By Haider Warraich MD a cardiologist
New York Times
We could learn a thing or two from the ancient Greeks’ understanding of suffering.
The United States uses a third of the world’s opioids but a fifth of Americans still say they suffer from chronic pain. The only demonstrable effect of two decades of widespread prescription of opioids has been catastrophic harm. With more than 47,000 Americans dying of opioid overdoses in 2017 and hundreds of thousands more addicted to them, it was recently reported that, for the first time, Americans were more likely to die of opioids than of car accidents.
This has forced many to take a step back and ponder the very nature of pain, to understand how best to alleviate it.
The ancient Greeks considered pain a passion — an emotion rather than a sensation like touch or smell. During the Dark Ages in Europe, pain was seen as a punishment for sins, a spiritual and emotional experience alleviated through prayers rather than prescriptions.
In the 19th century, the secularization of Western society led to the secularization of pain. It was no longer a passion to be endured but a sensation to be quashed.
The concept of pain as a purely physical phenomenon reached its zenith in the 1990s, when medical organizations such as the American Pain Society and the Department of Veterans Affairs succeeded in having pain designated a “fifth vital sign,” alongside blood pressure, temperature and breathing and heart rate.
This coincided with the release of long-acting opioids like OxyContin. Doctors believed they now had an effective remedy for their patients’ suffering.
Decades of research suggests that opiates provide little to no benefit for chronic noncancer pain. One recent randomized trial of people with chronic joint and back pain showed that patients using opioids experienced slightly more pain compared with those using medications like acetaminophen and ibuprofen.
Why is this? Studies have shown that opioids can reduce patients’ pain thresholds. They can also result in a condition called opioid-induced hyperalgesia, in which people feel more and more pain as they are prescribed higher and higher doses of opioids.
While the expression that suffering is “all in your head” is too often used to diminish others’ agony, the mind does play a pivotal role in the experience of pain. After a pain signal reaches the brain, it undergoes significant reprocessing.
How much something hurts can vary depending on factors like your expectations, your mood and how distracted you are. Just seeing someone else in pain can make you feel worse, too. This phenomenon has been demonstrated in studies of both rodents and humans. In other words, pain is contagious and transmittable.
There is also an incredibly strong association between pain and mental health. Conditions like depression and anxiety greatly increase the chance of developing chronic pain, while patients who experience pain are at high risk of developing depression or anxiety. This vicious cycle is partly a result of the fact that there is considerable overlap in the areas of the brain that deal with pain and emotion.
Additional clues about the fuzzy line between sensation and perception come from pain’s creepy bedfellow: itching.
The sensation of itchiness, which is perceived by some of the same skin receptors that are on the lookout for pain, may seem like a purely physical phenomenon, but it’s not. Just seeing someone else scratch, or thinking about feeling ticklish, can make you itchy, too. Like pain, it can be alleviated through distraction. And like pain, it is closely linked to mental health issues such as depression and obsessive compulsive disorder.
All this is not to say that there is no physical component to these feelings. Objectively, there is no doubt that illnesses and injuries can cause immense suffering. The question is how severe that suffering is, and how long it lasts. Recent research shows that pain sensitivity varies significantly among people, most likely as a result of genetic differences. There is so much that we still don’t understand about the fundamental biology of pain, and that needs to change.
There is a pressing need to increase funding for research into strategies that don’t just involve taking more drugs. Not every person who experiences acute pain goes on to develop chronic pain. We need to learn more about which interventions work to prevent this transformation.
Pain management should continue to be emphasized in medical education, but future doctors should be taught that pain is part of the story of the person who suffers from it, not just a separate physical phenomenon. And this education should incorporate ways to avoid prescribing opioids for chronic use.
Progress is already underway, as opioid prescription rates have been dropping since 2012 in the United States. But we still have a long way to go: The amount of opioids prescribed per person remains three times higher than it was 20 years ago.
Perhaps the most important tool physicians need to manage pain is empathy.
If chronic pain is an emotion as well as a sensation, then it is unlikely to be managed successfully without compassion. A 2017 study of doctors in Spain found that those whose patients rated them as empathetic were more effective at relieving their patients’ pain. Physical therapy that doesn’t just manipulate joints but also addresses the context pain comes alive in, encourages optimism and builds emotional resilience has been found to be more effective.
All this takes more time and attention than just prescribing a pill, and unfortunately our health system encourages doctors to see as many patients as possible as quickly as possible. We need to change how physicians are paid in order to give them the time to really talk with patients about their pain.
Back in medical school, I dislocated a disk in my back. In a snap, pain became my constant companion: It was the last thing I felt before I slept, the first feeling I had when I woke up. Unable to leave my dorm, I fell into a dark hole. I looked fine on the outside but was moth-eaten on the inside. I was adamant that I would avoid painkillers, especially opioids. I had no idea about the science that would emerge over the next few years. I felt that the pain was my body’s way of telling me that something was wrong, and I didn’t want to silence that voice with a temporary fix. What pulled me out after almost a year of agony was not just rigorous physical therapy that molded my spine back into shape but also the kindness of my friends, my family and my future wife.
When I see a patient with chronic pain, I try to see that person through the eyes of my younger self. When someone experiences chronic pain, there is no way to quantify it — no blood test to draw, no imaging test to order. It requires physicians to practice medicine the way it was long before the discovery of morphine. In essence, it represents the purest of medical encounters, and an opportunity, if not to cure, then to heal.