I took care of a 74-year-old man, Daniel, with bone metastases from prostate cancer. Daniel told me that he was in pain and admitted that he was not taking his full pain regimen. His son said, “my father is just being stoic”. Daniel’s response was: “son, there are worse things than pain”.
This remark struck me, mostly because many of the patients I had seen over the years had seemed to feel that there was nothing worse than pain. When I asked what he meant, Daniel clarified: “I want to be here for this”, he said with a sweep of his hand around the room, “even for the pain. Not really being here would make me suffer.”
This reinforces the erroneous belief that taking pain medication makes you “not really here”. When taken for pain, opioids do not create euphoria or “altered states”. In fact, it is agonizing pain that takes us away from our lives, leaving us with only with desperation for some relief.
“You Americans are so concerned with comfort! Don’t you think anything should be difficult? This patient is dying.”
I can’t help but wonder why dying should be intentionally made any more difficult.
When I asked the patient about this, she explained: “Pain is necessary. It is a reality one needs to face. Running away from it is what leads to suffering.”
When one’s hand is held over a flame, running away from it is the appropriate action.
From listening to Thai patients and physicians, I encountered two explanations about pain: one based on a worldview in which the idea of kam (karma) is important, and another based on a difference between pain and suffering.
being present to the pain was a way to suffer less from it. Suffering and pain were not the same.
Interestingly, among the physicians I met during my fieldwork, the distinction between pain and suffering was understood in relation to a different conception of addiction
rather than linking addiction to the pharmacological properties of opiates, people seemed to link it to pain relief itself.
This demonstrates the complete ignorance about addiction we are seeing in our own country among lay people without scientific knowledge. Addiction is not created by relieving physical pain, but by the neurological development of irresistible urges and compulsions.
One Thai physician, Dr Lek, told me: “Pain is part of all things. Wanting 0/10 means looking outside oneself to escape reality.”
We pain patients long ago learned that zero pain is impossible. Even with the best pain management, we consider ourselves lucky if we can remain at 5 or below.
“The mind is already addicted, before ever taking anything. But one shouldn’t have 10/10 pain, either—that is too much for the mind! Maybe the goal should be 5/10.”
Obviously, his idea of level 5 pain is only his own, and his attitude makes it clear that he considers that level to be mild, not severe.
When I heard this explanation, I thought about my oath as a physician to relieve suffering, an oath that still guides my every moment in clinical practice.
When I asked Dr Lek about this, he gave a common Buddhist scriptural response about the need to accept the painful reality of existence enough to be present to it, and thus to avoid suffering from it
When pain becomes so severe that it prevents any activity, acceptance without action is self-defeating. This kind of pain demands action, takes us out of our own life as our survival instincts kick the body into high gear.
“If there is too much pain”, he explained, “then we cannot focus at all.”
My point exactly.
But if we want there to be no pain, we suffer endlessly trying to make it disappear, to achieve the impossible.
Here is another common misconception: that taking opioids can make pain disappear. All it does is “take the edge off”, so that we can think straight and at least get out of bed.
That is addiction. And it is not limited to patients. We doctors are uncomfortable seeing pain, and want 0/10 for our patients. We are part of it.”
I have never known or heard of a doctor that believes it’s possible to reduce chronic pain to zero, or even close to that.
In western biomedicine, physicians learn that the “stoic” patient and the “drug-seeker” are separate tropes, that the desire to relieve pain is different from what makes us addicted.
This is exactly true!
I was trained to think of Daniel’s pain as different from that of a “drug-seeking” patient because of the aetiology of his illness. Daniel had cancer, whereas so-called drug-seeking patients often live with some kind of chronic pain
But in my discussions with Dr Lek, I encountered a view in which such a distinction was dissolved. He told me that “The connection between escape and suffering is not just with chronic pain: cancer patients suffer as much as anyone from trying to escape reality. In cancer, the suffering may be overshadowed by the course of illness, but it is there.”
There is another trope that physicians encounter in pain medicine: the so-called drug-seeking patient, who seems intent upon acquiring opiates at all costs.
There is an informal sense among practitioners that many patients on opiates can fall into either the “stoic” or “drug-seeking” category, and we spend much time encouraging the former towards treatment and steering the latter away from it.
Yet Daniel’s claim about the difference between pain and suffering, as well as the existence of something “worse than pain”, casts some light onto these poles of judgment about how people relate to pain.
But when I think about Mahu, Mali, or Daniel, for whom trying to achieve a 0–3/10 pain score would itself cause suffering, I wonder about the merit of this conceptual approach.
Yet it also does not make sense to leave people in severe pain, which Dr Lek explained as “too much” for the mind. Is there a “middle path” between these two poles?
The question is who gets to decide what is “too much” pain. These days, it seems that decision is being made by law enforcement, politicians, moneyed interests, uninformed lay people “experts”, and the media.
All these various entities, not actual pain patients, are deciding how much we should suffer with untreated pain.
We pain patients and our doctors
have less influence on our pain treatment
than non-medical bureaucrats and politicians.
More about Dr. Stonington:
Dr. Stonington’s research is based in Chiang Mai, Thailand, and Boston, MA. His work in Thailand addresses the globalization of end-of-life care, bioethics, pain management and Buddhism. His book manuscript, “The Spirit Ambulance: Life, Death and Ethical Tension in Thailand,” is in process with Cornell University Press. His work in Boston focuses on medical epistemology and the importance of social concepts for delivering effective and equitable health care.