PROVIDENCE – It took a long time, two-and-a-half hours in, after five presentations by brain experts organized by the Norman Prince Neurosciences Institute on “Addiction: The Substance behind the Substance,” to finally get to the nitty-gritty.

A member of the sparsely attended forum on May 1 at the Warren Alpert Medical School asked the impertinent question: Why was Rhode Island experiencing such an epidemic of addiction?

The answer that emerged was not psychological but clinical: the medical decision to elevate the treatment of pain as the fifth vital sign may have been a mistake, according to Dr. Robert Swift, professor of psychiatry and human behavior at the Warren Alpert Medical School at Brown University.

Swift acknowledged that the pendulum in how pain is treated had perhaps swung too far toward attempting to eliminate pain for patients through medication. “All pain is not bad,” he said, in relation to the process of healing. “Some residual pain is not bad.”

Green, in turn, said that efforts to control abuse of prescription painkillers – making them more difficult to obtain, and changing the formula to make them more difficult to abuse – may have precipitated heroin becoming the drug of choice.

Didactic tone
Up until that point, the evening’s experts – all members of the medical school faculty – had lectured on the clinical aspects of substance abuse, often in a didactic tone of expert talking to student.

Dr. Janette Baird, assistant professor of emergency medicine, gave an overview addiction in Rhode Island by the statistical numbers. No surprise here – Rhode Island has a big problem, with the death toll for accidental overdoses in 2014 at 90 and counting.

Dr. Jane Metrik, assistant professor of behavioral health, delineated the dangers of marijuana and the brain. Metrik warned about the dangers of people under the influence of marijuana operating motor vehicles.

Swift lectured on the long-term deleterious effects of alcohol on the brain, still the leading choice for substance abusers.

Traci Green, Ph.D., assistant professor of emergency medicine, discussed the use of naloxone, or Narcan, as an effective, preventive measure to halt overdose deaths from opioids.

And Dr. Jason Hack, associate professor of emergency medicine, expounded on the dangers of unused medication, citing the problem of accidental poisonings in children.

Right before the lecture began, Hack had called his source at the Drug Enforcement Agency to get the actual number – more than a ton – of drugs disposed in the take-back medication day the previous weekend.

Cause and effect – and response
Another member of the audience, Sandra Gervasio, posed a question to the panel, asking them whether treatment should look at the reasons why a person would be self-medicating – and not just about how to get them off the addictive substance.

“I would like to see more of a balance between treatment – and not just a quick medication, or a medication to take the place of another medication – but to actually treat the problem at hand,” she told ConvergenceRI after the lecture. Too often, she continued, “it just gets buried, it gets lost. Patients are given an anti-depressant, but they’re not treated for why they are depressed.”

For Gervasio, it was very sad to see how quickly doctors prescribe painkillers, even with teenagers. “They’re just getting immune and they’re using the lingo,” she said. “When teenagers come into the emergency room, they’re asking for pain medication by nickname, Vikes, as if they’re their buddy.”

Relationship to pain, psychological trauma
When another audience member asked: “Do we need to rethink the way we deal with trauma by giving patients pain medication?” the panel responded with a stunned silence for about 20 seconds.

“That’s a big question,” Baird finally said.

Let’s limit the discussion to psychological trauma, such as post-traumatic stress disorders, the questioner said, pointing to high incidence of sexual violence and abuse in Rhode Island.

Swift said that PTSD does cause brain changes, reducing the size of the front lobes. “People with PTSD respond to stress differently,” he said. To some extent, he continued, “the use of substances might be seen as a self-medication to take away the psychic pain.”

When people come into treatment because they have a substance abuse disorder, Swift said, but they may also have this underlying condition. “A person needs treatment for both.”

Two separate levels of discourse
Less than a week after the “brain power” forum, on Tuesday, May 6, the Prince Neurosciences Institute will host a full-day symposium on pain research, “Mechanisms and Biomarkers,” featuring many of Rhode Island’s top neuroscientists.

The topics include: markers of pain in the human brain, molecular, cellular and system approaches to pain, and treating pain with brain stimulation, using both invasive and non-invasive therapies.

Among the presenters will Dr. Tipu Zahed Aziz, professor of neurosurgery at John Radcliffe Hospital in Oxford, who specializes in the use of deep brain stimulation; Dr. David Borsook, director of the Pain and Imaging Neuroscience Group in Boston; Dr. Frederick Burgess, chief of anesthesia at the Providence VA Medical Center; Julie Kauer, Ph.D., a professor of medical science at Brown and a leader in the field of synaptic transmission of plasticity; Diane Lipscombe, Ph.D., a professor of neuroscience at Brown whose research has focused on cellular mechanisms used to optimize calcium ion channel function; and Dr. Timothy Mariano, a third-year resident in the Department of Psychiatry and Human Behavior at Butler Hospital, who is investigating the potential for using transcranial current stimulation to treat pain.

The closeness in timing of the two forums – and the apparent disconnect between them, targeted at different audiences – one for general public consumption, the other for academic researchers – reflects the need for a more holistic approach to dialogue and decision-making around clinical treatment of pain, trauma and depression.