Tuesday, 18.05.2021

Peter R. Martin: Historical Vocabulary of Addiction




       According to the current electronic version of the Oxford English Dictionary (OED) the noun pain is a borrowing from the French peine which was derived from Anglo-Norman and French variants meaning “physical or bodily suffering” (from the second half of the 10th century); “trouble taken in accomplishing something, effort” (from c1050); “mental suffering” (from c1100)’ “difficulty” (from early 12th century); “punishment or suffering thought to be endured by souls in hell” (from early 12th century); and “legal punishment” (from c1165).  The noun pain also has origins in the classical Latin noun poena meaning “penalty, punishment.” 

       The noun pain was first used in the English language according to OED circa 1300, extolling the life of Saint Thomas Becket (1119 or 1120–1170), Archbishop of Canterbury until his murder by followers of Henry II (Horstmann 1887): “Ich hote ov euerechone þat ȝe beon..at Clarindone...For-to confermi þis lawes; ope peyne þat i schal ou sette, Ich hote þat ȝe beon þare.”  The meaning of pain in this quotation (“Punishment; penalty; suffering or loss inflicted for a crime or offence”) is somewhat different from another entry in the same volume, lauding the life of Saint Mary Magdalen (“The punishment or suffering thought to be endured by souls in hell, purgatory, etc.”): “God us schilde fram peyne and to heouene us bringue!”  Both quotations refer to pain as a consequence of a misstep, either a legal offence or a religious transgression, the punishment of which is in this life or the afterlife, respectively. 

       There are two meanings of pain, from among multiple definitions in OED, which seem appropriate in the context of addiction.  These refer to the word’s original meanings, namely the experience of either physical or emotional distress, feelings that may seem most amenable to self-medication and eventual progression to a drug use disorder (Martin 2019).  Later uses of the word, which relate to punishment for one’s actions or thoughts, seem derivatives from the original meanings of pain as they cause suffering not directly from one’s own body or mind, but rather via an external decree or law, which is likely not responsive to self-medication.  The first of the relevant definitions is: “Physical or bodily suffering; a continuous, strongly unpleasant or agonizing sensation in the body (usually in a particular part), such as arises from illness, injury, harmful physical contact, etc.”  This was first used circa 1330 in the Middle English poem Of Arthour and of Merlin (Macrae-Gibson 1973): “What for sorwe & eke for paine, Sche les winde.”  A very relevant quotation for understanding addiction is found in the novel The American (1877) written by Henry James (1843-1916), the American author considered a key transitional figure between literary realism and literary modernism: “He had a fit of his great pain, and he asked her for his medicine.” The other meaning for pain that is also compatible with addiction refers to: “Mental distress or suffering; anguish, grief; an instance of this.”  This use first appeared in the English language circa 1330 in Sir Tristrem, a Middle English Romance based on the legend of Tristan and Iseult (MacNeill 1886): “Tristrem..sikeþ..Wiþ sorwe and michel pain.”  A modern use, reflecting emotional pain is found in a semi-autobiographical, precursor of the psychoanalytical novel Way of Flesh (1903) by the English author, Samuel Butler  (1835-1902): “He still felt deeply the pain his disgrace had inflicted upon his father and mother.” 

       It is evident to clinicians who deal with addiction that a significant proportion of their patients report that they suffer from “pain,” whether it be physical or emotional in nature (Martin, Weinberg and Bealer 2007).  Patients often recount that their pain, which frequently has a combination of physical and emotional elements that may be difficult to disentangle, antedated their regular use of drugs or alcohol.  Patients explain that part of the reason they continued to use these psychoactive agents was because they initially reduced the pain.  However, many patients continue drugs or alcohol, even after the cause for beginning drug use subsides.  Alternatively, patients in whom pain persists may notice that their pain eventually becomes more severe and disabling as sporadic drug use progresses to full-blown addiction (Ho and Dole 1979; Zale, Maisto and Ditre 2015; Witkiewitz and Vowles 2018). 

       As a direct consequence of the opioid epidemic of the 2010s, it has become evident that initiation of pain relieving medications all-to-often begins with a physician’s prescription (Shah, Hayes and Martin 2017).  This is explained by the unfortunate fact that many pain medications are so very effective at first, but quickly result in neurodaptation and have abuse liability.  Additionally, it is important to recognize the frustration physicians who desire to alleviate their patient’s suffering feel, when eliciting pain as a symptom without being able to objectively determine that it is present.  Indeed, the answer to the question — What then is pain? — has challenged practitioners throughout medical history.  A quotation of Edward Henry Sieveking (1816-1904), a German-trained English physician who was fascinated by pain and in 1858 invented the aesthesiometer, a device for measuring tactile sensitivity of the skin, exemplifies this conundrum (1867): “Few inquiries in physiology and pathology would be fraught with more general interest and with more practical results, if conducted to a satisfactory conclusion, than a comprehensive investigation of pain in all its relations. Strange to say, although pain is man's melancholy birthright, he scarcely knows what it is: attempts to define it end in vague assertions or tautological phrases; and, as no means of measuring it are known, we cannot in any way render it tangible, tabulate its variations, or train our students to a proper estimate of its relative importance.  When Unzer [Johann August Unzer (1727-1799) was a German physician whose work with the central nervous system, reflexes and consciousness influenced modern physiological studies] says (1851), "A very strong disagreeable impression is pain," he does not, in reality, get much further than Polonius, who, in attempting to define madness, avers: "To define true madness, What is it else than to be mad?"  Sieveking’s explanation of pain via the trope of madness in his quotation may be more tautologic than he intended, as pain is very frequently associated in those sufferring from physical and emotional disorders (Shulman 1977).

       Mechanistic understanding of pain has been a focus of traditional Chinese medicine (Chen 2011), “the term for pain appeared for the first time in the ancient medical book Huang Di Nei Jing more than 3000 years ago, which was translated into English as The Yellow Emperor’s Classic of Internal Medicine (Veith 1966)…and The Medical Classic of the Yellow Emperor (Zhu 2001)…pain was believed to be a result of imbalance between yin and yang. Predominance of yin results in ‘han’ (cold), causing damage to the ‘xing’ (form of a substance) which is now known as tissue injury or damage, and leads to swelling, while predominance of yang results in ‘re’ (hyperthermia or heat) which causes damage to the ‘qi,’ namely pneuma (previously referred to as ‘chi,’ the concept of energy circulating in the hypothetical 12 channels) and leads to pain. That was probably the first description of the symptoms and signs of nociceptive and inflammatory pain in the medical literature. Based upon this principle,…treatment of pain, regardless of pharmacological or non-pharmacological approaches, has focused on restoration of the balance between yin and yang, including the use of acupuncture analgesia.”  The reported effectiveness of acupuncture for treatment for opioid withdrawal using traditional Chinese medicine offers support for a mechanistic relationship between pain and addiction (Chen 1977).

       In ancient Greece, pain was first described in the epics of Homer (circa 8th century BCE), the Iliad and the Odyssey (Chen 2011).  In Western philosophy and medicine, physical and emotional aspects of pain have long been confounded, as documented historically (Dallenbach 1939) and supported by the range of descriptors of pain employed by patients (Melzack and Torgerson 1971).  Perl (2007) suggested that this has contributed to most of the uncertainties encountered in elucidating the underpinning mechanisms of pain: “…since Aristotle (384–322 BC) considered the heart to be the seat of feelings. Taking cognizance of pain’s usual importance for disposition, he argued it to be an emotion… Galen (130–201), a leading physician-surgeon of Alexandria, used experimental studies along with earlier observations to disagree [with the Aristotelian perspective]. Galen recognized the brain as the organ of feeling and placed pain into the sphere of sensation. Avicenna (980–1037), a renowned Muslim philosopher and physician, noted that, in disease, pain can dissociate from touch or temperature recognition, and proposed pain to be an independent sensation… [New ideas] in the eighteenth century [were] due in part to changing insight into the physical world and proposals by Newton (1642–1727) and Hartley (1705–1757) that neuronal messages were vibrations of substance in nerves.  Despite much work and thought… fundamental issues about pain remain unresolved…”  Nevertheless, since the American dentist William T. G. Morton (1819-1868) publicly demonstrated the use of inhaled ether as a surgical anaesthetic in 1846 (Thoma 1946), significant advances have been achieved in managing often intolerable pain during surgery.  The importance of this discovery to mankind was poetically honored on 16th October, 1896 at the commemoration of the fiftieth anniversary of the first public demonstration of surgical ansesthesia, by S. Weir Mitchell (1829-1914), an American physician, considered the father of medical neurology, who discovered causalgia (complex regional pain syndrome) and erythromelalgia and pioneered the rest cure:

“Though Science patient as the fruitful years,

Still taught our art to close some fount of tears,

Yet who that served this sacred home of pain

Could e'er have dreamed one scarce-imagined gain,

Or hoped a day would bring his fearful art

No need to steel the ever kindly heart.”

       It is much more challenging to relieve pain that continuously compromises daily life than is counteracting pain using anesthesia, when an individual can essentially be rendered insensate during a finite period of a surgical procedure.  In addition, conceptualization of the pathophysiology and treatment of chronic pain has been particularly muddled in Western medicine, in part, a legacy of the Cartesian mind-body dualism (Descartes, Haldane and Ross 1912). Parenthetically, the altered states of consciousness repeatedly experienced during addiction-associated intoxication by self-administration of alcohol or other drugs are not dissimilar in character and goals to that achieved in anesthesia (Martin 2020), a notion supported by the OED definition of to feel no pain, which in slang means “to be insensibly drunk.”  Accordingly, it is not difficult to appreciate why repeated self-intoxication is often used, but is destined to fail in management of chronic pain — the major consequences being neuroadaptation, increasing use with diminished pain control and progression to addiction (Andrews 1943).

       It was not until the second half of the 20th century that integration of the multiple neuronal inputs that contribute to the character and intensity of pain was proposed by Melzack and Wall (1965) as the gate theory of pain: “The model suggests that the action system for pain perception and response is triggered after the cutaneous sensory input has been modulated by both sensory feedback mechanisms and the influences of the central nervous system… A ‘modality’ class such as ‘pain,’ which is a linguistic label for a rich variety of experiences and responses, represents just such an abstraction from the information that is sequentially re-examined over long periods by the entire somesthetic system.”  In fact, the emotional features of pain are supported by the vocabulary patients use to describe the experience (Melzack and Torgerson 1971).   This conceptual advance has led to development of multimodal pain management rather than simply using opioids that may often lead to addiction.  This approach is intended to result in “significant decreases in pain, depression, anxiety, somatization, hostility, and analgesic ingestion (Khatami and Rush 1982),” all recognized concomitants of the chronic pain syndrome that must be addressed to enhance quality of life.  In fact, there is considerable overlap of multimodal pain management and broadly based addiction treatment programs (Martin, Weinberg and Bealer 2007). 

       We owe the tremendous impetus to manage chronic pain (Keefe and Somers 2010) and even to conduct surgical anesthesia without opioids (Devin, Lee, Armaghani et al. 2014) to the greater cognizance by the medical profession and society of the risks of addiction as a result of the opioid epidemic of recent years.  As reviewed above, very important clinical linkages have long been recognized between the suffering that results from physical and mental pain and addictive disorders.  These connections go beyond phenomenology and also include the recognized benefits of antidepressants and anticonvulsants in management of these syndromal presentations (Martin, Weinberg and Bealer 2007) as well as the particularly impressive antidepressant effects of opioids (Medakovic and Banic 1964; Benningfield, Dietrich, Jones et al. 2012).  Not until recent advances in immunology, has it become possible to understand that these associations may mechanistically operate through the pathophysiology of  inflammation (McClintick, Xuei, Tischfield et al. 2013; Yuan, Chen, Xia et al. 2019; Mehta, Stevens, Li et al. 2020).  Appreciation of these interconnections has arrived relatively late in Western medicine.  Nevertheless, this newly-recognized interdigitation of mind-body elements through neuroinflammation seems to be in agreement with concepts that have been accepted in treatment of mental and physical disorders for centuries in Asia.



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November 26, 2020