No One Wants To Be the Candy Man: Ambivalent Medicalization and Clinician Subjectivity in Pain Management

Abstract

Pain, despite being an elemental bodily experience and the most common reason for seeking medical care, occupies a place of profound ontological and moral uncertainty in American biomedicine. Taking seriously the highly charged emotions – frustration, anger, even disgust – frequently expressed by clinicians regarding their patients with pain, this article draws on ethnographic research to explore both the origins and the implications of such anxiously ambivalent responses to pain and pain medications among the clinicians charged with treating it. Set against the recent history of pain medicine as an emergent specialty in the highly fragmented landscape of American biomedicine, we examine at close ethnographic range some of the key ways that U.S. clinicians frame the experience of contending with pain in their everyday practice. Emergent from these clinician experiences are the ways in which pain and pain medications remain both incompletely medicalized and ineffectively medicalizing in American biomedicine, as well as the threatening effects on what we term the pharmaceutical subjectivity of clinicians themselves of this persistently ambivalent medicalization.

About the Authors

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House Call MD, "Pill Bottle." October 23, 2012 via House Call MD.

Megan Crowley-Matoka is an Assistant Professor of Medical Humanities and Bioethics at Northwestern University. She earned her PhD in Anthropology from the University of California, Irvine and completed a postdoctoral fellowship in Clinical Medical Ethics at the University of Chicago. She has an abiding interest in the messy entanglements of biotechnology, clinical uncertainty, medicalization, and shifting forms of subjectivity. She has conducted ethnographic research on organ transplantation in Mexico, Spain and the U.S. and is completing a book manuscript with the working title Iconic Bodies: Imaginings of Self, State and Organ Transplantation in Mexico. Her current research explores the political and moral economies surrounding pain management in American biomedicine.

Gala True is a medical anthropologist and folklorist at the University of Pennsylvania with affiliations at the Center for Health Equity Research and Promotion, Philadelphia VA Medical Center. Her research focuses on understanding and reducing health disparities and access to care through a patient-centered focus. Her current work involves the use of narrative and ethnography to understand barriers to mental health care for veterans returning from combat deployments in Iraq and Afghanistan.

Interview With the Authors

1. Your examination of the medicalization of pain took place at VA hospitals. These insitutions service individuals whose pain (and possible addiction to opiods) may be a direct concequence of the services (and treatment) they provided in defending their country and fellow citizens. How might this unique aspect of your fieldsite influence how physicians both perceive and treat/manage their patient's pain?

The VA of course provided a very particular context in which to conduct this research, given that, as you say, the physical and psychological damage for which patients in that setting who are seeking pain relief may often (but not always) be related to their military service.  But it is important to be precise about the specificities of the VA setting, in particular to avoid assimilating that setting to the imagery from the active duty Military Health System – sites such as the now-defunct Walter Reed Army Medical Center – that has come to dominate popular perceptions of military medicine through recent media attention.  The VA is not a setting primarily characterized by recent amputees learning to put their bodies and lives back together after a devastating IED blast – those patients are largely still being cared for within the active duty medical system, which is wholly distinct from the VA system.  The vast majority of VA patients are now decades beyond their service experience, and the medical needs that bring them to the VA are as often the routine diseases of aging such as arthritis, diabetes and heart disease.  And it is important to remember that the injuries sustained during military service are not just dramatic combat-related wounds, but also the more mundane, progressive wear-and-tear of the daily hard physical labor that is required by all of the non-combat tasks required to make the military machine run.  Shoulder, neck, back and knee injuries related to repetitive heavy lifting, to jumping or falling from moving vehicles, or simply from wearing weighty protective gear are all exceedingly common – and not dissimilar from the kinds of injuries routinely sustained in other physically demanding jobs outside of the military.  This does not, of course, make these kinds of injuries any less debilitating, even devastating for the patients who experience them, but it does mean that they do not necessarily register as powerfully in the kind of sacrificial logics of bodily harm that may suffuse clinical interactions around more dramatic combat-related woundings.  Indeed, for VA clinicians (who, unlike clinicians in the Military Health System, are not usually military members themselves) the service-related aspect of patients’ health problems often seem just an informative part of the medical history – in the way that the physical dimensions of any patient’s work history would be – without necessarily activating an explicit moral economy of bodily wounding and national debt.

That said, there are distinctive – and consequential – dimensions to the way the suffering ofindividual patients sometimes registers as more clearly sacrificial in the service of the nation, as well as how different cohorts of veterans are generally perceived within the VA system.  Many veterans, of course, fall into conflict-related cohorts – such as the WWII vets, the Vietnam vets, and the more recent OEF/OIF vets who are now entering the VA system in larger numbers.  And each of these conflicts are marked by a particular history of the kinds of combat experiences they generated, the kinds of characteristic woundings they produced, and the ways in which they have been come to be judged in political and moral terms.  The distinctive character of these different conflicts is part of the background culture of the VA such that comments like “he’s one of these tough old WWII guys,” or “he’s one of those guys who’s been pretty lost since Vietnam” encode a rich set of associations made with each conflict and its cohort of veterans.  These associations, which include ideas about the relative characteristic stoicism or vulnerability to psychiatric and substance abuse problems of different veteran cohorts, resonate with many of the values and fears clinicians bring to interactions around pain.  And importantly, these cohorts are distinguished not just by conflict, of course, but by generation as well – and age itself also carries considerable weight in clinician deliberations about the use of opioids. Generally speaking, older patients are both more likely to be believed to have “real” pain as an expected consequence of the aging process, and less likely to be viewed as apt to go dangerously, criminally awry with pain medications.  And younger patients, conversely, are more likely to have both their pain and their motives treated as suspect, in part because many clinicians so dread the prospect of starting someone on opioids who might then be needing (or wanting or demanding) those drugs for the next thirty of forty years.  What this points to is the need to understand the dimension of military service (and the kind of sacrifices it is imagined to entail, and the kind of debts thus incurred) as both highly differentiated and always interacting in complicated ways with other non-military aspects of patient (as well as clinician) identity in pain-related interactions.

Clearly the complex political and moral economies of not just pain care but of health and embodiment in general within the military system merit sustained anthropological attention – and are receiving it in the form of some very fine recent work in this vein (Kenneth MacLeish’s work is one such example).  But what has been so striking to us in the course of this research is how deeply the dynamics we describe in the article seem to resonate with clinicians outside the VA as well.  We have presented this work in collegial conversation and formal academic presentations to clinician audiences in various forums around the country, and the signal response has been one of recognition.  The dread-filled asides about pain patients, the notion of “getting burned stories,” and the pervasive, persistent sense of unease and vulnerability these index seem to be acutely (sometimes uncomfortably) familiar to these audiences.  So while the setting of the VA certainlyinflects our findings in important ways to which we want to remain attentive, we also have come to believe that our analysis of how pain and pain medications are ambivalently medicalized, and how this is often experienced as threatening to clinician subjectivity have wider relevance in other areas of American biomedical practice as well.

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NYCMarines, "Memorial Day Parade." October 23, 2012 via Flickr.

2. Pain, much like cancer, has brought to the surface the limitations of biomedicine and biotechnology. Might it not be the feeling of "failing" as a "healer" or recongition of the limitations of biomedicine that results in physicians both perhaps being overly dependent on own "healing kit" (surgery and pharamceuticals as opposed to physical therapy and social work) and desiring extensive control over the patient and the patient-treatment interaction?

Absolutely, a central contention of our paper is that it is precisely the sense of failure and frustration that clinicians so frequently experience in managing pain that leads both to some of those strikingly stark expressions of distaste for pain patients, and to the almost adversarial exercises of power over these patients that are a common (though certainly not universal) feature of pain-related interactions in American biomedicine.  Whether that sense of failure binds clinicians more firmly to what you describe as their own “healing kit” of surgery and pharmaceuticals seems more difficult to say.  Certainly clinicians operate – and are made able to operate in Brigitte Jordan’s sense of “moral requiredness” – in their daily practice out of a tremendous faith in their own biomedical tools.  And part of what seems so threatening about pain is precisely the way it can shake clinician faith in those tools – all too often treating chronic pain patients brings clinicians right up against the impotence of what they feel they have to offer in the face of patient suffering.  At the same time, it seems important to remember that clinicians are also operating in a world where that faith in biomedicine’s primary tools is sedimented into the institutional and economic structures of the U.S. healthcare system, such that accessing the tools of physical therapy, psychiatry, social work and other “alternative” therapeutic modalities is often far more logistically cumbersome and far less easily paid for than the dominant tools of the pill, the needle and the surgeon’s knife.  Moreover, patients themselves often partake deeply of this faith as well, such that many patients stridently resist referrals to physical therapy or psychiatry or social work, seeing them as pointless at best and delegitimating, even stigmatizing, at worst.  These realities at once reinforce the power of clinicians who wield these valued tools, but also constrain it in important ways.  Trying to get at this sort of more nuanced sense of how clinicians themselves experience the power we so often impute to them – how that power is wielded and consolidated, but also how it is constrained and rendered vulnerable – is one of the goals of the paper and of our larger project.

That said, it also seems important to flag that both individual clinicians and healthcare systems seem increasingly not only to recognize the limits of standard biomedical tools for addressing pain but also, sometimes, to be reaching out for strategies beyond the pill and the scalpel as a result.  Pain thus becomes a potential site not just for the kind of failure and frustration we describe, but also – perhaps – for change as well.  So, for example we did hear from individual clinicians whose response to their inability to “fix” their patients’ pain according to the standard biomedical “cure” model was to search for more affective, collaborative ways of engaging with their patients – as one put it, one of the key things he could offer his patients was simply to show them that he was going to “take their pain seriously.”  Another clinician talked to us about how he was beginning to believe that one of the primary therapeutic interventions he had to offer was a kind of “accompaniment” – so that while he might not be able to cure his patients’ pain, he could be sure not to abandon them.  And at a more institutional level there is a push both within and outside of the VA to move toward a new model of healthcare delivery centered around the notion of a “patient-centered medical home” which tries to establish ongoing collaborative relationships between patients and an integrated, multidisciplinary healthcare team, one that includes not just physicians, but social work, mental and behavioral health, and other kinds of “alternative” services as well.  This is, of course, a concept motivated by and subject to a complex set of political and economic forces operating in and on American biomedicine, and interpreting its meaning(s) and tracking its effects is no simple task.  Yet there are at least some ways in which we can see such initiatives as trying to respond to precisely the kinds of challenges that pain – and many other forms of chronic illness – presents to the standard logics and structures of existing American biomedical practice.  Such initiatives should also, however, be seen as part of a long and halting history of trying to render healthcare in the U.S. more truly, deeply “multidisciplinary,” and it remains to be seen where they will – or will not – go.

3. You have added "the other side" of the story of pain management through pharmaceuticals. What does this more complete picture offer in terms of addressing the growing social burden of opiod dependence and addiction?

Of course there are far more than two “sides” to this story, and we try in this paper to offer just one among many possible angles of insight into what seems an enormously complex tangle of scientific, moral and political economic uncertainties surrounding the question of how best to care for those in pain.  Among those many uncertainties is just how to understand the shape and scope of what you term the “growing social burden of opioid dependence and addiction.”  There is a long history in the U.S. of waxing and waning both in levels of opioid use and in the moral panics and regulatory campaigns that emerge around that use (David Musto has a classic historical account of this).  And both opioid use and responses to it (be they more tolerant and permissive, or more restrictive and punitive) are, of course, historically- and culturally-situated, deeply structured by various shifts in the political, economic and social climate.  More specifically, wartime and its aftermath (from the Civil War, to Vietnam, to the current conflicts) has frequently been a key catalyst in these dynamics, with returning soldiers who have encountered opioids in the course of their military service returning to an often still-divided society that is anxious both about how to reintegrate those soldiers and about the habits (pharmaceutical and otherwise) that they may have acquired in combat.  Throughout these different eras, how opioids themselves, the people who may use them, the trouble they can cause and the scope of the problem are represented have often been politically charged and highly contentious.  Our current era is no different.  It does seem clear that opioid prescribing levels have increased significantly in the U.S. over the last two decades or so, in large part due to the growing consensus around pain as a problem in and of itself that we describe in the paper.  And clearly there are people for whom opioid use has devastating consequences of addiction and even death.  Yet it seems important to keep in mind that there is also serious debate about how such categories as “dependence” and “addiction” as well as “opioid-related overdoses” or “opioid-related deaths” should be properly constructed and hence counted – statistics, as always, can be slippery things.

So there is a deeper historical perspective on these issues that seems helpful to keep in mind.  But beyond this we think that our findings contribute to untangling some of the clinician anxieties that so often result in pain patients being made to feel like morally-suspect addicts.  Doing so seems worthwhile because the fraught clinical world thus created has troubling consequences, for it is inescapably coupled with a lively street drug economy where prescription opioids are abundantly available.  In the VA environment where we have been working it is not uncommon to hear returning soldiers (who were first given opioids to keep them going during their military service) report that upon returning home to a VA setting reluctant to release opioids it seems sometimes easier – both logistically and perhaps emotionally – to seek pharmaceutical relief for their suffering through the informal drug markets of street corner and bar room.  This is an uneasy, counter-productive, yet in many ways mutually-constituting relationship between the clinic that makes people “feel like a drug addict,” and the street that perhaps (for some) feels increasingly “clinic-like” in its role as a place to seek treatment – one that our larger project hopes to explore.

Questions for Classroom Discussion

1. How has biomedicine medicalized pain?

2. The medicalization of bodily conditions considered “normal” such as conception, pregnancy, childbirth, and arguably pain has been perceived as both positive and negative. How has the medicalization of pain been both advantageous and deleterious to health?

3. From an anthropological perspective, what might physicians consider when developing a pain management program for their patients?

4. How do the wars in Afghanistan and Iraq complicate the treatment of pain, particularly in institutions serving veterans?

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NYCMarines, "Veterans Salute." October 23, 2012 via .

Multimedia

House Committee on Government Reform and Oversight Prescription Drug Abuse - House Oversight Committee - 2006-07-26

Subcommittee on Criminal Justice, Drug Policy, and Human Resources. Witnesses testified about prescription drug abuse, access to prescription drugs through physicians, the Internet, and patients, as well as the extent of the problem in the U.S. They also talked about the costs associated with prescription drug abuse including diversion programs, theft and other crimes, law enforcement assets, and addiction support. Filmed by C-SPAN.

Relavent Links

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Judy Treible, "US Centers for Disease Control and Prevention." October 23, 2012 via .

Center for Health Equity Research and Promotion (CHERP)

Exhibit at the Philadelphia VA Medical Center on the project PhotoVoice: From War to Home through the Veteran's Lens that is working with recently-returned veterans to produce collaborative visual/textual narratives as a means of working through their military and re-integration experiences

Topics in Brief: Substance Abuse among the Military, Veterans, and their Families

Pentagon study revealing alarming rates of prescription drug abuse among active duty soldiers. The study found that an alarming 1 in 4 soldiers admitted to abusing prescription drugs, most commonly pain killers. A spokesman for the military stated that the prescription pain killers were being used for pain and also for "behavioral health issues." 

Substance Use Disorders in the U.S. Armed Forces

Institute of Medicine report analyzing Department of Defense policies and programs pertaining to what it terms a public health crisis in substance use disorders among active duty military members, members of the National Guard and Reserve, and military families. 

The House I Live In

Award-winning documentary on the history, politics and devastating consequences of the 40 year "war on drugs" in the US.

Related Readings

Susan Greenhaigh. 2001. Under the Medical Gaze: Facts and Fictions of Chronic Pain. Berkeley: University of California Press.

Mara Buchbinder. 2011. "Personhood Diagnostics: Personal Attributes and Clinical Explanations of Pain." Medical Anthropology Quarterly. 25(4):457-478.B.

Berthold Wolff and Sarah Langley. 1968. "Cultural Factors and the Response to Pain: A Review." American Anthropologist. 70(3):494-501.

Jean E. Jackson. 2005. "Stigma, liminality, and chronic pain: Mind–body borderlands." American Ethnologist. 32(3):332-353.

Troy Lisa Holbrook, Michael R. Galarneau, Judy L. Dye, Kimberly Quinn, and Amber L. Dougherty. 2010. "Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder." New England Journal of Medicine. 362:110-111.

Matthew J. Friedman. 2010. "Prevention of Psychiatric Problems among Military Personnel and Their Spouses." New England Journal of Medicine. 362:168-170.

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