Stories We Tell Ourselves

Stories We Tell Ourselves

There are a lot of things now that we likely can’t imagine doing without: electricity, antibiotics, indoor plumbing, anesthetic. When the power goes off for an hour, it’s a nuisance; when it goes off for a week, you’re unable to meet all your commitments and responsibilities. Strep throat isn’t all that terrifying anymore, and neither is surgery to have your appendix removed. Certain technologies and inventions we have completely accepted. They’ve become part of the story of our lives.

History teaches us that technological change is often accompanied by narrative change. Many new inventions mean new ways of doing things, and new ways of doing things can be scary. What if the new way leads to something worse than we’ve got now? Often, before a new invention is fully integrated into society, there is a change in the stories we tell ourselves about what we need and what is good for us.

Pain relief is an ordinary part of many medical procedures, and over-the-counter pain medicines are familiar household items. Many people expect practitioners to discuss how pain will be managed. That expectation differs from the attitudes described in the historical account that follows.

For much of human history, options for pain relief were limited. Alcohol, plant remedies, and other substances offered some relief, but many painful conditions and procedures remained difficult to treat. The development and adoption of surgical anesthesia changed what patients could expect.

Given the burden of pain, you might expect an effective means of relieving it to be adopted immediately. The history of anesthesia is less straightforward. Discovering an effect, finding a reliable medical use, and persuading practitioners and patients to accept it were different steps.

Take the case of nitrous oxide, also known as laughing gas. It was discovered by chemist and polymath Joseph Priestley in 1772, and chemist Humphry Davy noticed its pain-killing properties in 1800. Davy wrote, “As nitrous oxide appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.”[15] That observation did not lead to immediate, widespread surgical use.

As Joanna Bourke explains in The Story of Pain, medical adoption lagged behind Davy’s observation;[16] nitrous oxide also circulated as a recreational drug before its medical use became established.[17] This delay is the example at issue here. It does not mean that earlier practitioners had never used substances such as opium to relieve pain.

Once nitrous oxide did come into medical use, it took many more years to become widespread, because many patients initially declined to use it. Why didn’t people race to start using nitrous oxide in surgery and the like? Why were patients and doctors so averse to implementing it once its pain-relieving properties were discovered? And why didn’t anyone try to invent anything similar earlier?

One way of understanding the use of painkillers is to look at this story through the lens of plot. Pain historically was part of a social narrative that is very different from the one we have today. Western culture in the nineteenth century and before didn’t have the same societal expectation that everyone was entitled to happiness and a life free from suffering.[18]

First, as Bourke writes, our attitudes to pain have always been closely connected to our perception of the value of different groups. If pain is integral to what it means to be human, denying that certain people could feel pain was an effective way of dehumanizing them. Doctors believed that a whole laundry list of groups either didn’t feel pain or only felt it in a mild way: soldiers, women, children, the elderly, immigrants, the working classes, slaves, and so on. Even as late as 1939, one medical author was adamant that children could undergo minor surgical procedures without feeling any pain.[19] For many doctors, their attitude toward pain medication was wrapped up in their beliefs about certain types of people. If someone couldn’t feel pain because they were somehow less than human, then there was no need to give medication for it.

Second, the way people do things over a period of time often comes to feel normal. As when we analyze a plot, in life, we have expectations of what is going to happen on the way to our anticipated ending. For both doctors and patients, the new story of pain medication felt like it didn’t have the same cause-and-effect elements that had previously defined their genre. Some surgeons, for example, said they disliked operating on silent, unmoving patients; it wasn’t like the good old days of surgery (which included, presumably, the need to be quick and to hold the patient down).

Patients too weren’t immediately sold on the idea of pain-free surgery. The idea of being unconscious disturbed many. People wanted to be aware and in control during procedures, even major ones. They weren’t sure how things like nitrous oxide worked, so they were naturally suspicious of them. The side effects painkillers cause in most patients added fuel to that fire. People felt that it was unnatural not to feel pain. They were used to it and worried that taking it away would have worse consequences.[20]

Finally, and perhaps the most important factor of all, was the fact that many people saw pain as something positive. The ability to bear it with grace was the ultimate hallmark of self-control and bravery. Those who underwent painful procedures without complaint were lauded for their courage. Religious beliefs at the time presented the ability to endure extreme pain as a virtue that would help secure a sufferer’s place in heaven. If someone were on their deathbed, coping with agonizing pain was a final chance to earn some extra brownie points and up their chances of getting into heaven.

Pain played a large role in many of the social narratives about bravery, courage, and virtue. Take it away, and now the possible cause-and-effect plot changes: If I don’t experience pain stoically anymore, am I still a good person?

Nitrous oxide is now a familiar option in dental care and some other procedures. The expectation that pain can be managed has become familiar too. This change invites another question: what do we lose sight of when a new expectation becomes so ordinary that we stop examining it?

The authors argue that relief from pain can become an expectation without enough attention to the costs and limits of particular treatments. Pain can provide information about illness or injury, but that observation alone does not decide when or how it should be treated.

The opioid crisis in the United States is the article’s example of how expectations about pain relief can interact with prescribing practices, policy, and commercial incentives.

The account describes a change in the 1980s, when the World Health Organization “began advocating more aggressive use of opioids for pain control for anyone who had ‘pain.’”[21] It also describes U.S. institutions evaluating pain control and linking reimbursement to patients’ reported experience. The authors connect these pressures with increased prescribing and the harms of addiction. Their account should be read alongside the other causes discussed below, rather than as evidence that one expectation produced the crisis.

There were other factors in the widespread uptake of opioids in the U.S. Major policy decisions were based on flimsy anecdotal evidence of the lack of addictive properties in opioids, and certain pharmaceutical companies lied about the addictiveness of the opioids they sold. These factors, however, played out against the social backdrop of the new belief that allowing patients to experience pain was inhumane.

The authors also question the evidence for long-term opioid benefits in chronic pain and discuss concerns about effects on healing and the interpretation of symptoms.[22] Those are questions about particular treatments and uses. The narrative lesson does not establish which treatment is appropriate for an individual patient.

Pain relief can be valuable, and a treatment can also cause harm. The account describes bad evidence, overprescribing, misleading information, and changing expectations contributing to those harms. Beliefs about pain matter because they influence how people interpret evidence and what they ask medicine to do.

The history of pain medication shows how beliefs can help or hinder the adoption of a technology. To understand a change, examine both the technology and the expectations that make its use seem necessary, acceptable, or wrong.