics of Pain Medicine explores.
As I suggested briefly above, recent evolutions in the theoretical and methodological approaches of rhetorical and cultural studies of science and medicine also contribute to my argument that now is the ideal time to revisit pain. As the second half of this book’s title— A Rhetorical- Ontological Inquiry suggests, this project allies itself with recent developments in rhetoric, technical communication, and science and technology studies (STS) that aim to place the material and the ontological at the center of inquiry. In the same way that pain science and medicine is working to transcend the binaries of modernity, critical scholars of science and medicine are working through new approaches to inquiry. These new approaches recognize that the binaries of modernity were not so much overcome as reified in postmodern inquiry (Latour, 1993; Mol, 2002; Pickering, 2010; Coole and Frost, 2010). Subsequently, The Politics of Pain Medicine aims to capitalize on this newfound potential for productive synergy between pain science’s biopsychosocial model and rhetoric and STS’s turn toward new materialisms. The goal, here, is to be mutually informative. A rhetorical- ontological study of pain will not only help us better understand contemporary practices of pain science and medicine; it will also contribute to the refinement of our own methods and theories. Indeed, I further hope the results of this inquiry will contribute to a better understanding of pain’s clinical and regulatory landscape for those who participate in that landscape on a daily basis.
In order to frame my exploration, this introduction must outline my theoretical and methodological approach to the study of pain science: what is a rhetorical- ontological inquiry? While rhetoric of science has a lengthy pedigree with a long focus on effective argumentation strategies in scientific discourse, I use the term “rhetorical- ontological inquiry” as part of an intentional effort to ally my approach much more closely with multidisciplinary STS and its concomitant focus on sociocultural and material issues of science and technology. Therefore, this book is as much an exploration of how to conduct a rhetorical-ontological study as it is an exploration of pain medicine. The isolated disciplinary conversations of rhetorical studies and STS have, indeed, made strikingly similar arguments and are thus ripe for hybridization. But how to demonstrate that to my readers? For better or worse, there is no other option than to rehearse the various arguments as a part of my analysis. Doing so is an act of calibration that mirrors the calibrations of the pain management communities. However, in so doing, I run the risk of treading through what for some readers might be overly familiar territory. However, what counts as familiar territory for scholars of rhetoric and technical communication may be entirely novel for my readers from STS, and vice versa. Subsequently, I have endeavored to clearly identify the origin and scope of each discussion of the more isolated disciplinary conversations. To the extent that any particular section is overly familiar to you, I invite you to skim or skip over it and proceed to the subsequent analysis.