ALL PAIN IS REAL
Everything You Wish You Never Needed to Know About Chronic Pain
Few experiences in life are more
universal than pain, which flows like lava
beneath the crust of daily life.
—PAUL BRAND and PHILIP YANCEY
Loretta was complaining about her chronic pain. As I shifted in my chair, careful to keep my expression neutral, trying my best to hide my impatience and frustration, I found myself thinking that the words whining and exaggerating certainly applied.
“I have excruciating pain in my back.” Loretta touched her lower back and grimaced, shifting her weight. “And in my neck.” For perhaps the third time, she closed her eyes and bit her lip, as if to underscore the severity of her pain.
I found myself not liking her very much. I wanted her to go away. A voice inside me whispered, “So, what do you expect me to do about it?” After all, I was an addiction medicine specialist. My work was to help people get off drugs, but Loretta, like so many patients with chronic pain, wanted relief from the pain at any cost and that meant she wanted more drugs than I was comfortable giving her. She admitted she was addicted to drugs and reluctantly agreed to enter treatment to deal with her addiction because of the pressure from her concerned family members, but she also reiterated in a rising tone of voice that her pain was intolerable without drugs.
“You have to give me something to take this awful pain away! I’m begging you!” she said. I found myself tightening my jaw and noticed a throbbing ache in my low back.
“And my hands,” Loretta said, gently rubbing her left thumb and index finger against the knuckles of her right hand, which were red and swollen. “My hands are killing me.”
“Killing you?” I asked, careful to keep my tone even. Clearly she was in pain, but I knew it wouldn’t kill her—what I needed to help her understand was the very real possibility that the drugs might. She was taking massive doses of painkillers: 10 mg of Vicodin, up to ten per day; 30 mg Percocet, six per day; and, depending on which doctor she saw that week, 80 mg of OxyContin or 60 mg of long-acting morphine three times per day. Her primary care doctor originally prescribed Vicodin and when that drug stopped working to relieve her pain even at higher doses, he referred her to a pain specialist who prescribed Percocet, then added OxyContin and, finally, long-acting morphine. She continued to visit her family doctor who dutifully prescribed 180 (10 mg) Vicodin per month, unaware of the magnitude of her opioid habit or the fact that she continued to get medications from her pain doctor and occasionally visited a local urgent care center or emergency room . . . where she was prescribed even more meds. But at some point, even the morphine stopped working. In fact, she told me that she was in more pain than ever.
I pointed to the pain level chart prominently displayed in my office. “On a scale of 0 to 10, with 0 representing no pain and 10 being the worst pain imaginable,” I asked Loretta, “how would you rate your pain?” “Nine,” she said, with no hesitation.
I consulted her file, flipping through the pages. “When you first went to your doctor for pain and started using Vicodin, what was your pain level?”
“Oh, maybe a 4 or 5,” she sighed. “But it’s gotten so much worse. I’m in agony. I can’t live without my drugs. I’m miserable with them, but where would I be without them? I’d rather die than live with this pain.” I took a deep breath and mentally reviewed the facts of her case. As Loretta’s tolerance increased, the drugs stopped working. Even steadily increasing doses of potent painkilling drugs didn’t appear to touch her pain. In fact, her pain was worse than ever. From everything she was saying, it became clear that the drugs were adding to her misery on many levels, rather than subtracting from it. I had seen this before in many other patients. At these dosage levels, overdose was a real possibility and in the meantime, the drugs were gradually robbing her of all meaning in her life. She could no longer work as a grocery store cashier, her marriage was in serious trouble, her three adult children were so frustrated after years of listening to her complaints that they rarely called or visited, and her friends had “abandoned” her. She couldn’t drive and was dependent on her husband for just about everything. She often spent the entire day in bed—even getting up to go to the bathroom was such a painful ordeal that her husband purchased a bedside commode. At forty-eight years old, she was, essentially, an invalid.
In the month before she voluntarily came to treatment, she had seriously contemplated suicide. “Sometimes I empty the bottle of pills into my hand and think about taking them all just to put an end to all our misery,” she confessed. “But I’m too big a chicken.”
Loretta’s emotional state was also a deep concern and I found myself wondering about the connection between the depth of her pain and the intensity of her emotions. As her pain increased, she admitted that she had become increasingly angry and depressed. Was it possible that her emotions were intensifying her pain, functioning as internal megaphones that amplified the “sound” of her physical pain?
And that’s when the lightbulb came on. Loretta wasn’t simply a complainer or a whiner. She wasn’t exaggerating. She was in real pain. Real pain that wasn’t being helped by the drugs she was taking; in fact, the drugs were making her pain worse. And she was suffering—mentally, emotionally, spiritually—as well. Her 9 on the pain scale was an accurate description of her overall experience of pain.
At that moment, almost a decade ago, something inside me shifted. Loretta’s pain was real. Her suffering was real and was a substantial part of her overall experience of pain. It was not my job to judge or label her; in fact it was my job not to judge her. It was my responsibility to help her as best I could, and I wasn’t going to be much help if I did what so many other doctors had done, and just passed her down the line—treating her addiction, assuring her that I had done all I could do, and referring her right back to her primary care doctor, a specialist, or a pain clinic. Loretta would go full circle and end up right where she was before she came to treatment, except even more frustrated and depressed.
I knew from experience that most doctors treat chronic pain with opioid drugs, increasing the dosages in a well-intentioned effort to reduce the pain. Or they refer their chronic pain patients to pain specialists who may prescribe even stronger drugs, adding anxiety meds and sedatives to the painkiller mix. The patient might be scheduled for a series of cortisone injections into the spine (epidurals) or other procedures, such as radiofrequency ablation, whereby the nerves are actually burned with electric current to prevent them from transmitting pain signals. When those procedures don’t work, the pain specialist or clinic might refer the patient to a surgeon who, in all likelihood, would suggest surgery because the medications and other techniques weren’t successful in relieving the pain. If a surgery was performed and judged a “failure” because it didn’t offer long-lasting pain reduction, the surgeon might suggest more surgery or, just as likely, tell the patient that the surgery was a success and therefore there was nothing more that could be done.
In essence, the message to the patient would be: “I did my job, so if you’re still in pain, you’re just going to have to live with it,” almost implying, “It’s your fault!” (That’s exactly what happened to Loretta after her fourth surgery.) A referral to a neurologist or rheumatologist might come next. Or a psychiatrist, who might prescribe antidepressants and more anti-anxiety medications. And on and on it goes.
At the time, back in 2006, I had almost twenty-five years of experience in addiction medicine. I was an expert at detoxing patients and guiding them through the recovery process from the disease of addiction. But when it came to chronic pain, I felt horribly inadequate. Loretta was not an isolated case—a huge percentage of the patients I was treating for opioid addiction, perhaps as many as 50 percent, were also experiencing chronic pain. In fact, many had started using opioid drugs because they were in pain, not because they wanted to “get high.” What was I going to do with these patients? How was I going to help them?
I knew at that moment that if I wanted to successfully care for people who were dependent upon or addicted to opioids and who are also living with chronic pain, I had to strip myself of those automatic judgments, learn everything I could, and find creative and innovative ways to approach the problem of chronic pain. I was already well equipped with a team of caring, highly skilled professionals adept at helping addicted patients by guiding them into long-term recovery. Adding chronic pain to the treatment plan would require that we rethink our approach and adjust our clinical services.