The Dimensions of Pain
The 9/11 Commission recently gave the government a failing grade for not following through on the recommendation that police, fire and other first responders be enabled to communicate with one another during a disaster. Although the technology for single wavelength, inter-agency communication is available today, the Department of Homeland Security says it cannot be implemented until 2009. When I heard this, I was reminded of the challenge of pain management. Since 1970, we have had the knowledge, techniques and medications to relieve most persistent pain, yet an unforgivable gap exists between that knowledge and our application of that knowledge. People continue to suffer. Do we, also, deserve a failing grade? If so, who is responsible? Are there some that deserve a passing grade, others who merit a failing mark?
The problem is fairly simple if we consider only one person at a time: prescribe the appropriate medications and/or treatments and follow through until optimal relief has been obtained. However, when we consider countless thousands with untreated or under-treated pain, the problem becomes quite complex and we can empathize with the Department of Homeland Security.
Do we deceive ourselves when we believe we are making progress over pain? Have we made significant progress? Or are we falling further behind each year? Is anyone keeping score? How do we measure success? Might there be better ways to proceed than those we now employ?
When I have concerns about the fact that significant numbers of people in this country experience persistent pain from whatever causes, I feel that we are not making sufficient progress. Yet if I look at the greater lack of pain management in developing countries, I am both heartened that we have made some progress and, at the same time, despairing over the social, economic and political and medical problems that persist in much of the world. Yes…we have made progress, at least in technically advanced countries. Yet there is still so much that must be done throughout the world to relieve suffering
Pain is a problem not only for those who experience it for whatever reason but also frequently for their families and, at times, for those who try to treat it. Pain also is a tremendous problem for health care institutions, for insurance companies and for society, if only for the economic loss from diminished productivity of workers.
Pain Has “Inertia”
Pain has a vexing history. Marvelous advances in analgesia and anesthesia have not eliminated pain. Although much can be done today to relieve pain, there are some who stubbornly believe that pain is inevitable. Some in our society believe that the experience of pain can enhance personality or strengthen character; others see pain as punishment or welcome pain as the requisite punishment for past offenses. This thinking stems from an era when it was wrongly believed wounds healed faster or better if they were infected with what was known as “laudable pus.” Students enter medicine with notions of pain derived from family and culture that saw pain as a fact of life. An oncologist friend told me that his mother insisted, “Carl…we are put on this world to suffer.” It is not easy to alter the course of beliefs that date back to our creation myths.
Machiavelli wrote in The Prince, “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its outcome than to take the lead in the establishment of a new order of things.” Doctors do not take readily to change. The director of a large cancer center told me he was taken aside during a dinner welcoming him to his new post and told by the local dean of practitioners, “We’re delighted to have you here and we’ll do anything we can to help you. Just don’t ask us to change.” I have had numerous doctors tell me that they could not order more than 10 or 15 mg of morphine every 4-6 hrs, prn, for patients with severe, persistent pain because that was all they had ever prescribed. Their artificial and un-scientific limit took precedence over the patient’s verbal description of pain.
Undertreatment of Pain Has Become Institutionalized
The problem has institutional support. Doctors who practice in hospitals tend to fall into a pattern based on what they believe is acceptable to other practitioners. Those whose prescribing practices fall outside the apparent parameters of that institution are nudged back into line so they conform to the herd. This helps to explain a story on the front page of the Wall Street Journal several years ago which stated that the majority of patients interviewed on an exit survey from a large hospital endorsed the statement, “At some time during this hospitalization, I experienced pain that was unendurable.” Why don’t patients unite and revolt? What factors enable them to endure pain that we know can be relieved? Is there something inherent in the patient role that allows for passivity in the face of discomfort. Must people show how “tough” they are? Do we want to be thought of as strong and non-complaining? After undergoing a painful medical procedure during which I was conscious, I asked the doctor what, if any, analgesic was administered. He said he had given me 1 mg of morphine, IV. I meekly suggested that, if I ever needed the same procedure again, he could well administer 2 mg.
Following an educational program for physicians, I was told by a doctor that no one in his hospital prescribed morphine for pain. This followed an incident in which, following surgery, a patient was administered morphine for breakthrough pain. The patient died shortly thereafter. It was assumed, apparently without any corroborating evidence, that morphine was the cause of death. There was apparently no autopsy. But all doctors since then have refrained from prescribing morphine in that institution. This is how “urban legends” are born.
The staff in hospitals can have an insidious effect on the evaluation and treatment of pain. I recall pausing at the nurse’s station before doing consult on a patient with a pain problem. While glancing through the chart of the patient I was about to examine, I found a terse note made by a nurse which read, “Pain is not as bad as the patient says it is.” That statement may, in fact, have been accurate. Yet there was nothing to support the claim, which then could easily be interpreted as, “I think this patient is malingering.” I have found it valuable for patients to keep their own record of their perceived level of comfort/discomfort. A visual analog scale maintained by the patient can be of great assistance to the treating physician while eliminating other personnel from judging pain which they, themselves, have not perceived
Pain Has Spiritual Dimensions
.The problem has spiritual dimensions. In the early days of my hospice experience, a doctor in our community referred a young man with advanced cancer for hospice home care. While two hospices nurses were doing an admission evaluation, the referring doctor entered the patient’s room. The patient immediately pleaded with the doctor for something to relieve the considerable pain he was experiencing. The doctor, I was told, frowned and said in great seriousness to the patient, “The reason you’re having so much pain is…the Devil’s in your body.”