Garland E, Sullivan MD, It is Time to Integrate Chronic Pain and Addiction Services for Patients with Opioid Misuse, J Gen Intern Med, 2025, in press
Excerpt:
Rather than blaming the patient, we must acknowledge the iatrogenic nature of opioid dependence, and recognize that the hallmarks of opioid misuse, dose escalation, and self-medication of negative affect are natural sequelae of the neuroplastic effects of chronic opioid use on brain reward circuitry. Thus, we call for an integrated primary care approach involving behavioral interventions delivered via insurance-reimbursable group visits combined with patient-centered opioid tapering supported by psychiatric management to assist patients in reducing to the lowest comfortable dose of opioids or switching to buprenorphine. This approach, building upon collaborative care models integrating behavioral health into primary care, will yield cost savings by preventing unnecessary imaging, emergency visits, and interventional procedures with dubious efficacy. Beyond cost-effectiveness, such an integrated and compassionate methodology to addressing pain and opioid misuse will alleviate incalculable levels of suffering and advance human flourishing, goals fully congruent with the ethos of medicine.
Sullivan MD, Williams AC, Social determinants and consequences of pain: accidental or essential?, J Pain, 2025, in press
Excerpt:
The recent review by Kapos et al, Social Determinants and Consequences of Pain: Toward
Multilevel, Intersectional, and Life Course Perspectives, is a comprehensive review addressing social pain phenomena at the interpersonal, group/community, and societal levels. The social element is often claimed to be the neglected aspect of the biopsychosocial model of pain, but that neglect is not evident in the 337 references cited here. What is neglected here, from our perspective, is a synthesizing theory for the myriad social effects noted by the authors. Are these effects the accidental product of a pain physiology designed to protect the tissues of biological individuals? Or is this social dimension of pain essential to its function in humans? We believe that the social dimension is essential to the evolutionary history and the survival value of pain for both individual humans and the human species.[3]
One of the fathers of modern evolutionary theory, Theodosius Dobzhansky, is often quoted as saying: “Nothing in biology makes sense except in the light of evolution.”[1] We suggest this should be extended to: “Nothing in the biopsychosocial model of pain makes sense except in the light of evolution.” Pain has survival value insofar as it shapes behavior to increase fitness. For humans, this survival occurs in a complex and pervasive social context, which involves balancing cooperation and competition, communication and deception, as well as individual and group survival. Human social capacities are widely acknowledged to be our most important capacities, enabling our species to dominate in every ecosystem on Earth.[4] Hence, understanding how pain interacts with and supports human social capacities is an essential part of understanding the role of pain in human life.
Sullivan MD, Williams AC, Questioning the boundary between pain and suffering, Pain, 2025, in press
Abstract:
Pain and suffering are important to patients and therefore their interaction is central to clinical care. It also encompasses issues at the forefront of pain neuroscience, evolution, epidemiology, and treatment development. While Medieval Europe understood pain as a religious problem and Enlightenment theorists framed pain as a social problem, over the past 200 years we have come to see pain as a medical problem. The medical problem of pain was originally addressed through the diagnosis and treatment of disease, but Pain Medicine has made the causation and treatment of pain a separate focus for research and clinical care. Palliative care reintroduced attention to suffering into the modern hospital. Eric Cassell argued that suffering arises from threats to the person that go beyond threats to the body. His theory of suffering has been criticized for being too focused on patients’ narrative and too tied to a nociception-centered notion of pain. In general, modern medicine has promoted a unidirectional linear model of pain causing suffering in the individual patient. But this model is not consistent with the latest pain neuroscience and is no longer adequate to guide research or clinical care. If we are to finally overcome dualism in pain theory and practice, we must begin by seeing the relationship between pain and suffering as circular rather than linear. Understanding pain and suffering as a unitary construct can advance pain research and clinical practice by providing a new framework for integrating biological, psychological and social strategies for treating and preventing pain.