A Journal of Rhetoric in Society
Research Update: Pain Medication
and the Figure of the Pain Patient
University of Birtish Columbia
, Vol. 2, Issue 2, 2012.
Research Update: Pain Medication and the
Figure of the Pain PatientJudy Z. Segal
Coalition, pain patients are "treated as
complainers, malingerers, and drug
seekers" (Walton). Clearly, there is some
need to rehabilitate the figure of the
pain patient in medical and public
My focus in this project is on the person
in pain, and this part of my research
began with an interest in returning
to an analysis Elaine Scarry proffered
in the 1980's. In "Willow Bark and
Red Poppies: Advertising Remedies
for Physical Pain," Scarry noted a
Judy Z. Segal is a Professor of English at
difference between pain-medication
University of British Columbia and has
advertisements for physicians (in
published numerous articles and book
particular, the convention of portraying
chapters on medicine studies and the
pain graphically for readers who
rhetoric[s] of health and medicine. Her
are not actually in pain) and pain-
medication ads in the popular press,
as published by SIU Press in
directed at people in pain, who don't
2005. A Social Sciences and Humanities
need much graphic representation
Research Council (SSHRC) grant recipient,
at all. Scarry used audience as a way
Dr. Segal is currently studying the
to account for generically different
relations of public discourse and personal
appeals. I wondered if, with changes
experience in matters of health and
in advertising platforms and policies,
illness. This piece on the rhetoric of pain is
the representation of the pain patient
rooted in that larger project and serves as
had changed in thirty years or so.1 I
a research update to her ongoing work.
discovered that, for the most part,
Scarry's contrast still holds: pain-
medication ads in medical journals still
About two years ago, Canada's national
typically feature a tormented-looking
newspaper, the Globe and Mail, reported
subject, while, for example, in mass-
that six to eight million Canadians live
circulation magazines, a currently-
with chronic pain, that pain conditions
running ad for the pain reliever Excedrin
cost the health-care system over $6
says only, "Relief starts in 30 minutes.
billion a year, and that medical students
Sufferers know how fast that is."
get five times less training on pain than
veterinarians do (Walton). According
Scarry's analysis provides a starting
to the President of the Canadian Pain
place for an examination of the figure
of the pain patient. Pain medication ads
of workdays lost and number of
are interesting to rhetoricians because
dollars correspondingly spent. In some
they are one means by which the pain
accounts, lost revenue amounts to over
patient is represented to him/herself
$15 billion per year (Kalra and Elliott).
and to others, in professional and public
spheres. They are also a means by which
Ads for pain medications, both in
suffering is measured and the need for
professional journals and in public
pain medication is calculated.
media, are aimed at getting the
sufferer back to work—and back in the
Pain is inflected with cultural norms,
family picture: sometimes literally. In
and so it can be experienced differently
a recurring ad for the migraine drug
according to local custom. Within
Relpax (eletriptan), an un-medicated
local custom, it can be experienced
mom is photographed with dad and
differently according to, for example,
two children. She is horizontal and only
gender, ethnicity, religion, and class. In
partially in view; she is under a boulder
this piece, I set aside those differences
of pain. A medical-journal ad for the
to focus on my more general question
migraine drug Imitrex (sumatriptan)
about public discourse and personal
pictures a woman and child and
experience. On the one hand, pain is an
features the refrain, "I'm back!" A direct-
event or condition socially negotiated;
to-consumer ad for the same drug
for the same reason, the pain patient is
features a distraught and disappointing
socially constituted. On the other hand,
mother, one who apparently has not yet
pain is experienced individually and, in
taken her medication.
many ways, privately. How does public
discourse affect the experience of the
Relief of a primary pain condition,
like migraine, stands apart in the
pharmacopeia from relief of irritable
Pain as Socially Negotiated and
bowel syndrome or arthritis or
depression, although each of these is
painful in its own way. Where pain itself
That pain is socially negotiated is a fact
is the problem, and not secondary to
that pain-medication ads exploit and
another problem, it is rendered in a
re-affirm. Pain is, in itself, invisible; it
series of rhetorical indirections. Pain is
is, in any case, frequently concealed.
difficult to express and hard to measure.
Pain is not, on its own, contagious;
It is frequently without external signs
there are no pandemics of pain. That
and only describable in extended prose
is, outside the bounds of the pain-
unsuited to medical contexts.2 For
afflicted body, pain is not threatening,
purposes of diagnosis and treatment,
except to the social fabric—and to the
prose is often elided, converted into
economy. In medical discourse and
pain-scale numbers and a finite set
in pain-medication advertisements,
of qualitative terms (pain, for most
the costs of pain to work and to family
patients, is self-reported on a scale
are proxies for the experience of pain.
from 1 to 10 and describable only by
Medical journal articles on migraine, for
adjectives such as "burning," "searing,"
example, take up the epidemiology of
"throbbing," or "pounding"). The patient
migraine, expressed not only in number
is pain's only first-hand witness, and
of people affected but also in number
self-report has its problems:
The merest schoolgirl, when she falls
to about thirty in popular magazines—
in love, has Shakespeare or Keats to
sometimes for non-prescription
speak her mind for her, but let a sufferer
drugs like Tylenol and Excedrin but
try to describe a pain in his head to a
sometimes for prescription drugs like
doctor and language at once runs dry.
Lyrica (pregabalin) for fibromyalgia and
There is nothing ready made for him.
neuropathic pain. In the case of each ad
He is forced to coin words himself, and,
I examined, I asked a central rhetorical
taking his pain in one hand, and a lump
question, "Who is persuading whom
of pure sound in the other . . so to crush
of what, and what are the means of
them together that a brand new word
persuasion?" My main concern, however,
in the end drops out. Probably it will be
was not the rhetoric of individual
something laughable. (Woolf 6-7)
ads so much as the larger rhetoric of
representation of the pain patient. So
Virginia Woolf here anticipates Elaine
my investigations took me beyond
Scarry's The Body in Pain, at the centre
advertisements and into the contexts of
of which is an argument about pain's
public discourse into which those ads
inexpressibility.3 Scarry also writes
about pain's characteristic admixture of
certainty and doubt. "[T]o have great
Here are three initial findings of my
pain is to have certainty," she says; "to
hear that another person has pain is to
have doubt" (7).
1. In many ads, across venues, lost family
time and lost work time are proxies for the
Pain is, at least, difficult to express,
experience itself of pain.
and much evidence supports Scarry's
claim that other people's pain can
While Scarry had noted one kind of ad
be doubtful.4 Furthermore, the
appeal for physicians and another for
relief of pain can be, for its part, also
pain sufferers, I found a shift for both
unspeakable since it may trespass
audiences to appeals focused not on
into pleasure and raise the specter of
pain itself but on what pain prevents
addiction.5 This being the case—that, in
a person from doing. Increasingly,
matters of pain, the inexpressible meets
the problem that advertisements are
the unspeakable—what are the means
positioned to solve is that pain keeps
by which we communicate about pain
people from being productive—from
and pain relief at all?
being good workers or good partners or
good parents. In the discourse of health
Representations of the Person in Pain
care, a complaint merits treatment
when it interferes with normal function.
Because Scarry wrote before 1997,
As a current television ad for non-
when legislation changed in the United
prescription Tylenol says, Tylenol lets
States to loosen restrictions on direct-to-
you "get back to normal, whatever your
consumer advertising for prescription
normal is."7 That is, pharmaceutical ads
pharmaceuticals, the drug ads she
link pain medications to the normal and
compared in "Willow Bark" were not
to expectable productivity, and they
necessarily for the same products. In my
make treatment an obligation of social
own study, I examined about thirty ads
beings, an imperative for social life. What
in medical journals and compared them
is interesting here, rhetorically, is not
simply the appeal itself (in fact, most
to the People Magazine confession,
medications are advertised according
exhibited little sympathy for McCain,
to a hierarchy of social values and
quoting her selectively in a way that
obligations8). What is interesting is that
seemed, more than anything else, to
pain itself, the personal suffering—that
mock her.10 This is the dubious way
very thing whose inexpressibility was
pain patients are represented in public.
the problem in the first place—has been
What sort of relief might such patients
proxied almost out of existence.9
conclude they deserve?
2. While pain patients are the credible
3. In public discourse, the pain patient is
subjects of pain-medication advertising,
sometimes confused/conflated with the
they are often represented in popular
discourse as suspect.
Features appear regularly in the media
One place to look for the figure of
on abuse of prescription painkillers.
the pain patient is in celebrity illness
Lately, the discourse has reached a fever
narratives. People Magazine and other
pitch, as Purdue Pharmaceuticals has
weeklies regularly publish the personal
acknowledged the potential for abuse
accounts of celebrities who are being
of its time-release opoid OxyContin and
rehabilitated after prescription drug
has stopped its manufacture, replacing
abuse. These illness narratives tend
the drug with OxyNEO. OxyNEO is,
to run in the same direction: X was
like its predecessor, a timed delivery
prescribed painkillers following an
system for the narcotic oxycodone, but
injury or illness; pain became chronic; X
the new drug is less susceptible than
began to self-medicate, to overuse, and
the old one to the sort of tampering
. . now he/she is in rehab. Perhaps for
that disables its time-release function,
this reason–the narrative conflation of
and so it is less susceptible to abuse.
pain, drugs, addiction, and privilege–
While there is panic in the media (e.g.,
when a celebrity goes public with a pain
Goldman; Morris) about abuse of
condition (as opposed to another health
prescription narcotics, we find, on series
challenge), s/he risks being treated
television, characters in two acclaimed,
badly in the press. When Cindy McCain
eponymous, programs—House and
was interviewed for People about her
Nurse Jackie—who get some of their
migraines (the "secret agony" [McNeil]
mystique, and some of their rogue
which had, indeed, led to an addiction
appeal, from their use of these very
to prescription painkillers), some readers
drugs (OxyContin, Percocet, Vicodin).
of the magazine wrote in supportively,
using the highly conventionalized
Mass-media displays of both moral
genre, letter in response to a celebrity
anxiety and moral ambiguity have
confession: "I hope Cindy McCain can
always been material for water-cooler
bring attention to [migraine] and help
conversation, or its online equivalent,
to its sufferers and I wish her well in her
but here the discussion can turn
own battle with this misunderstood
reflexive. That is, when we take a
affliction" (Wolfe). Some people,
position on the use of unprescribed
however, were unmoved by McCain's
prescription drugs, we are, in some
illness narrative. In the New Yorker,
cases, taking a position on ourselves:
columnist Lauren Collins, responding
we are, if we think about it, many of us,
prescription-drug abusers ourselves.
How many drugs do we take, exactly,
and on whose authority? Did we really
This piece has explored some of the
need to finish the bottle of Tylenol
ways that public discourse on pain
3's the dentist gave us when we had
represents persons in pain and affects
that root canal? Have we neglected
the perception, and self-perception, of
to dispose of the remainder of the
the pain patient. It has suggested that
morphine we brought home from the
the experience of being a pain patient
hospital after a recent surgery? In the
is, in part, an effect of rhetoric, and that
midst of an anxious and ambivalent
rhetorical reform may be one means by
public discourse on prescription drugs,
which the pain patient can be rescued
the pain patient may well wonder not
from the effects of a problematic
only what to do and what to take but
identity. These are matters I take up in
also how to see and judge him/herself.
ongoing work on pain discourse and
pain patients, and, more generally, on
In medical journals, advertisements
the relation of public discourse and
for opioids address the question of
personal experience. That research is
addiction directly, if sometimes a little
focused on the way public values are
too subtly.11 In the absence, however, of
taken up in individual bodies, on how we
advertisements for opioids to patients—
become ill in the terms most available
for there are no such advertisements—
for us to become ill in, and on how we
pain patients are left to figure out for
see ourselves when we see ourselves
themselves the relation of prescription
reflected through the public gaze.
and addiction. They use what meager
information is available to them formally.
(Post-operative patients are told, for
example, "Do not worry about becoming
addicted to your pain medication.
People only become addicted if they
take their pain medicine for reasons
other than to control pain" [Vancouver
Coastal Health 2]; that is, sadly, false.)
Often, they rely for information on
support groups and online resources,
including web sites sponsored by
pharmaceutical companies. Sometimes,
what seem like grassroots pain sites,
such as Partners Against Pain, the
domain name for the site owned
by Purdue Pharmaceuticals (
"Astroturf" sites (Pezullo), animated not
by the public but by stealth commercial
sponsors. That is, being structurally
suspect, pain patients are left, ironically,
with nothing but potentially unreliable
sources of information.
9. A counter-example is worth
mentioning: A direct-to-consumer
1. Scarry did not anticipate direct-to-
magazine ad for the prescription
consumer advertising for prescription
migraine drug Treximet (sumatriptan
pharmaceuticals: "Prescription drugs
+ naproxen) features a decapitated
themselves will not be the subject of
woman holding her head in her hands
public medical advertising, since the
(she'd rather have it off than on), and
public cannot on its own purchase such
pain, rather than poor productivity, is the
drugs" ("Willow Bark" 47).
topic of the appeal.
2. Many say there is no better account
10. Collins writes, "McCain . . this year
of migraine pain than in Joan Didion's
participated in a clinical trial to test the
essay, "In Bed." See also Claire's Head
effectiveness of Botox in alleviating
by Catherine Bush, a novel about
migraine. ‘You know, they ring your head
two sisters, one of whom has gone
in it,' she said. ‘It hurts like the dickens.
unaccountably missing. Migraine is the
But I'll do anything . . if it would help me
sisters' bond. The trail left by the pain
get rid of this.'" This comes after Collins
(I imagine a bracelet that says, "What
has described McCain as she addressed
would the headache do?") helps solve
the American Headache Society: "She
the mystery and reunites the sisters.
was dressed in spectator pumps and a
chartreuse piqué suit. Everything about
3. While pain scholars acknowledge
her seemed lemony—tart yellow bob,
Scarry's contribution to pain studies as
pursed lips . . " (38). Collins makes it
significant, some have begun to take
hard to take McCain seriously, or see her
a critical look at her claims about pain
experiment with Botox as unconnected
as inexpressible. A recent paper by
to any possible cosmetic effect of the
Elizabeth Anker is emblematic of this
shift in reception.
11. See ad for OxyContin (Purdue
4. See Craig, Hyde, and Patrick for an
Pharmaceuticals) in American Family
example of the literature on "faked" pain.
Physician (June 1, 2008): "Oxycodone can
be abused in a manner similar to other
5. On this topic, see, for example,
opioid antagonists, legal or illicit. This
should be considered when prescribing
or dispensing OxyContin in situations
6. Since I wrote this paper, Meldrum
where the physician or pharmacist is
has published an excellent essay on
concerned about an increased risk of
"the [opioid] prescription as stigma."
misuse, abuse, or diversion" (1497).
Her essay is, in many ways, also on the
relation of public discourse and personal
experience in the realm of pain.
Anker, Elizabeth. "Toward a
Phenomenology of Pain." Modern
Languages Association 2012. Seattle, WA.
8. See my "What, in Addition to Drugs,
8 January 2012. Conference presentation.
Do Pharmaceutical Ads Sell?"
Bush, Catherine. Claire's Head. Toronto:
McLelland & Stewart, 2005. Print.
Morris, Ethan. "Prescription for Abuse."
KTCS 9 Documentary. PBS. KTCS
Collins, Lauren. "Not Tonight Department:
9, Seattle. 30 Jan. 2012. Television
Head First." The New Yorker 21 Sept 2009:
36, 38. Print.
Pezzullo, Phaedra. "Resisting ‘National
Craig, Kenneth D., Hyde, Susan A.,
Breast Cancer Awareness Month':
and Christopher J. Patrick. "Genuine,
The Rhetoric of Counterpublics and
Suppressed, and Faked Pain Behavior
their Cultural Performances." Quarterly
during Exacerbation of Chronic Low Back
Journal of Speech 89 (2003): 345-365.
Pain." Pain 46 (1991): 161–71. Print.
Derrida, Jacques. "The Rhetoric of Drugs:
Scarry, Elaine. The Body in Pain: The
An Interview." Differences 5.1 (1993):
Making and Unmaking of the World.
Oxford; New York: Oxford University
Press, 1985. Print.
Didion, Joan. "In Bed." The White Album.
New York: Simon & Schuster, 1979. Print.
—. "Willow Bark and Red Poppies:
Advertising the Remedies for Physical
Edmeads, John. "The Dark Side of
Pain." Resisting Representation. New York:
Medication Abuse." Editorial. Headache
Oxford University Press, 1994. 13-48.
29 (1989): 190-191. Print.
Goldman, Brian. "Generation Rx: Town
Segal, Judy Z. "What, in Addition to
Hall." White Coat, Black Art. Canadian
Drugs, Do Pharmaceutical Ads Sell?:
Broadcast Corporation. 5 Dec 2011.
The Rhetoric of Pleasure in Direct-to-
Consumer Advertising for Prescription
Pharmaceuticals." In Joan Leach and
Kalra, Arun A., and Debra Elliott. "Acute
Deborah Dysart-Gale, eds., Rhetorical
migraine: Current Treatment and
Questions of Health and Medicine.
Emerging Therapies." Therapeutics and
Lanham, MD: Lexington Books, 2011.
Clinical Risk Management 3.3 (2007): 449-
Vancouver Coastal Health.
McNeill, Liz. "Cindy McCain: Her Secret
"Laparoscopic Gallbladder Removal
Agony." People 14 Sept 2009: 147-149.
Instructions." May 2011. Print.
Meldrum, Marcia. "The Prescription as
Walton, Dawn. "Canadians in Pain Aren't
Stigma: Opioid Pain Relievers and the
Seeking Proper Help from Doctors."
Long Walk to the Pharmacy Counter."
GlobeandMail.ca. The Globe and Mail, 12
In Jeremy Greene and Elizabeth Siegel
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Watkins, eds., Prescribed: Writing, Filling,
Using, and Abusing the Prescription in
Wolfe, Laurel. Letter. People (October 5,
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Hopkins University Press, 2012. 184-206.
Woolf, Virginia. On Being Ill. 1926.
Ashfield, MA: Paris Press, 2002. Print.
Professor Segal teaches rhetorical
history and theory and rhetoric of health
and medicine at the University of British
Columbia. Her recent essays appear in
journals such as Written Communication,
Journal of Medical Humanities, Journal
of Sex Research, and Cephalalgia, and in
collections such as Sage Handbook of
Rhetorical Studies (Lunsford et al, eds.,
2009) and Rhetorical Questions of Health
and Medicine (Leach and Dysart-Gale,
eds., 2011). In 2011, she was a Visiting
Scholar in the Department of Social
Studies of Medicine at McGill University.
Drug-Induced Encephalopathy Julius-Maximilians University Würzburg, Department of Neurology 1. Introduction Drug-induced encephalopathy is a disease entity often caused by impaired cerebral metabolism that is not attributed to structural brain lesions. However, some drug-induced encephalopathies can develop structural lesions and share other underlying pathophysiological mechanisms (table 2). Leading symptoms are acute or chronic disturbances of consciousness, brain function and personality changes with concomitant neurological symptoms such as asterixis, myoclonias, paresis or seizures (see table 3). Isoniazid-induced encephalopathy was one of the earliest descriptions of a drug-induced encephalopathy (Adams & White, 1965). Clinical symptoms depend on the type and severity of the drug-evoked encephalopathy. A well-described and frequently-reported drug-induced encephalopathy is valproic acid encephalopathy, first described in the late 1970s. This acute encephalopathy was characterized by altered behaviour, worsening seizure control and confusion. After a reduction in the valproate acid dose, the patient's symptoms resolved completely (Chadwick et al., 1979). Encephalopathies have been reported after consumption of several types of drugs as depicted below (table 1).
Iontophorese mit Voltaren® Emulgel® als eine mögliche physiotherapeutische Behandlungsmethode bei Schmerzzuständen Erläuterung am Beispiel von postoperativen Schmerzen nach einer mikrochirurgischen Bandscheibenoperation in der Lendenwirbelsäule Wissenschaftliche Hausarbeit zur Erlangung des akademischen Grades einer Magistra Artium