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.