 The speaker is Dr. Megan Crowley-Mitoka, professor of Crowley-Mitoka to medical anthropologist and assistant professor in medical humanities and bioethics at Northwestern University. Her research is primarily focused on the socio-cultural dimension of organ transplantation. More recently, she's focused on pain management. She will be speaking to us today about, quote, the simultaneous epidemics of chronic pain and prescription drug abuse. Megan? And thank you, Mark and the McLean's. Of course, I'm so just delighted and grateful to have this community and to have an opportunity to sort of think out loud with this group another time and sort of see what sticks. So I want to begin with just the observation that something curious is converging around pain in American medicine. Jockeying for public attention and moral positioning are two firmly entrenched constituencies simultaneously decrying the under and the overtreatment of pain with nearly equal fervor. Couched in the compelling language of public health alarm, we thus have concurrent calls to arms about the epidemics of pain and of prescription drug abuse. Thus, in 2011, a report released by, oh, sorry, no financial relationships to disclose. I'm an anthropologist. Nobody really pays me for anything, except I get paid to do this work for which I feel incredibly grateful. By my institution, not by a pharmaceutical company. So in 2011, a report released by the August Institute of Medicine invoked a shocking and widely cited 100 million Americans suffering from chronic pain each year. In the same year, a high-profile series of alerts and policy briefs from the CDC conjured a chilling three to four-fold increase in drug overdose deaths over the past decade, an increase thought to be driven largely by prescription painkillers. Critically, the epidemic stories thus proffered and picked up and proliferated across both popular media and scholarly literatures are not only concurrent or even just interconnected. They are, in a sense, competing. For they make their respective claims in such a way as to suggest that taking the dangers of one epidemic seriously necessarily requires, at least to some degree, discounting the damage of the other. One must, it comes to seem, decide whether you'd rather accept leaving some patients to suffer untreated pain or accept exposing others to the ravages of drug abuse and addiction. Holding the harms of both in some kind of relation beyond a sort of head-to-head or even zero-sum oppositional one comes to seem hardly possible. In the brief time I have today, I want to try to begin to think through what's at stake in summoning the language of the epidemic to talk about the place of pain and pain medications in just this way. Doing so will require, I think, thinking about questions of rhetorical strategy and narrative effect in this particular form of competing public health storytelling. It will also require thinking about the move to the public health frame at all. At what point and to what purpose does pain and the medications used to treat it become not just an individual but a collective problem? That is when and why do pain and its remedies become a threat, not just to a singular suffering in body itself but to the wider social body. Now I come to trying to think about pain in the register of public health by way of the clinic from the midst of an ongoing ethnographic project and the sociocultural dimensions of pain management in American medicine. In that larger project, I've been thinking and writing about pain and its medications as it emerges in the everyday practices of clinical care, particularly in the primary care emergency medicine and specialty pain clinics where I've been doing observations and interviews. These are key spaces in which pain is constituted and often disputed in the intimate and fraught relations between frustrated patients seeking relief and clinicians frequently unsure and uneasy about how best to provide it. Within those spaces, it's been impossible to ignore how pain and many of the substances used to treat it are persistently haunted by questions of doubt in both ontological and moral terms. Most fundamentally, is this pain real? That is, is it a sign of material bodily damage, of psychological distress, of malingering or maybe even moral turpitude? And further complicating matters, are the drugs one might offer to ease the suffering really for pain or are they for pleasure? Do they promise, if not cure, at least a form of care? Or are they more likely to be, even in the face of real pain, harmful, even corrupting instead? I've been intrigued by how such unsettling, insistent questions seem to render both pain and its remedies profoundly ambivalent in American medicine in many ways, both incompletely medicalized and ineffectively medicalizing. Such ambivalence affects not only patients who so often feel rendered suspect by their claims to pain. Clinicians too may feel vulnerable, made vulnerable by the uncertainty surrounding pain. Vulnerable, that is, to failure for pain, particularly chronic pain, so often resists the magic bullet fix of biomedicine. Vulnerable to deception by patients motivated either to evade the demands of legitimate work or to embrace the illicit pleasure of a high. And vulnerable to the sometimes contradictory oversight and sanction of their pain management practices in which they risk being damned for treating pain either too much or not enough, but damned either way. Such manifold vulnerabilities can produce what we might think of as a sense of threat and subjectivity among clinicians themselves, for whom dealing with pain and its medications may, at least sometimes for some clinicians, trouble their sense of professional and moral self. Now, as I've been tracking these tensions in the clinic, I've also started seeing them surface in some of the pain-related academic conferences and scholarly literatures that I've been trying to keep an eye on as well. Indeed, as I attend national pain medicine, addiction medicine meetings, and more local conferences and grand rounds, I keep encountering this sense of kind of entrenched constituencies. I keep hearing the mutually frustrated comments of colleagues and friends responding to a presentation on one side or the other of that, should we worry more about pain or about abuse divide? And so one colleague turned to me recently after a talk about the growing burden of pain with a shake of his head in the comment that just battering us with the numbers, I get it, pay attention to pain. But they pushed and pushed and now look what we've got. We're a bunch of pushers and people are dying. Well, another colleague, clearly speaking from the other side of that front divide, voiced his frustration about the sort of constant repetition of those CDC overdose numbers in this way, saying, so overdose is close to us from car accidents, huh? Not good, for sure. We need to do better on the diversion stuff. On the other hand, I don't see a government crackdown trying to take away access to cars. Such back and forth reactions are sort of the on the ground iterations and reverberations of those epidemic claims and counterclaims with which I began. And I'll come back to those claims in a moment, but first I think a brief word on the kind of recent history of pain as a newly emergent problem in and of itself in American medicine helps to sort of ground and contextualize what follows. So making pain count. Now pain, of course, is nothing new in the practice of medicine. It's both an elemental bodily experience and the most common reason for seeking medical care. Elemental, yet hardly elementary, the embodied experience and social import of pain has varied substantially across culture and history. Since the late 19th century, the clinical gaze of Western medicine regarded pain primarily as a sort of bluntly material diagnostic sign, something to be read as a symptom merely pointing the way to the underlying disease or injury that was the true concern of the clinician. Yet beginning in the mid 20th century, the place of pain in medical practice began to shift, becoming a problem in and of itself. And so we now find ourselves in an era in which pain can no longer simply be read, but must, as the current medical lexicon has it, be managed. This is a complex shift in which the changing epidemiology, politics and economics of illness in our late modern times are all implicated. A far larger and still unfinished story than I can tell today for sure. The massive demographic shifts towards longer and more chronically ill lives is surely part of the story, as is the emergence of palliative care and the cultural shifts within medicine itself that that emergence both marks and materializes. Also critical are the changing politics of health with the rise of patients rights groups around illnesses from AIDS to breast cancer to autism and now pain that powerfully combine political advocacy and identity formation. Not merely sprung de novo from the proverbial grassroots, however, the history and the advocacy of such pain patient groups really can't be understood without attention to the support that's poured into them from major pharmaceutical companies, providing not just money, but market building messaging about pain relief as a basic human right as it's often put. Such companies seem clearly engaged in an all too familiar strategy of helping to constitute a pharmaceutical need which they're poised to meet. And so we now find ourselves in an era where pain matters differently. No longer merely sign or symptom pain has become itself a form of disease. This is a move fundamentally grounded in claims both moral and scientific. In claims that is that ignoring suffering while holding the means to relieve it is simply and deeply wrong. And furthermore that untreated pain is not merely experiential ephemera, unpleasant but ultimately at least biologically unimportant. Rather emerging evidence that untreated pain leads to adverse physiological changes bolsters this assertion that pain on its own merits clinical attention and intervention. The assertion that is that pain now counts in a new way. Both reflecting and reinforcing the way pain has come to count as a problem in and of itself is the requirement that pain must now in fact be counted in a different way. And so pain is now designated of course as the fifth vital sign and must as mandated by Jacobi measured assigned a number from one to ten at every clinical encounter. On one level this requirement ensures that patient suffering though thinly reductively rendered enters the medical record with a consistency that both insists on its importance and invites tracking and study. For clinicians the message not only that pain counts but is something for which they are accountable is loud and clear. Thus newly counting, counted and made a sight of accountability in recent years it's perhaps not surprising that pain has also become a new area of specialization in the highly fragmented landscape of medicine. And so the notion of pain medicine as a distinct field of medical knowledge and practice has been gathering force and materiality in recent years accruing professional organizations, specialty journals, training programs and in many places though not all specialty pain clinics. Yet this remains a field in formation continuing to struggle for professional standing institutional power and research funding. And trying to carve out its own particular place in the world the field of pain medicine took as its mission what's become one of its most visible and controversial contributions creating a more expansive place for opioid medications in the treatment of chronic non-cancer pain. It was an intervention deliberately designed to unsettle long standing attitudes of fear and moral distaste surrounding opioid medications attitudes strategically dubbed by some as opiophobia. Increasingly however and in light of those rising rates of overdose deaths it's an intervention criticized for being based largely on a moral commitment to relieving pain rather than on a robust base of evidence. The now notoriously sparse evidence base in pain treatment however is surely the product of complex forces, factors and institutional arrangements. To name just one, pain is relevant to virtually all of the NIH institutes and centers but central to none. Seeming to fall through the institutional cracks pain research has been estimated to account for less than 1% of NIH funding up until very recently. In contrast it seems worth noting that drug abuse and addiction has had its own dedicated institute, NIDA, since 1974. So this is just a very kind of brief sketch of this sort of larger backdrop against which those competing epidemic claims are playing out. So turning to those epidemic stories I wanna ask, what does it mean to name something be it pain or prescription drug abuse as an epidemic? There is of course a basic technical meaning of the term. Oops, there we go. Paradigmatically though not necessarily infectious in nature the implicit threat of the epidemic of course is always that this burgeoning disease could continue to grow overwhelmingly out of control. In this sense framing something as epidemic shifts the locus of concern from the individual bodies afflicted with illness to the larger social body that must be protected from such spreading harm. It's perhaps precisely this shift that invests the notion of the epidemic with such attention getting power. It's a means of making illness not just about those unlucky others who fall in prey to illness but at least potentially about all of us. As such epidemic claims are always it seems to me simultaneously about ethics and about evidence. There are about empirical questions of who is sick, who's at risk and at what scale as well as about moral questions of who should be protected and at what cost. And yet such questions of ethics and evidence cannot of course be so neatly divided. For ethical decisions about who and what counts in the sense of mattering, fundamentally drive decisions about counting itself in the sense of measuring. It's fundamentally ethical kinds of decisions then that work to constitute the empirical to produce the evidence base. With this in mind, I wanna consider at least briefly preliminarily the ways that both ethics and evidence are marshaled in the signaling of epidemic pain and prescription drug abuse. To really do this properly of course would be a big job. There's a daunting body of discourse and data and debate mounting on either side. Just considering the policy briefs alone issued by the kind of alphabet soup of government bodies weighing in on the issue from the CDC to the FDA to the DEA to the NIH among others could keep us here all day. But those key 2011 statements from the IOM and the CDC with which I began offer, I think a strategic point of focus. Because the numbers proffered in those reports have been widely promulgated. They're the go-to touchstone statistics with which virtually every subsequent study and commentary on the topics of pain and prescription drug abuse now begins. So the IOM report commissioned as part of the Affordable Care Act begins with a bang with a shock of pain on a scale and at a cost simply staggering to imagine 100 million Americans every year were told to suffer from chronic pain. Because it is, it's a number that doesn't even include the millions more experiencing acute pain every year we're cautioned. And indeed embedded in that number are other exclusions as well. For we learn by footnote that this number also leaves out not only children but those institutionalized in nursing homes and prisons as well as those serving in the military. Given what we know about the high prevalence of pain in those populations it seems a kind of counterintuitive omission. Until that is we move on to the next level of accounting. An accounting in which it's clear that not just pain but productivity is at issue. For that embodied number of 100 million people in pain is quickly extrapolated into an even more exorbitant economic one. The estimated up to 635 billion in medical costs and lost wages inflicted on the American public by those multitudes in pain. These are the pained unproductive bodies that pull on the larger social body of a nation already under great strain at this particular historical moment. Exclusions and inclusions abound in such economic tallying up too of course. For producing such estimations is complex and sometimes contentious. Here I'll mention just one to me particularly poignant leaving out. Quietly buried in the very last line of a small print footnote to that 635 billion number is the observation quote, this estimate also excludes the emotional cost of pain. At once a straightforward acknowledgement of the limits of quantification it's also I think a statement of priorities to some degree. Of the way that things that can be counted come to count. But numbers of course are powerful and those numbers in the millions of bodies and billions of dollars do in fact make a compelling case for what the IOM report describes as its first underlying assumption that effective pain management is moral imperative. Yet this is a moral imperative increasingly troubled by that growing crisis of prescription drug abuse tracked in reports by the CDC and others. Here the shock of numbers is crucial as well with rates of increase reported in multiples rather than millions of threefold or fourfold increase in overdose deaths in which prescription painkillers appear to be a driving force. Translating to nearly 15,000 overdose deaths overdose deaths involving prescription opioids this is a scale of mortality measured in the report against the deaths from car accidents as we heard earlier and from heroin and cocaine as well both of which it now exceeds. Shocking as those comparisons are here too I find myself wanting to attend not just to the numbers given to the numbers made visible but to the numbers not given as well. For while those close to 15,000 deaths are surely disturbing, devastating what sense are we to make of the epidemic claim over those deaths and kind of alarm over those deaths in the face of the more than 16,000 annual deaths from NSAID induced gastrointestinal complications that's been estimated by HRQ. Clearly it's not just the scale of the damage from pain relief more generally that's at issue here. Recalling my colleagues earlier, raw observation as with cars there's no government crackdown on NSAIDs or we might think of the 23,000 annual deaths attributed to another form of harmful drug misuse, diversion and over prescribing. Deaths that is from antibiotic resistant bacterial infections. And here again imagining the response to opioid abuse transposed onto another situation seems illuminating. What if doctors started going to jail for inappropriate antibiotic prescribing in the way that they have for opioids. Such substantive thought experiments obviously can only carry us so far but I think that kind of attention not just to the numbers invoked and the comparisons drawn but to those accountings and comparisons not made visible are I think one way into what we might think of as a kind of narrative numeracy at work in the epidemic claims and counter claims I've just started to try and think through here today. A way that is to begin to think about the co-constitution of ethics and evidence in the language of numbers. About the powerful ways both are marshaled in determining how pain among many other things comes to count in contemporary society. Comes to count that isn't how we think about questions of harm and well-being for both individual lived bodies and the collective social body. Reflecting back to John's talk this morning I find myself thinking about how this kind of narrative numeracy too is part of the moral conversation. Part of how we're making and morphing ethics. Thanks. Keep reviewing.