SOURCES OF PAIN: OPPORTUNITIES FOR PREVENTION
Social circ*mstances often dictate whether people will be exposed to injury or disease. Therein lie opportunities for engaging in primary prevention, precluding the likelihood of pain before it happens. Epidemiological approaches to studying the distribution and determinants of pain have identified sociodemographic variations, social risk factors and population health trends in the prevalence and care of diverse painful conditions (
). In establishing the complex web of causation, opportunities for prevention emerge. For example, oestrogen therapy for postmenopausal adult women is associated with increased risk of temporomandibular disorder (LeResche et al 1997). Awareness of this relationship contributes to cost–benefit analysis of hormone replacement therapy, perhaps decreasing the incidence of this painful condition. In this manner, social factors, public awareness and policy may have an impact on use of a biomedical intervention strategy for chronic pain.Characterization of social origins or risk factors has received minimal attention, despite interests of epidemiologists in risk and ecological factors (Dworkin et al 1992). Major categories of social risk factors can be conceptualized (see Box 3.1). The illustrations are not exhaustive; they are designed to highlight potential social causes of pain across the major social contexts of people’s lives. The balance between interpersonal and intrapersonal control of these sources of pain is not always evident. Some events may be the consequence of personal decisions of the person in pain, such as risk taking in dangerous sports, but social pressures and constraints influence such decisions. Pain imposed by others in the interests of the person, but entered voluntarily, is perhaps best typified by medical procedures, including medical prophylaxis, diagnosis and treatment (including surgery). Medical pain usually is construed as an undesirable, but inevitable, event. Nevertheless, recent interpretations increasingly characterize pain as an adverse event and argue that more should be done to preclude or mitigate pain (Chorney et al 2010). Pharmaceutical, psychological and environmental interventions can prevent or minimize immediate pain and the long-term consequences arising from medical procedures. For example, substantial neonatal exposure to pain is often characterized as the inevitable consequence of risk factors associated with preterm delivery, very low birth weight or congenital conditions. Nevertheless, there is reason to believe that exposure to pain is often unnecessarily excessive and disposes to adverse pain experience and behaviour later in life (). Similarly, early life experience of dental pain predisposes children and adults to dental fears and avoidance of treatment (). Thus, social factors again appear responsible for the risks associated with painful exposure and its consequences early in life.
Box 3.1Social actions antecedent to pain
Delivery of medical services (prophylactic, diagnostic, treatment)
Early childhood play and accidents
Risk taking (sports, recreational activities, motor vehicles)
Exposure to danger at work or in domestic settings
Social rituals (circumcision, adolescent rites)
Intentional aggression (criminal acts, police or military action, corporal punishment)
Self-inflicted pain (tattooing, piercing, branding, cutting, masoch*stic acts)
Many other sources of pain outside health care are shaped by social factors. Pain may be a consequence of intentional, aggressive acts, such as in domestic violence, criminal behaviour and police enforcement or military action. Harm can also be the consequence of unintentional or voluntary exposure to risky settings in work, domestic and community environments if protective procedures, training or equipment are not provided or utilized. For example, workplace safety standards depend on policies and procedures and the subsequent compliance by employers and employees. Similarly, major risks associated with driving a motor vehicle have been diminished by programmes designed to enhance vehicular safety, such as use of child restraints, highway engineering, improved signage and markings, and reducing driving under the influence of alcohol. Both illustrate how social interventions can prevent painful injury.
Painful experiences also may be maintained or exacerbated by social events. Stress accompanies both daily life and periods of major social adjustment, and can contribute directly to psychophysiological disorders, lower immune functioning and promote tumour growth. This may compromise healing, thereby contributing to the manifestation, exacerbation and preservation of painful diseases and injuries (Antoni et al 2006). Stressful family, employer or other relationships tend to have a negative impact on coping and result in increased healthcare utilization. Under this strain, there is potential for vicious circles of family conflict, dysfunctional relationships, unemployment and social isolation that in turn perpetuate stress and pain. Alleviating circ*mstances creating stress for the individual can have an impact on the experience and expression of pain.
In general, healthcare systems that promote health provide a multifaceted and sustainable means of addressing pain. The major advances in preventive health care, including immunization programmes and public sanitation, dramatically diminish exposure to pain and suffering associated with infectious diseases. Similarly, injury prevention programmes are effective in reducing the incidence of painful injury (Pike et al 2010). Advertising campaigns, legal regulations and required certification and training all serve as preventive measures to diminish exposure to pain. Many examples of socially oriented programmes, such as ensuring a safe food supply and reducing tobacco use and alcohol abuse, have yielded long-term benefits, including reduction of health costs and the experience of pain. Thus, attention to healthcare policies and public education can be of considerable importance.
