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A Journal of Rhetoric in Society Research Update: Pain Medication and the Figure of the Pain Patient University of Birtish Columbia Present Tense, 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 drug addict. 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.
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Vancouver Coastal Health. McNeill, Liz. "Cindy McCain: Her Secret "Laparoscopic Gallbladder Removal Agony." People 14 Sept 2009: 147-149. (Cholecystectomy): Discharge 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 May 2010. Web.
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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.

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