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10 Articles in Volume 6, Issue #1
Bioethics
Do Topical Herbal Agents Provide Pain Relief?
Infusion Catheter Epidural
New Report of a High-Dose Morphine Metabolite
Pain Education and Pain Educators
Suspecting and Diagnosing Arachnoiditis
Tennant Blood Study — First Update
The Demise of Multidisciplinary Pain Management Clinics?
The Dimensions of Pain
The Role of Psychology in Pain Management

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.”

A current co-worker of mine recalled how, prior to one of her deliveries, she complained to the obstetrical nurse about the intensity of her pain and was told to, “Offer it up to the Blessed Mother.” She relates that her anger augmented the intensity of her physical pain. The fact that some religious mystics have been able to suppress pain through meditation is of little value to one in the midst of an unrelieved bout of intense pain.

Should the spiritual beliefs or values of healthcare givers trump the valid need for pain relief of a suffering patient?

Another extreme position was made clear to me after I offered pain relief to a gentleman who had considerable persistent pain from cancer of the lower bowel. He demurred, saying, “I need this pain.” From what I could learn, it appeared he wanted to make use of the pain to cleanse himself of guilt for past indiscretions. Indeed, ancient religions stress the need to accept pain in order to atone for our sins, as well as the sins of our forbears.

The Problem Has Psychological Dimensions

The problem has psychological dimensions. Following my comprehensive presentation on how to provide relief of severe, chronic pain to a large gathering of nurses, the first comment came from a nurse who said, “This is all well and good, doctor…but don’t you also believe that suffering can enhance one’s character?” It’s a good bet that this nurse had not personally suffered severe, unrelenting, all-encompassing pain herself. A corollary of the psychological maturation is the saying among athletes, “No pain, no gain.” The ability to endure pain is sometimes seen as an indication of personal strength of character. It can also be taken as an indication of masochism. Unrelieved pain can be used in a variety of ways, not all of them healthy. I recall the woman with advanced cancer who made a show of refusing to allow her husband to help her carry things. It appeared that she was needlessly enduring pain (and displaying it) as a way of expressing anger toward him for whatever reason. I recall one woman who cleverly sabotaged efforts over many years to relieve her pain. She would not take medication as prescribed. Suffering had become a way that she could control a very successful husband whose personal world had expanded after their marriage. It was only after confronting her with the evidence of how she foiled attempts at analgesia that she admitted to her true fear that, if she did not have pain, she would lose her husband.

Pain can contribute to aggravated assault, murder, and. among other things, abuse of drugs and alcohol. I have a collection of newspaper clippings describing how husbands have killed their wives purportedly to “end their suffering” when pain relief was not provided. A patient who claimed his pain was inadequately treated returned to an emergency room in my area and shot and killed several persons he believed were responsible for his under-treated, persistent, severe pain.

Pain Relief Has Legal Dimensions

Pain is not merely a medical problem. It has, over time, acquired legal dimensions through governmental regulations about what substances can be used to treat pain.

Cannabis, though still controversial, is known to be a relatively safe and effective analgesic. Yet in California, pain patients whose doctors have legally prescribed medical marijuana for relief of their pain, are now subject to prosecution under federal law. What has been deemed legal under California law is considered illegal under Federal law where the cultivation of marijuana for self use by a pain patient is considered a violation of the commerce clause of the Constitution. From a medical perspective, the issue of prescribing a safe, effective, inexpensive analgesic has been subverted to legalistic concern over the commercial implications of allowing intra-state cultivation of a miniscule amount of medication. Even this pseudo-issue is subsumed under the larger, ongoing struggle be tween the rights and powers of individual states vs. the rights and powers of the Federal Government.

On another level, the federal Drug Enforcement Agency (DEA) has been investigating physicians who are thought to be improperly prescribing narcotic medications. Thus far, over 450 doctors have been prosecuted out of the nearly 6,000 who have been investigated for “drug diversion.” The benefit of ferreting out offenders has been offset by the chilling effect the DEA has had on physicians who properly prescribe analgesic medications for patients with persistent, severe pain. The chronic problem of under-treatment of pain is further aggravated when physicians fear scrutiny of their pain prescribing practices by powerful regulatory agencies. The “Just say, No” mentality, begun as a well-intentioned effort at curbing illicit drug abuse, has adversely influenced the legitimate prescription of analgesic drugs.

Is There Reason to Be Hopeful?

Despite the concerns outlined above… and these are but a few of our legitimate concerns, I believe there is reason to be hopeful for the future of pain relief. A review of the history of analgesia and anesthesia reminds us of how far we have come in only a few generations. The new medications and techniques available to relieve pain truly border on the fantastic. Extended-duration opioids, nerve blocks, electro-stimulatory devices, surgical procedures, improved anesthetics…all can provide relief undreamed of at the start of the last century. The many efforts to draw attention to the need for change in pain relief also provide reason for optimism. The state pain initiative movement, the numerous professional and even lay organizations supporting education and research in pain management, the nationwide efforts of the American Association of States Attorneys General… come to mind. The work of hospice programs to bring end of life pain management into nearly a million homes each year is certainly a significant achievement. The efforts of researchers and clinicians to bring scientific pain relief to infants undergoing painful procedures proves that it is possible, in fairly short order, to overcome centuries of neglect of those who have suffered without relief. The educational efforts of professional organizations and pharmaceutical companies play an important, ongoing role in relieving pain.

Yet there are caveats, notably that voiced by McCleane,1 who wrote recently:

“But has our ability to treat pain actually improved? An emphatic yes to this question can be given by those living in the so called “developed” world. But could such a positive response be given by those living in more under-developed areas? Most newly released drugs come with such a hefty price tag that their use would be prohibitively expensive in many areas of the world.”

We cannot celebrate the several victories over pain in our “developed world” while people less fortunate continue to suffer. But we can learn from our successes and share with those in need. We are far from finished.

Last updated on: December 28, 2011
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