Asking the Right Questions on Pain

In the quest to suppress pain, are we blocking our body’s own ability to heal? That’s one of the key questions explored at recent scientific meetings, including the International Association for the Study of Pain (IASP) World Congress on Pain, which I attended in September, and the Interagency Pain Research Coordinating Committee (IPRCC) meeting a few weeks ago, where I serve as chair. 

While the discussions at both meetings were wide ranging, the conversations on the relationship between pain and healing were especially compelling. At both meetings, attendees heard from Luda Diatchenko, M.D., Ph.D., of McGill University. During her talks at both IASP and IPRCC, she presented provocative findings from her research on the connection between the use of nonsteroidal anti-inflammatories (NSAIDs) and chronic pain after an injury. Her research, leveraging data from UK Biobank, found that the risk of acute pain turning into chronic pain increases when NSAIDs are used in the acute stage. 

These findings build on a growing body of research that suggests that the body’s inflammatory response is tightly interconnected with physical healing. Interrupting the inflammatory response with NSAIDs may, in turn, inhibit the necessary immune response involved in resolving pain. This healing pathway, observed through changes in gene expressions and other biomarkers, is not yet fully understood. But what we do know may “flip the script” on our understanding of chronic pain. As Dr. Diatchenko put it, the issue of chronic pain may be less a presence of a pathological process, and more an absence of an active resolution process. 

This shift in our scientific understanding challenges the conventional wisdom that inflammation is inherently harmful and should always be suppressed. Clearly, patients burdened by acute pain should not be left between a rock and a hard place, choosing between suffering pain in the short term and accepting a higher risk of persistent pain in the long term. Patients and their health care providers need better tools to ensure the individual needs of patients can be met to achieve the best possible outcomes. 

This urgent need underscores why pursuing whole person research is so critical. The evidence tells us that injury, pain, inflammation, and healing don’t occur in isolation. Deeper investigation is needed to better understand the relationships among different types of pain, treatments for pain, and the cascade of biological processes necessary for the body to repair itself. As we consider potential treatments, the complex impact of pharmacologic and nonpharmacologic approaches must be assessed through a multifaceted prism, including what happens in both the long and short term. Just as Dr. Diatchenko’s research raises questions about lasting harms, other research may point to durable benefits of interventions like acupuncture. 

As we continue our work to define the methodologies that can serve as the framework for more complex whole person studies, there is something especially exciting about advancing this area of research. The interest in whole person health that I’m seeing in the research community is increasingly matched by stakeholders in the health care delivery system. A recent announcement from the Centers for Medicare & Medicaid Services (CMS) is just the latest signal that those on the frontline of delivering care are recognizing the interconnectedness of health and the need to treat the whole person. 

In the meantime, research that is already underway and designed to recognize the multiple factors that impact people’s experience with pain, is poised to offer rich insight into our understanding of nonpharmacologic interventions. These studies include those that the National Center for Complementary and Integrative Health (NCCIH) is supporting through the National Institutes of Health (NIH) Helping to End Addiction Long-term^® Initiative, or NIH HEAL Initiative^®, including the NCCIH-led Pragmatic and Implementation Studies for the Management of Pain to Reduce Opioid Prescribing (PRISM) program.

I’m encouraged by these discussions and the new ground being uncovered by thoughtfully designed research. While there is much yet to learn, each conversation is important and will ultimately help ensure that, as clinicians and patients wrestle with decisions on how to manage pain, we aren’t getting in the way of real healing.