#8220;If you’re in pain, then I’m not doing my job.” That’s what my mother, a longtime hospice nurse, tells her patients. In hospice, the prevailing idea is to palliate — which literally means to put a cloak over someone’s symptoms. Providing comfort is the key consideration.
Chronic pain is another story, which I learned the hard way.
A year ago, I herniated two discs in my back. While a disc herniation can often be asymptomatic, mine was not. My back slowly improved, then suddenly worsened. The pain was intense. I asked my doctor for a refill on a pain medication. It was a low dose, and I showed none of the signs typical of prescription medication addiction (early refill requests, taking a higher dose than prescribed, obtaining prescriptions from different physicians).
But her mind jumped there immediately. “I don’t believe you’re being honest with me about how much you’re taking,” she said, her voice rising.
I sat there stunned as she accused me of drug abuse. In the end, she halfheartedly offered me a final refill. At the end of my appointment, she noticed I was silent (not my usual state). “Is something wrong?” she asked. I had been shocked into silence and shook my head no. She smiled, clearly relieved, and proffered her hand. “Hang in there!” she cheered.
That one encounter left me afraid to be honest with doctors about my own chronic pain. And I know my experience is all too common.
Don’t misunderstand me. I don’t think the answer is to throw opioids at everything that says “ouch” long and loud enough. Abuse and misuse of these drugs are real problems. According to the U.S. National Institutes of Health, 5.1 million Americans abused pain relievers in 2010.
No, we need to approach this rationally. The first step in solving any problem is identifying what’s really wrong. When it comes to chronic pain, many people miss the point. To put it bluntly, “chronic pain management,” as a discipline, is the victim of long-term neglect.
From my perspective, nearly all health care can be classified into four treatment categories: preventive, acute, comfort, and chronic. Preventive care doesn’t require pain management. The other three do. Comfort care has taken strides, with the hospice and palliative care movements helping make patients comfortable in their last days. Acute care is rapidly catching up. In the late 1990s, pain was labeled the official “fifth vital sign” in the United States, joining temperature, pulse, respiration rate, and blood pressure. Walk into any emergency room, urgent care, or even primary care doctor’s office in America and you’ll see a pain scale with either words or pictures, sometimes both.
But chronic care still lags far behind acute and comfort care both in terms of recognizing the impact of pain on the patient, and then designing or defining interventions for that pain.
Aside from issues of misuse and abuse, part of this lag is the nature of chronic pain: chronic means chronic. It rarely resolves itself. That fact alone means some wary medical practitioners would prefer not to deal with it. Patients in chronic pain are the difficult ones, the ones that can sap a physician’s financial and emotional resources.
Defining, measuring, and understanding the experience of pain present its own challenges. Everyone’s pain threshold is different. Everyone experiences pain differently. There is a vast difference between pain and suffering. A true interdisciplinary treatment team works to tease apart the two facets, treating physical pain with medical interventions and non-physical suffering with other methods such as counseling and bolstered social support.
But pain and mental illness often coincide, complicating the separation process. Add to all that a lack of education regarding the manifestation of chronic pain at all levels of practice — medical school, residency, fellowship, veteran practitioner. These complex layers leave people like me wringing their hands in frustration.
Maybe someday we’ll have better pain medications, though I’m already familiar enough with biochemistry to realize that’s not realistic in the near future. But more efficient medications would solve only part of the problem. We also need to fund and encourage other kinds of treatment to accompany the assistance provided by medication, among them massage, guided imagery, and counseling.
In my mind, the best solution at the moment runs against following established guidelines, which is at the heart of today’s medicine. For example, when it comes to dosing acetaminophen, the common ingredient in Tylenol or Panadol, the guidelines — three grams daily — exist to protect patients from dangerous complications, liver toxicity in particular. But you can’t treat chronic pain with this same cookie-cutter approach.
I’m not suggesting tossing out the guidelines, but creating leeway to deviate from them based on sound medical judgment. I’m also advocating a comprehensive, interdisciplinary approach rather than a strict biological one.
That’s the approach I wish my doctor would have taken with me, and one I hope to apply when I become a doctor some years from now. Physicians examining patients who suffer from chronic pain should treat them on a case-by-case basis, not in general terms. They should begin with three basic steps:
Listen to the patient.
Avoid jumping to conclusions.
Put understanding ahead of judgment.
In human and medical terms, that’s a start