Editor’s note: The 17th IASP World Congress on Pain took place September 12-16, 2018, in Boston, US. At the Congress, 12 early-career pain researchers took part in the PRF Correspondents Program, a science communications training experience that provides participants with knowledge and skills needed to communicate science effectively to a wide range of pain researchers, and to patients and the wider public. As part of this program, the participants conducted interviews with plenary speakers at the meeting.
Here, plenary speaker Daniel Carr, MD, chats with PRF Correspondent Perri Tutelman, a PhD student in clinical psychology at Dalhousie University and the IWK Health Centre, Halifax, Canada. Carr is a past president of the American Academy of Pain Medicine, an honorary member of the International Association for the Study or Pain, and has served in multiple other pain-related professional organizations including the American Society of Anesthesiologists and the American Pain Society. He has a primary appointment in public health and secondary appointments in anesthesiology and medicine at Tufts University School of Medicine, Boston, US, where he is founding director of its Pain Research, Education and Policy Program. He has published widely on pain research, evidence-based medicine, clinical practice, and the social aspects of pain relief. He has served on multiple editorial and governmental advisory boards, most recently on Massachusetts’ Governor’s Medical Education Working Group on Prescription Drug Misuse, the Massachusetts Department of Public Health’s Drug Formulary Commission, the US National Pain Strategy, and the US National Institutes of Health (NIH) Interagency Pain Research Coordinating Committee.
In this interview, Carr discusses his journey in the pain field, his interest in pain education, and his work with the US National Pain Strategy. Below is an edited transcript of the conversation.
How did you become interested in pain research?
When I was a medical student I decided to go into endocrinology, in part because of the outstanding level of the endocrinology service at my medical school, Columbia University. This was around the time that a new dimension of the classic hormonal stress response—the endogenous opioid system—was discovered and its many implications started to unfold. Some of these implications concerned infertility: If the body makes its own morphine-like compounds during stress, maybe those compounds were responsible, in part, for impaired fertility among female athletes; morphine has long been recognized to impair reproductive function.
So, we did a study where we recruited female college students who were sedentary, and had them ride on a stationary bicycle for 30 minutes up to a certain percent of maximum heart rate. Then they began a daily exercise program that over a couple of months progressed from jogging to running. We tested them monthly and found increasing amounts of beta-endorphin, an endogenous opioid, in their blood as they became fitter over time. We published the study in the New England Journal of Medicine, a high-profile venue. This study—widely misreported as involving “runner’s high,” which it didn’t address in any way!—attracted a lot of attention, including many prospective research collaborators.
I was in the lab one day after the study was published and my lab mate got a phone call. He put his hand over the mouthpiece and said, “Dan, how’d you like to give a talk?” Cleveland Clinic was planning a big conference on opioids and anesthesia, and they wanted a lead speaker who could talk on these new discoveries about endogenous opioids and their receptors. They had lined up a Nobel laureate, but he got sick and couldn’t do it. I went out there to give the talk, and the anesthesiologists could not hear enough about opioids—they were so interested.
I thought about where the understanding of the endorphin system was likely to have a long-term impact. It was probably not in reproductive science, but very likely in pain. The endogenous opioids are peptides, and as an endocrinology research fellow I had studied peptide synthesis. So I knew how, or at least knew people who knew how to make analogs of these endogenous opioid molecules and tweak their structure to devise new molecules with the promise of fewer side effects or greater efficacy. I then did another residency in anesthesiology and specialized in pain. So my interest in pain was based on my interest in endorphins and my combination of lab and clinical studies.
What drew you to the area of pain education?
When I moved from Massachusetts General Hospital to Tufts, many organizations were starting specialized pain fellowships and other educational programs on pain, and I thought we could do something along these lines. Around that time, one of the health services researchers at Tufts, a medical sociologist, got a grant to do cancer pain education using linguistically and culturally appropriate materials. She sought me out because I was the head of the pain clinic, and she wanted some expertise on pain medicine. It was eye-opening to work with her, because her point of view was totally different from that of a molecule-oriented lab person like me, so it was intriguing. We thought about putting together a pain program that covered the expected curriculum, but if we did this from a public health perspective, we could also include courses on epidemiology, institutional change, social justice, and ethics. That’s when we started the Tufts Pain Research, Education and Policy Program.
Tell me more about the program.
It’s a two-year master of science program. From day one it’s had a public health perspective. Our idea was not to offer a clinical fellowship in pain medicine, like anesthesia or neurology specialties might have; I myself had started a couple of these medical board-certified training programs for physicians learning how to perform specialized injections and pain-relieving procedures. Instead, we wanted to fill gaps in pain education for mid-career learners.
Our program’s content includes biomedical science that you would see in just about any curriculum for pain. What are nociceptors? How does pain sensitization occur? How do the different analgesic drugs work? We also have courses in pain assessment, psychological aspects of pain, mindfulness and pain, culture and pain, palliative and end-of-life care, and social and ethical dimensions of pain. There is also an epidemiology and biostatistics course requirement so that students can learn to look at a research paper critically. Several of our courses address stigma and pain.
We also offer a course in organizational analysis and change, because if our students go out to a healthcare center or network, and they’re the pain resource people, as much effort needs to be devoted to making systems of care that run smoothly as to understanding a molecule hitting its receptor.
What about the clinical side of things?
Although it has never been a goal of this program to provide clinical certification, we feel that whatever background the students have, they really should know something about the most prevalent pain conditions such as back pain, cancer pain, zoster pain, or diabetic neuropathy, and should be able to understand the vocabulary that their biomedical colleagues employ. And if they have their own findings or ideas, they should be able to communicate them using a vocabulary and concepts that their colleagues will find understandable. Thus, all students in the program take a course called Introduction to Clinical Pain Problems, as well as a course on the clinician-patient relationship. What if my focus is just on getting the right molecule to the right place—why would I even care about the clinician-patient relationship? And the answer is, it matters a lot.
Our program has a strong emphasis on the interprofessional aspects of pain management. Many of our graduates work as part of an interprofessional team, so we offer a whole course on interprofessional team dynamics in pain management. Our program has an interprofessional faculty including nurses, pharmacists, dentists, physicians, physical therapists, and psychologists.
You have been deeply involved in pain management policies over the course of your career, including in the development of the United States’ National Pain Strategy. Why should pain scientists, clinicians, or trainees contribute to policy?
I was fortunate to launch my career in pain research and practice at a time when major advances were taking place worldwide not only in laboratory studies but also in patient-centered care and evidence-based medicine. Much of my career has been spent at the intersection of these trends, for example, in co-chairing US federal panels that produced the earliest evidence-based clinical practice guidelines on any medical topic; ours was acute pain. In recent years, as the US and several other countries have struggled to deal with a dual crisis of undertreated pain and soaring rates of opioid use disorder, multiple groups from professional societies to governmental agencies have addressed these devastating problems.
At the US federal level, a comprehensive effort was launched several years ago to integrate and prioritize key pillars of a national pain strategy (NPS) to address both pain and substance abuse. These pillars include clinical pain control that employs non-opioid and nondrug measures to reduce or avoid reliance upon opioids for acute pain. This multimodal approach is discussed at length in the 2019 IASP monograph on pain after surgery; its contributors include members of IASP’s Special Interest Group on Acute Pain, as well as IASP’s current president, Lars Arendt-Nielsen.
The NPS’s pillars also include professional education, healthcare reimbursement policies, public education, inequities in access to care, pain prevention and care, and the epidemiology of pain. Given my 30 years of experience in educating healthcare professionals, I participated not only in the NPS’s clinical care working group but also its working group on professional education. The NPS is a huge effort, run masterfully by NIH’s Linda Porter and initially Stanford’s Sean Mackey, and now the National Institute of Neurological Disorders and Stroke’s (NINDS) Walter Koroshetz. I continue to serve on NIH’s Interagency Pain Research Coordinating Committee with many other professionals and patient advocates. These efforts are resulting in funding opportunities such as the new Helping to End Addiction Long-term (HEAL) Initiative.
IASP’s 2018 Global Year for Excellence in Pain Education was the culmination of decades of work by dedicated pain educators too numerous to identify individually. At the conclusion of my plenary talk on postmodern pain education, I emphasized that being part of a good cause that’s larger than yourself is one of life’s great satisfactions. There’s a famous quote from Bernard Shaw on happiness. He said it much more eloquently than I will, but it’s something like: Be involved in a cause bigger than yourself, give it your all, be chewed up, spat out, and exhausted after doing that, but know that you really tried to fight the good fight. To me, today’s good fight involves trying to address the needs of people with pain while trying to bring under control the public health crisis of substance abuse. This is why it’s important to contribute to pain policy.