30 October 2004


Some online resources on hedonism:
The Cyrenaics and the Origin of Hedonism

A summary of Sidgwick's Method of Ethics

Stanford encyclopedia entry

19 October 2004

Pain history archive

I suspect I'm going to be spending a lot of time here: http://www.library.ucla.edu/libraries/biomed/his/pain.html
The goal of the UCLA History of Pain Project is to promote and ensure the study of the history of pain research and pain therapy in the post-World War II era, in particular, the origins, growth, and development of the international, interdisciplinary pain field. Its major initiatives to achieve this goal are the creation of the John C. Liebeskind History of Pain Collection at the Louise M. Darling Biomedical Library at UCLA and the active dissemination of information about the Collection and the history of pain to appropriate audiences.

The Liebeskind History of Pain Collection includes:

* Oral histories with scientists, physicians, and other health professionals in the field of pain, and with chronic pain patients. Forty have been completed of the core collection of sixty interviews. These include interviews with leading pain scholars and clinicians such as John Bonica, Kathleen Foley, Ainsley Iggo, Ronald Melzack, Cicely Saunders, Richard Sternbach, and Patrick Wall. Master copies of the tapes and transcripts are available in the Biomedical Library after final review by the oral authors.

*Personal papers of pain pioneers and selected leaders in the pain field such as John J. Bonica (1917-1994), William K. Livingston (1892-1966) and William Noordenbos (1910-1990).
*Archival records of major pain organizations, including the American Pain Society (APS), the International Association for the Study of Pain (IASP), and the American Academy of Pain Management (APPM). Document collections are processed according to archival standards at the Biomedical Library and finding aids are developed to aid scholar access.

* Group interviews with leaders in the pain field, recorded on videotape for deposit in the Library. Three group interviews have been completed: "Perspectives on Pain" (1993), "The Bonicas: Passion is the Fuel of Life" (1994), and "Current Issues in Pain Management" (1995)

* Bibliographies of books, journals, and other materials relating to pain in the UCLA Biomedical Library; and listings of source materials available at other libraries and archives.

The Collection is supported by the extensive holdings of the Biomedical Library, which are regularly augmented with accessions of recent publications and classic works on pain.

War on drugs; war on pain

From the NYT:
In February 1999, Dr. Frank Fisher, a general practitioner in Shasta County, Calif., was arrested by agents from the California state attorney general's office and charged with drug trafficking and murder.

The arrest was based on records indicating that Dr. Fisher had been prescribing high doses of narcotic pain relievers to his patients, five of whom died. He lost his home and his medical practice and served five months in jail before it was discovered that the patients had died from accidents or from medical illnesses, not from the narcotics he prescribed.

All charges were dropped last year, and Dr. Fisher now has his medical license back. Yet his ordeal lingers as a cautionary tale of what can happen to doctors who treat pain aggressively.
No one questions that abuse of opiate painkillers is a problem. But federal and state law enforcement agents, who wield considerable power in deciding whether to initiate investigations, as well as the prosecutors and jurors who determine a doctor's fate if the case goes to trial, are often misled by obsolete ideas about the practice of pain medicine and the effects of opiate drugs.

Pain treatment itself is an area ripe for misinterpretation. Many patients who seek doctors' help have already tried nonsteroid anti-inflammatory drugs, conventional opiates like codeine and even surgery, yet they are still in severe pain from cancer, degenerative arthritis, nerve damage or other conditions. Large doses of medicines like hydrocodone (Vicodin), oxycodone (OxyContin), morphine or methadone may be required.
The red flags that rightly alert regulators to potential misconduct by doctors are, paradoxically, the very features that can also mark responsible care for intractable pain. These include prescribing high volumes of narcotic painkillers for extended periods, prescribing potentially lethal doses or prescribing several different drugs. In some regions, patients use several different pharmacies, at their doctor's instruction, because some pharmacists are reluctant to dispense large quantities of the medications.

To complicate matters further, doctor shopping can also be a sign of what is called pseudo-addiction: the efforts to obtain drugs look on the surface like drug addiction, but in fact represent the patient's attempt to attain an adequate level of pain control. Once that is achieved, the patient no longer presses for more narcotics.
We are unable to refer patients to doctors who will treat pain, if only because once a name gets out there, patients understandably flock, and then the doctor is targeted," said Siobhan Reynolds of Pain Relief Network, a patient advocacy group based in New York. The Association of American Physicians and Surgeons, based in Tucson and dedicated to the concerns of private practitioners, has gone so far as to warn doctors against managing chronic pain, lest they face of years of harassment and legal fees, even prison. "If you do," the association enjoins, "first discuss the risks with your family."

Scattered evidence confirms these impressions. A 1998 survey of more than 1,300 physicians by the New York State Medical Society found that 60 percent were moderately or very concerned about the possibility of being investigated by regulatory authorities for prescribing opiates for noncancer pain.

A third said they prescribed lower quantities of pills and lower dosages "frequently" because of the possibility of eliciting an investigation. When asked how often they avoided prescribing a preferred drug for noncancer pain, because doing so required triplicate forms, half said "frequently." Link


05 October 2004


I've been trying to write a 200 word summary of my eight-million chapter dissertation. I'm having trouble writing anything that is at all informative and coherent. At risk of embarrassment, I'd like to know what you think.
Pain is a fundamental evil. It is also a topic on which all extant views of intrinsic value are intuitively inadequate. The badness of agony doesn't seem to lie just in your not liking it; claiming that its badness lies in its unpleasantness seems pleonastic. These views are incomplete, but not wholly implausible. Your dislike of a pain, the way it impels you to escape, and the way it feels, all seem to be part of its intrinsic badness.

I believe the intrinsic badness of pain lies in the way it usurps a sufferer's control over herself. All creatures capable of purposeful action properly have a particular kind of control over aspects of their mind and body. By usurping this control, a pain undermines the dominion necessary for a being's well-functioning.

This accounts for what was plausible in the extant views. In disliking a pain we rebel from the foreign invader; we are passive in its impelling us to escape; and part of the usurpation is the way a pain feels as though it consumes one's mind.

Along with practical implications for the ethics of palliative care, my view has deep implications for our understanding of the nature and sources of value. It yields, inter alia, insights into the reality and strength of our reasons to alleviate other's pains; the role of subjective desire in value-theory; the nature of torture; animal's pain; and the structure of pleasure. [237 words]

Gastrointestinal pain in children

The NYT has an article up on unexplained chronic gastrointestinal pain in children. It is, of course, non-technical enough that it probably isn't really useful, but underscores again one of my hobbyhorses: Things like anxiety, depression, and broader psychological responses, aren't as easily separable from pain as most think. As you all now know, I believe that many such factors ought to be regarded as intrinsic properties of the pain.

Nothing in this article argues for that point, but it does raise one (admittedly philosophically lame) consideration for it: Part of the stigma of receiving psychological/pscyhatric treatment for pain may lie in the thought that the sufferer is somehow deficient or abnormal in her response to pain. If we take such responses to partially constitute the pain (that is, to be part of what the pain is), then the perceived deficiency is incoherent.* It plausibly assumes that we cannot be criticized for our pains --like kidneys they are parts of us but not under our control. But if the 'response' partially constitutes the pain, then the response cannot be open to criticism.

Anyway, enough about me, here's a bit of the article

New approaches to treating pain - including cognitive behavioral therapy; alternative treatments like relaxation techniques and massage therapy; and antidepressants - are already being used in adults, but they have not been widely adopted for children, in part because only a handful of small studies support such use.

In recent years, however, experts have begun to understand more about the connections between the brain and the gut, a relationship that is reflected in popular expressions like "a gut-wrenching experience" or "having butterflies in your stomach."

The gastrointestinal tract is awash in nerve cells and neurotransmitters. About 95 percent of the body's neurotransmitter serotonin is in the intestinal tract. Stress, nervousness, fear and other emotions often play out their own drama in the gut. In children with abdominal pain, the intestinal tract becomes hypersensitive to stimuli, with the slightest bit of gas, for instance, sending a flood of pain signals to the brain

The problem appears to be a mismatch in signaling between the brain and the gut, said Dr. Lonnie Zeltzer, director of the Pediatric Pain Program at the David Geffen School of Medicine at the University of California, Los Angeles. "If you have ongoing pain, you can develop abnormal pain pathways, so that the volume of pain signaling is being turned up and up," Dr. Zeltzer said.

What causes the hypersensitivity is not completely understood, but experts believe that it is often set off by a stomach virus or an infection

"It's not uncommon that a family will get viral gastroenteritis, the whole family gets better except the child," said Dr. Zeltzer, whose book, "Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood," will be published by HarperResource in January. "The pain system is turned on and stays on."

"It's not uncommon that a family will get viral gastroenteritis, the whole family gets better except the child," said Dr. Zeltzer, whose book, "Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood," will be published by HarperResource in January. "The pain system is turned on and stays on."....

As an understanding of the brain-gut connection grows, however, some centers have begun to use techniques like cognitive behavioral therapy, relaxation training, massage therapy and other alternative approaches as a first line of treatment.

The effectiveness of these therapies is still debated, and the number of studies examining their effectiveness in children is very small, experts say. In one study published in the August issue of The Journal of Pediatric Gastroenterology and Nutrition, 18 children ages 8 through 17 who had pain for about a year were taught guided imagery and progressive relaxation.

In four to seven sessions, 89 percent of the children reported a reduction in pain, to an average of two episodes a week, from six, said Dr. Youssef, the lead author of the study. The children had fewer missed school days, and their quality-of-life scores rose significantly.

"Our goal is to help them relax about the pain," Dr. Youssef said. "If you don't worry about the pain, you don't get pain." Link

Btw: I think Dr. Youssef should have said 'If you don't worry about the pain, there is no pain'. Picky, picky, picky.

*I'm overstating the metaphysical point here. Constitution may be too strong a relation for what I have in mind. But that is a subject for another post.