On the (f)utility of pain

On the (f)utility of pain – The Lancet

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.

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7 thoughts on “On the (f)utility of pain

  1. leejcaroll

    “This demonstrates the complete ignorance about addiction we are seeing in our own country among lay people without scientific knowledge” because the media presents it as it is those in chronic pain who are the drug seekers, malingerers, responsible for the “opiod epidemic”
    The stance of the ‘unbiased’ media needs to change. I just wish I knew how that can be accomplished.

    Liked by 1 person

    Reply
    1. Payne Hertz

      We can accomplish it by boycotting the media. The media in this country is so vile boycotts are something all Americans should be doing anyway, regardless of their experience with pain or political affiliation. Fox News, CNN, The Nation, “liberal” “conservative” or whatever, they are all a pack of liars and we should put them out of business just for general purposes. We should keep on thinning out the weeds until a more honest and legitimate information source rises up in their place.

      We should also boycott any politicians or political party that supports the drug war, or any other war. The political hygiene of our society will improve dramatically by throwing the bums out and letting someone who gives a damn about the people have a chance at leadership.

      The beautiful thing about boycotts is you don’t need a big organization to accomplish them; you can do it on your won simply by not buying newspapers, watching news shows or voting for political hacks of any stripe,

      Liked by 1 person

      Reply
      1. BirdLoverInMichigan

        Payne:

        I used to be a member of the media. I worked in radio as a morning drive news anchor and reporter for over a decade. I agree honesty and ethical reporting are often missing in much of what we’re exposed to since the story that has sex appeal is all that’s on most reporter’s minds. If it bleeds, it leads, as they say.

        Case in point: I’ll never forget the glee, and I mean uninhibited, smiling arousal, of two of my fellow news people at a multi-station newsroom back in the 90s the morning a fatal house fire killed at least one person in our area. I was horrified they were delighted they had a news story to lead with that was so intense. I told both of these guys they were sick, but that didn’t faze them one bit. It was before six in the morning and they had a home run in their hands.

        My point is there’s often not a lot of humanity in those warm voices and smiling faces you hear and see in the media. Is it any wonder those of us plagued with chronic, unquenchable pain simply don’t register as they true subject of the stories that are created today involving our issues? Drugs apparently have more sex appeal than the person ingesting them so she can go on living. Intense imagery and narrative driven emotion have made many forget about the sacredness of human life.

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  2. painkills2

    “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.”

    I think you’re confusing physical and mental pain, just like the author is. And while the two are obviously linked, they are distinctly different.

    There’s a reason that the word “anguish” is not used with physical pain — mental anguish can be just as debilitating as physical pain. The relief of pain — whether physical or mental — is a feeling of freedom. And freedom from pain can be addictive, especially if drugs are the only thing you’re using to relieve it.

    Addiction is caused by many things, and one of them can be the relief of physical pain. But instead of being addicted to the drugs, pain patients can be addicted to the relief. I know that feeling. Perhaps the reason I am not addicted to opioids right now is because my brain isn’t sensitive to addiction, and that includes being averse to risk. And maybe those who suffer from addiction don’t have any aversion to risk at all.

    This cancer patient who the author is talking about seems to be more afraid of death than the pain. Fear can be a powerful motivator, and the patient would rather feel everything there is to feel in the time he has left than relieve his pain. Some people prefer to suffer — some people even enjoy suffering. But maybe what this cancer patient doesn’t realize is that constant pain without relief can make his time here a lot shorter — it taxes the brain and can shorten your life.

    Liked by 1 person

    Reply
  3. Payne Hertz

    This strikes me as another example of what I like to call the “Iron Man Fallacy” or the belief that there are individuals out there who are completely impervious to pain despite having diseases that are worse than whatever it is you are suffering from. Doctors love to invoke this fallacy to stigmatize pain patients as whimps and complainers who need to toughen up and change their attitude to cope with pain.

    The reality is this very stigma encourages many patients, particularly males, to play the hero and tough guy in order to please their doctors and avoid being seen as a whimp. They are rewarded with no treatment but a pat on the back and a mention on some anti-patient hate blog as a shining example of how “real men” deal with pain.

    I have met enough “Iron men” in my day to know the reality is far more nuanced. If you were to get “Uncle Bob’s” side of the story, he would tell you his life is a living hell, the pain is driving him mad, and he can’t talk to anybody about the pain, not even his doctor nephew, because they cut him off right away whenever he mentions it. He thinks about suicide constantly. Yes, he goes to work every day in severe pain but what choice does he have? The alternative is seeing his family starve.

    Uncle Bob is on a one-way track to an early grave, suicide or a destroyed liver from alcoholism, but at least he can serve as a cudgel to beat down whiney chronic painers who need to learn that pain isn’t suffering.

    Liked by 2 people

    Reply
    1. painkills2

      You’ve described one reason why the suicide rate for men is so high and is higher than the rate for women: stigma. The other reason is that men use guns more than women, and there’s no coming back from that kind of injury.

      Liked by 1 person

      Reply
      1. Payne Hertz

        The *successful* suicide rate is higher for men, but women are four times as likely as men to *attempt* suicide. Men succeed because they tend to use more lethal methods as you say, whereas women go for overdosing themselves with drugs, which we are told can kill them by the thousands in ordinary therapeutic doses but somehow fail to do so in massive, deliberate overdoses.

        The same is true for the (successful) suicide rate among doctors. It is twice as high as everyone else largely because doctors have the knowledge and access to the drugs needed for a guaranteed death, not because their lives are so much harder. There the difference between males and females vanishes and the suicide rate among female and male physicians is roughly the same. I suspect veterinarians have the highest successful suicide rate because they have access to drugs which are used to euthanize animals as well as in assisted suicide where it is legal.

        Liked by 2 people

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