Considerations in Treating Intractable Pain
By the nature of their condition, intractable pain patients, as a group, are not like any other patients. The essential difference about pain is that it is compelling beyond all other symptoms. A patient may live with loss of appetite, weakness, shortness of breath, visual changes, lack of coordination, and virtually every other symptom with relative tolerance. But pain is absolutely imperative. The common suggestion by doctors that a “patient should learn to live with their pain” is a bizarre conundrum. It reveals the speaker’s ignorance on the subject, as any human being who has ever been in severe pain knows that this is a ridiculous suggestion. It would be comparable to a heart surgeon telling a patient with mitral valve prolapse to “learn to live with it.” To belabor the point, another example would be to tell a patient with an ice pick stuck in his brain to “learn to live with it,” because the doctor was afraid to remove it. One should never tell a pain patient to learn to live with their pain. It will irreversibly establish the speaker as an incompetent and/or sadist in the mind of the pain patient.
Understanding Personality Types
To fully understand the presentation of a pain patient requires understanding personality types. Predictably, patients’ responses to pain vary in relation to their character structures. A person with an hysterical personality pattern, for example, will respond to pain hysterically. Similarly, an obsessive-compulsive patient will be obsessive about their pain, frequently coming to the doctor with detailed descriptions and notations on their symptoms. More importantly, if a patient has a dual diagnosis, for example if they also suffer from a bipolar affective disorder, they may vary dramatically in their behavior toward their pain. On one visit they may be controlled and phlegmatic; on the next visit they may be chaotic and desperate. The pain has not changed, but they have. Frequently these variations are misinterpreted by the physician to imply that the patient is faking the pain, since the responses are so inconsistent. Beware of hasty generalizations.
As another example, a sociopathic personality will approach their physician very differently from the approach of a religious conservative. The religious person may come in with a deep despairing depression, having interpreted their suffering as a personal punishment from God. The sociopath, however, having no capacity for human trust, will feel it is impossible to relate directly and honestly to the doctor. Not believing in compassion and not able to experience it within themselves, they will not believe that the doctor can be trusted to be compassionate. So, invariably they will believe that their needs can only be met through manipulation and duplicity. Their behavior does not mean that they are not in real pain. It only means that they are structurally crippled in their ability to relate directly and with trust. But even sociopaths have real pain.
“Intractable pain patients present with the most daunting, complex and frustrating conditions a physician will ever have to confront. Intractable pain patients rarely get entirely well; with effective care they can be stabilized sufficiently to have some quality to their life.”
The essential fact is that the competent physician must have his or her mind and eyes open for all aspects of the patient and all diagnoses. Stereotyping is as undoing in the successful treatment of pain as in every other medical condition. For example, just because young women rarely have heart attacks doesn’t mean that a young female patient with crushing chest pain shouldn’t have an EKG. Blind obedience to stereotyping is the handmaiden of medical malpractice; most particularly in the management of intractable pain. Just because a sociopath is manipulative, duplicitous, and conniving, doesn’t mean that they are not genuinely suffering from pain and have an absolute right to treatment and relief. It only means that the doctor must be wise enough to understand the whole patient and perceptive enough to see beyond stereotypes.
Unique Nature of Intractable Pain
Intractable pain patients present with the most daunting, complex and frustrating conditions a physician will ever have to confront. Intractable pain patients rarely get entirely well; with effective care they can be stabilized sufficiently to have some quality to their life. Intractable pain patients have, by definition, an intractable condition. They will require ongoing prescriptions of various narcotic pain medications. This will create problems with opiophobic pharmacists, other practitioners, and in some states without Intractable Pain Acts, possibly even review and regulatory harassment by medical boards or boards of pharmacy.
Unless the physician is adequately trained to be expert in the use of opioids — particularly sustained release preparations — and professionally committed to proper intractable pain management, he or she should simply refer these patients to someone who is. Otherwise the inevitable result will be frustration, anger, suspiciousness, and alienation between the doctor and the patient. Typically, doctors will unconsciously vent their frustration by “blaming” the patient for not getting well, or by accusing them of being addicted to narcotics (true pain patients virtually never suffer physiological withdrawal from opioids, but they do suffer withdrawal from the relief of their pain). Also doctors frequently displace their own fear of regulatory harassment — or doubt about their own effectiveness — into resentment of the patient.
One of the most common occurrences is the labeling of patients as “drug-seeking.” This is commonly used as a basis upon which to ignore or deny effective relief to the patient. The reality is that patients rarely are seeking drugs. In fact, they are seeking relief. There is a categorical difference. The point is that unless the physician can consciously deal with all these complications, they should refer the case rather than succumb to inadequate medical practice.
Treatment of intractable pain may be fraught with numerous iatrogenic complications — chief among them being inadequate treatment. Treatment is inadequate if insufficient medication or if the wrong medication is prescribed, as described below.