Jack Hamilton | Ending POP* Culture (*Prescription of painkillers)
When it comes to solving chronic pain, our approach has remained largely the same for 500 years.
500 years ago, scientists made the groundbreaking discovery that opium could be used for the treatment of pain. But since then, we haven’t actually made a whole lot of progress. Opioid based medications remain by far the best for treating short term acute pain, but long-term chronic pain is a different story.
Our best answer for chronic pain remains an indefinite, perpetual prescription of pills, which have a range of debilitating side effects and carry severe risks of addiction and abuse. Given that pain is something we have all experienced in our lives, isn’t it time to come up with some different solutions? With a better understanding of how pain actually works, thanks to neuroscience, some radical new treatments are in the works that will help us move beyond prescription painkillers.
UNSW Centre for Ideas: Welcome to the UNSW Centre for Ideas podcast. A place to hear ideas from the world's leading thinkers and UNSW Sydney’s brightest minds. The talk you are about to hear, Ending POP* Culture (Prescription of Painkillers), features UNSW Sydney’s student Jack Hamilton, and was recorded live. This talk was a part of ‘Fresh Blood’, an event of short talks in the 2022 Festival of Dangerous Ideas.
Jack Hamilton: The year is 1543. And you, the astronomer Copernicus, have just finished writing a paper on your latest discovery that the earth in fact revolves around the Sun, not the other way around. You're extremely proud of your achievement. But you've developed an intense pain in your wrist from the many hours spent at the desk dripping your quill. So you go to your local physician and you ask for some relief. You've heard whispers of these ‘stones of immortality’ that can supposedly make pain go away, you're granted your requests and begin your course, popping these little black pills whenever the pain appears. Life's a dream. Fast forward 300 years to the 1820s. And you, the poet Elizabeth Barrett Browning, are attempting to saddle your horse when you suddenly feel a nerve pinch in your back. So you go to your local physician and you ask for some relief. You're prescribed laudanum, a solution made from the opium of poppies. The same key ingredient is that in Copernicus's stones of immortality, the pain disappears and life's a dream. Except that when your back heals, and the pinching stops, your habit of taking opium doesn't. You continue to use it, yes for pain and illness here and there. But also to help slow your speeding heart when you're anxious, or just because it's easier to get to sleep at night. You continue taking opium for another two decades after your saddle injury, unable to stop for fear of the stomach cramps, muscle aches, nausea and agitation that occurs when you try. Life's not so dreamy.
Let's fast forward once more, another 200 years. It's 2020, and you're an everyday citizen living in everyday life going about your everyday things. Except you, like 30% of everyone around you put up with a persistent ache, or stabbing or burning or throbbing, perhaps in your neck or your wrist or back or leg. So you go to your local physician and you ask for some relief. You're prescribed oxycodone, and told to take one tablet three times a day. And to come back in three months if you're still in pain. You asked what options are next, if that's the case, but are met with a sad smile. So without much choice, you take your prescription and begin your course. Now, one very last time, let's just fast forward those three months, you're back, the pain still there. But now, too, a severe dependence and addiction to your prescription. When you try to stop, all the withdrawal symptoms felt by Browning 300 years ago, plagued you too. You can't work, you can't think, you can't enjoy the things you used to. All the while your pockets are being empty on packets of pills to no avail. But perhaps worst of all, is the fact that no one around you truly understands what it's like. No one truly appreciates just how unbearable and distressing it is to live like this. Life at this stage is more of a nightmare.
When we think of the leaps and bounds that we've made in science and medicine in recent times, we think this would apply pretty generally to all fields of research. But when it comes to solving chronic pain, our approach has remained largely the same for just about 500 years. While we're all very familiar with pain, we know what it feels like. We know the sorts of things that cause it. Even the pain experts among us are still understanding exactly how chronic pain works, and more importantly, how to treat the many different types of chronic pain. For 500 years our main approach to combating this evasive sensation has been the prescription of painkillers, of pills made from poppies, pop culture. Now it's important to acknowledge there’s quite a good reason for this. Opioid based pharmaceuticals are extremely effective as medicines against pain. In a matter of seconds, they can make even the most intense episodes of acute or short term pain disappear. For things like broken bones or pain after surgery, opioids win every time. And in this sense, they really are a phenomenal medical success. An issue though, lies in the way that they use has evolved. Since they've proven to be such a great answer to short term pain. They've been translated across as a treatment for all types of pain, including chronic pain.
Now to understand why this is such an issue, we need to just take a quick look at some of the fundamental differences between acute and chronic pain. Where acute pain alerts us to danger or damage to our bodies, but then disappears as we heal. Chronic pain on the other hand, outlasts the period of injury. And because of this, it no longer serves its protective purpose. On a more microscopic level, where normally a trigger for acute pain, like something sharp or burning hot, would first activate these specialised pain receptors in our skin that would send electrical signals along our nerves to our spine, and then up to our brains for us to become aware of it. In chronic pain, this complex system is diseased and dysfunctional, and these pain signals can give our brains the wrong information. Not only can the pain seem to last longer than it's supposed to, but it can become infinitely more intense, or be caused by things that it shouldn't. This can look like a warm shower feeling like fire on your skin, or soft carpet suddenly feeling like spikes to walk on. This is particularly true for people suffering from neuropathic pain, which is a particular type of chronic pain caused by damage to your nerves or your nervous system. This can be caused by things like a traumatic injury, or chemotherapy treatment. But while the pain itself can be widespread, it's often a very localised nerve injury that's responsible. What this means is that traditional opioid based medicines that work at the level of the brain to dulled down sensations of everything, are acting more like a sledgehammer for a job that requires a scalpel. And along these lines, our goal isn't to completely eradicate pain, but rather to turn it down or regulate it to a level that allows us to live our life.
So this is where I come in with the dangerous idea that I'm working on. I'm part of a research team at the University of New South Wales called the Implantable Neuromodulation Unit. And we research ways to use electrical current to change the way our nervous system behaves. Now, given what we know about a misbehaving nervous system in chronic and neuropathic pain, my specific research is focused on using a new, special type of current to interrupt these misbehaving pain signals, before they can even reach your spine, let alone your brain, to be perceived as pain at all. We're working to achieve this by using a small, surgically implanted device that's designed to wrap around one of your nerves and deliver a stream of this new electric current to it. Now this idea of using electricity to treat pain isn't completely new in of itself. We've had things like spinal cord stimulators that try to mask back pain since the 60s, and even my grandpa reckons he can treat a headache by holding on to the electric fence down the back for five minutes. But the difference now is that recent years have seen an explosion of research and detailed understanding about how our nervous system works. We now know what's going on in our nerves, how they're talking to each other, how the electricity within them behaves. What this means is we can now use this knowledge to create solutions that are much more precise and localised. We're achieving this right now with our device. In a feat that's never before been possible. We can program our device to silence just the parts of your nerve carrying the pain signals, while leaving the other parts carrying information about how things feel to touch, or about our movements, completely unaffected.
While still in its development stage of research, as this and other neuro modulatory technologies emerge, we're going to see drastic changes in the way that pain treatment is approached. Medications like paracetamol, aspirin and codeine aren't always going to be the answer. Soon enough, you will no longer be prescribed pockets of pills, but an implantable neuromodulation technology like that of our device, you will be able to control it through Bluetooth from your phone to turn your sensations of pain and only pain off and back on or down and back up with no side effects. No addiction, no overdose. No more 500 year old pill popping sledgehammer approach. But with such drastic change can come some uncertainty.
The reality of being able to artificially change our experience of the world is no trivial thing. And the thought of implantable electronics that do this, can seem pretty daunting and uncomfortable, and can naturally raise some big questions. When thinking about these, though, it helps to realise that the only reason we're comfortable at the moment, popping pills for chronic pain is because we've been doing it for 500 years. But not only does this approach already artificially change our experience of the world. But we've seen how with misuse, it can completely destroy it. If the ultimate goal of medical science is to improve our quality of life, and reduce suffering, why wouldn't we embrace innovation that offers this? With neuro modulation, we can achieve this in ways that have never to this point been possible. We can give complete control back to patients and allow them to manage their conditions with confidence so they can live a full life once again. This is the hope for patients with chronic pain, that when we fast forward a few more years to the 2030s, neuro modulation, this scientifically sophisticated and no longer unfamiliar approach, will have made chronic pain a thing of the past. It will overcome what is currently a mammoth medical challenge, and allow us to pull the plug on pop culture, once and for all.
UNSW Centre for Ideas: Thanks for listening. This talk was presented by the UNSW Centre for Ideas and Festival of Dangerous Ideas. For more information visit centreforideas.com, and don't forget to subscribe wherever you get your podcasts.
Jack Hamilton is completing a Bachelor of Advanced Science (Hons) – majoring in neuroscience – in the School of Medical Sciences, Faculty of Science at UNSW Sydney. He is investigating a new treatment for chronic pain that involves modulating the nervous system via electric currents. In 2021, Jack was awarded the Faculty of Science Dean's Award for Academic Excellence. Following his Honours, Jack plans to study medicine alongside completing a PhD.