Friday, August 15, 2014

The Trouble with Pain

When I made the decision in college to turn from my pursuit of becoming a psychologist to that of a physician, it was based on my perception that medicine was a field of black and white answers and not the uncomfortable gray of psychology.   How wrong I was!  I have since learned that medicine is not black and white equations with simple answers, but complex paradoxes with many unknowns.  Ironically, I spend time now treating one of the most nebulous realms in all of medicine; pain and suffering.

One difficulty with pain is subjectivity.  Unlike a broken bone that we can see on an x-ray, or a number we can read on a machine, pain on the outside cannot be seen or verified by any test.  It is strictly the experience of the injured person.  We try in medicine to objectify pain, by asking patients to put a number on their experience.  But what does a 7 out of 10 rating for pain actually feel like?  If a wasp were to sting two random people, each one may rate the pain of that sting differently.  One may feel it was 10 out of 10, another just 2 out of 10 in severity.  The insult was the same, and yet the perception and experience of the pain differs from person to person.

Thus, the first rule in pain management is not to judge what we think should or should not be painful, but to take a patient by their word, and try to reduce the severity of their experience with the tools we have available.

If the pain has a source, the first treatment should be to fix that source; notice I did not say the first treatment should be to mask the pain with medicine.  If the pain is from a broken bone, fix the fracture, if from infection, fix the infection, if from arthritis, reduce the inflammation.  It is only when the source of the pain cannot be healed that we turn to masking the pain with pills.  The goal with masking pain is crucial. It is not to escape from the reality of the pain, but to return the ability to function to the person who has pain.

Here is the true problem of pain, especially at the end of life; much of what people call “pain” is actually suffering.  Pain in the physical sense originates in the body. You can point to where you hurt.  Suffering on the other hand is in the mind.  It is the mind that questions why this diagnosis, the mind that worries about what happens after death.  It is the mind that remembers the past, harbors guilt, longs for forgiveness, and races with fear.  It the mind that says, “I hurt” and “this isn’t fair”.

In hospice, we term suffering ‘existential pain’, acknowledging that like physical pain, it is real and should be treated in the same way.  If possible, this means tackling the source of the suffering and is why hospice includes a team of social workers, chaplains, nurses, volunteers and physicians, all there to listen and explore and help heal.  When time is too short to fix the source, then like other pain, we turn to medicine; however, existential pain requires different medicine than physical pain, which again adds to the complexity.

To experience pain and suffering, or watch someone else endure it is excruciating, which is why I for one, am on a lifelong quest to better understand and treat this complex issue. 

Image Credit: Pablo Picasso "Weeping Woman with Handkerchief"