The
Zen of Science
Pain
By MARC RINGEL, MDAs
I’m
writing these words, I can feel the burning of healing road rash
on my right elbow, knee and shoulder, abrasions acquired on a
spill from my bike. The shoulder also aches a little from the
jarring and, if I touch it, so does the bruise on my temple, the
only ill-effect of the blow to my head that shattered my helmet
instead of my cranium. A little tip of my head reminds me of the
tightness verging on pain on the left side of my neck. It’s
been there for a couple of years, ever since my head collided
with the beach to conclude, abruptly, a body-surfing ride on a
particularly good wave. If I extend my neck and rotate it to the
left I can tweak a nerve enough to cause slight tingling in my
shoulder and thumb. Since I am sitting quietly at my desk, my
arthritic knee joints are sending no signals of distress just
now.
Do you get the picture? It’s pretty typical, I think, for
a man whose body has spent 56 years on this planet. As the Buddha
said, pain is inevitable. The longer you live, the more pain you
can count on having.
None of the aches and pains I described above is intolerable.
The one significant effect they have on me is to remind me that
I shouldn’t try to leap fences or walk on my hands as I
did in my youth because I’d likely hurt myself. These are
limitations and pains I can live with.
So
far, I’ve been fortunate. The few pains I’ve had that
reached the level of unbearable have been short-lived, resulting
from acute injuries, severe intestinal cramping and the like.
I sometimes wonder how I’d react to really intractable pain.
In spite of seeing patients with high levels of distress every
day that I practice, hurting that much myself is still not imaginable
to me—reminding me that pain is always subjective, always
the sole experience of the person who hurts.
Of course, physical pain is a sensation we cannot live very well
without. Take, for example, a diabetic amputee. One of the main
reasons for having to sacrifice that foot stems from the damage
done to sensory nerves by chronically high blood sugar. The foot
may have become so numb as to never alert its owner of the infected
abrasion that progresses to threaten life and limb. Pain gives
us, in the words of the Godfather, an offer we cannot refuse;
or, at least, a message we cannot afford to ignore. Without pain
to make us attend to a problem, we are at much greater risk for
serious injury.
It’s only in recent years that medical professionals have
been taught to manage pain. When I came up through the ranks,
the prevailing attitude was to discount pain. As a medical student,
I watched in numb horror as writhing patients were subjected by
the teachers who served as my role models to having their burns
picked, their wounds packed and their uteruses scraped without
so much as an aspirin on board. Later, when I became a teacher,
I routinely instructed my residents on rounds that one of the
jobs of a family doctor was to come in after the surgeons had
seen our patients and write significantly less-stingy narcotics
orders to keep our post-operative patients more comfortable—and,
in fact, even healthier, because being free of severe pain allowed
them to breathe and move better.
Today,
the working assumption for pain management is, as I stated above,
that all pain is subjective. A doctor is expected to take seriously
her patients’ reports that they hurt, no matter how little
the pain seems to jive with her own experience. Nevertheless,
we doctors cannot prescribe as many narcotics as it would take
to make every ache and pain go away completely. A society drugged
into complete freedom from physical pain would look like the world
in Night of the Living Dead. It is true that there is a narcotic
dose to take away almost any pain. On the other hand, such a high
dose given often may turn the most functional person into a zombie—an
addicted zombie—which is what makes pain management such
a challenge.
When
the goal is comfort in a terminal cancer patient, managing the
pain is pretty easy. You administer as much medicine as it takes
to give relief. Even when the patient is barely conscious, you
can judge analgesic effect by monitoring blood pressure, pulse,
respiratory rate and restlessness. The real problem comes with
patients who are not terminal, who are functional but distressed.
It is not fair to rob them of their lives with too much dope.
I’m
much less parsimonious than I used to be with narcotics prescriptions
for otherwise healthy chronic pain patients. Severe pain can rob
a life of quality and dignity. If it takes regular doses of narcotics
for a patient to reclaim her life, so be it. Should the painful
condition get better, we can always deal with drug withdrawal
later. I’ve seen as many patients’ lives saved by
chronic narcotics as I’ve seen them sacrificed to drugs.
The trick is in knowing whom you’re going to help and whom
you’re going to hurt with the medication.
Treating people with a history of substance abuse and chronic
pain is especially challenging. On the one hand, they need relief.
On the other hand, prescription narcotics can be the slippery
slope that shoots them right back down into a life ruled by mind-altering
substances.
An even bigger challenge is to manage patients with distortions
of their pain perception. Take, for example, the patient with
an exaggerated pain response, who may suffer a mild ankle sprain
or head congestion from allergies, but claims to be (and subjectively
probably really is) in agony. Prescribing weeks of narcotics that
can stretch out to years or even a lifetime is not the way to
treat minor maladies. Keeping in mind that all pain is subjective,
how then, as a physician, should I respond when faced with a patient
who demands narcotics for every minor ailment so as to feel no
pain at all?
The easy answer would be either to prescribe the dope to get her
out of my hair or to refuse and hope she’ll go see somebody
else. I try to do neither. But the middle way is not the easy
way. If I’m to do such a patient any good, it’s going
to take time. We’ll have to establish a relationship, which
also takes work. Together, the patient and I will explore why
she hurts so much. Likely as not, we will uncover patterns of
perception, response and behavior that go back to childhood: She
only got attention when she was hurting physically; she was especially
neglected when she was hurt; she has displaced to her unconscious
the emotional pain that arises from sexual or physical abuse and
that pain resurfaces as physical pain; etc.
Generally it takes months or years of regular visits before I
can safely ask the big question of a chronic pain patient, “What’s
going on emotionally right now that might account for the increase
in your pain this week?” If I make that inquiry too soon
I’m liable to scare the patient away, because she misinterprets
my words to mean that I think she’s a “head case,”
that I don’t believe her pain is real.
Pain
is not just a simple alarm rigged to go off in your brain when
something is wrong. It is laden with meaning. With some patients,
my job is to help them to change the meaning of their pain, not
to make it go away. You can’t always make it go away, not
completely. That’s something I certainly understand myself,
as a normal 56 year old.
Here’s what’s cool about doctoring a patient with
chronic pain. I do have the credibility, intellectual preparation
and prescription power to reliably search for the source of pain
and treat it. And, armed with potent pain medications, I really
can diminish hurting, at least temporarily, to a bearable level.
These tools serve, not only as ends in themselves, but sometimes
they give me the leverage I need to pry out, over time, the source
and meaning of suffering. Suffering, the Buddha reassures us,
is not inevitable.
So,
here I sit with my own aches and pains. And, though I’d
gladly not have them, I do embrace what they’ve taught me
about being alive.
Marc Ringel, MD, is a family practitioner and writer based in
Greeley, Colorado.
SEPTEMBER/OCTOBER 2008 FEATURE ARTICLES
