It’s interesting that nothing was mentioned about cultural influences. I’ve had the opportunity to work in several different countries and regions. In our clinics we would always ask patients to indicate their pain level on a Visual Analog Scale VAS. Basically place a mark on a line, where they perceived their pain level to be. In the one clinic, primarily a blue collar region, nearly 75% of patients would list their pain at an 8/10 level. In an other clinic where most of the patients had attained high levels of education it was rare to see the mark above 4 or 5. The first group was clearly an anomaly as I’ve worked in other blue collar areas where the average pain perception was never that high. Many factors influence pain perception and maybe one of the biggest influences may be the micro culture to which one belongs, whether it’s family, neighbourhood or occupation.
6
Americans are lazy- always looking for the quick fix and easy way out..
1
I now expect the Times to publish OP Eds by anti-vaccers, since the publication of this piece makes plain its indifference to science and to human suffering. Quite a shameful business.
11
Both
1
It's both.
2
Please... so tired of all of it. Pain is personal as well as actual. Maybe we all want Mama to kiss our bubu and make it all better.
So far as using MJ to treat pain -- let those who would do so grow their own.
Does there always have to be a middle man and a tax!! because we won't tax the super rich sufficiently nor on their toys. (10% federal luxury tax supported by that Republican George HW Bush (done away with by Bill Clinton because it hurt yacht makers in CT!)...and the Clinton Democrats wonder why members of their party turn against them!!! and vote for Sanders!!
1
The word "Or" in the title is the wrong word, It should be "And", as stated later in the article.
1
"Is Pain a Sensation or an Emotion?" Both. It's also the ultimate motivator. The stronger the pain the more motivated you are to stop the pain - and resolve the damage of what's causing the pain.
Pain is experienced by the mind in the same way it experiences pleasure at the opposite end. Indeed, life IS all in the mind. For obvious reasons it seeks pleasure (orgasmic) at one end, and avoids pain (disabling, deadly) at the other end.
After an extremely painful spinal cord injury I've had a long time to reflect and contemplate on pain. Weirdly, during the worst pain, if constant and unchanging, instead of distracting my self from it I would focus my mind intently on the pain to a point where I almost felt detached from the pain. I could examine it, try to decipher & interpret it, figure out what the hell it really is, isolating different flavors of pain & locations - made the pain more or less tolerable. The spell would end if the intensity unpredictably changed and-or moved location. Try relaxing as a dentist drills a tooth even though there is no pain- until the unpredictable & intense 'ouch'.
The brain's on 24/7, experiencing life, with pain signals as warnings and alerts, How do you turn off pain without turning off the entire mind - as during surgery? Too bad nature didn't provide an off or acknowledged switch to specific pains when no longer of use. Paralysis can turn off all but phantom pain, but very inconvenient as it turns off all mental control of paralyzed parts.
3
Ouspensky covered this a century ago.
1
What we were supossed to learn from the ancient Greeks?
5
Pain has ~30 dimensions is very personal we FEEL within OUR mind, body, spirit, mental, emotional, future, past, present, WHAT WE FEEL is everything WE ARE are as divine spiritual beings EXPERIENCING LIFE-LIVING WITHIN OUR OUR SOUL!
36 year in primary care board-certified family medicine 20 years mastering acupuncture, chiropractic, osteopathic, CAMs, and old-school physical muscle medicine and rehab; pain is normal life multiple stress-strain contusions resolves naturally with hours of restorative personal and master level care.
THE KEY IS what "pain" is not:
-CANNOT BE VISUALIZED ON AN X-RAY, MRI or CT scan.
-cannot be documented WITH BLOOD TESTS, BIOPSY, or by any human means contraptions diagnostic equipment!
-cannot be denied, mitigated, NEGATED, minimized, assessed by anyone other than the individual.
The invention of the x-ray gave birth to a NEW EMPIRE allowing doctors to use a picture of you to determine your destiny. That is equal to using a crystal ball and a psychic reader determine your destiny.
A group of orthopedic surgeons profoundly ignorant arrogant stupid crossed the line in 1940 from Honorable the dishonorable when they did the 1st hip replacement for arthritis.
Those individuals should've never conceived or even attempted to use a bone saw amputating natural tissues gluing in an auto part for the treatment of pain.
Unchecked questioned today something which should've never been done is now ritualistic butchery for profits.
1
“Recent research shows that pain sensitivity varies significantly among people, most likely as a result of genetic differences.” I was impressed by Dr. Warraich’s well accounted article until this sentence. It’s absolute hogwash. That research concerned interspecies. It is a huge faux pas which has to draw into question the entire letter.
2
It is amazing how much doctors write about pain and medicine without ever addressing the most obvious: problem solving.
Pain (not caused by injury) is the body screaming that change is needed. The body has a problem and we are begged to solve it. Instead, too many of us take a pill to suppress the pain. How foolish.
Most pain (not caused by injury) is caused by wrong inputs. Whereas every thinking human can understand we should not put sand in our gasoline tank, almost everyone put almost everything in their stomach if it looks edible.
And the doctors, who are paid to solve the health problems, do ... nothing. My dad of 92 moved to a nursing home. It is killing him, just because he got a change in diet. He is now constipated. What does the doctor do? Ask about his diet? Ha! He simply prescribes some magic powder. Now my dad cannot sleep because of stomach pain. What does my dad do? Stop taking the powder? Ha! He drinks beer to be able to fall asleep. More imbalance. Getting closer to death.
My young children know: If "food" makes you tired, sluggish, feel pain, dizzy, or hungry, or if it makes you gain weight, stop consuming it. Treat it as trash. Don't trash your body.
The 2nd cause of pain (not by injury) is bad posture. Can be treated without pills. Yoga helps. Alexander Technique too. But most of all: The willingness to solve the problem.
So now you know: We are responsible for our own health. Yes, that's tough. No excuses. No escape. Deal with it.
1
Dear Dr. Warraich,
There’s an amazing scene in “The Green Book” where the previously bigoted white driver flips out on the racist police officer who mistreats his black passenger and employer, Dr. Shirley, a gifted musician, landing them both in jail.
When Tony Lip tries to justify his actions to his boss, Shirley snaps back that “You’ve been dealing with this for one day - I’ve been dealing with this my whole life.” He goes on to tell him that maintaining one’s dignity is what must be done above all else.
Similarly, one’s reaction to pain says a great deal about one’s character. More than that, it reveals it.
Cordially,
S.A. Traina
3
Yeah, I don't know about this article. Sounds a little Goop to me. My husband, who never complained about anything, was having problems with his shoulder. GP said it was probably from his work (lineman for a utility company), which entailed a lot of physical stress. He had just passed his company physical which included a digital rectal exam.
Long story short, when he finally couldn't take it any more and one evening stared at his dinner and said he was too tired to pick up his fork (and his GP was on vacation), a fill-in doc ordered a blood panel with everything checked off. Turned out he had a PSA of over 2,000. (Yes, that's on the 0-10 PSA scale.) He was dead in 14 months. I guess he was an outlier, but I often think if he had complained louder, he might have had his PSA and imaging studies done when he would at least have had a chance. He was loaded with metastases - neck, shoulder, back, hips. It was straight to palliative care.
I think because he was physically active, had a high pain tolerance, and had a youthful attractive wife and a 14 year old son and a daughter in college, his doctor didn't take his pain seriously. He had even fainted about nine months before he was diagnosed, but his doctor said it was probably from the heat.
You pretty much have to diagnose yourself. I'm not saying everybody has lethal cancer and I like the ancient Greeks like the next guy, but geez - sometimes people are legitimately sick.
11
So you say to just grin and bear it. Well, that may work for you but it does not for me, I'll continue to take Lortab for my chronic and acute ailments.
4
It's not "either/or."
1
I have no idea what the author thinks pain is.
9
The question betrays ignorance of the answer.
3
Why not both?
1
God, or something, created or evolved noiception, and God also created opiate receptors. God created endorphins. God created poppies. God created scentists who intensified substances that build on morphines. God created NSAIDS. God created cannabinoid receptors and cannabinoids, and people who could craft them into extra-special cannabinoids. God created alcohol receptors and fermentation to help them along too.
I guess it could be said God also created masochists...excuse me, Greeks. But they had less choice, due to all these miracles of God and science and industry and ingenuity.
I suppose we could get all philosophical and say that when the alarm clock you set to wake you up rings, it is somehow valuable that it keep on ringing, and ringing and ringing and ringing. And ringing and ringing and ringing.
But you know, it is harder to produce with all that ringing...and harder to generate more empathy with all that ringing. Yes, we can be grateful that the clock rings so we can get up. After that...really?
3
No. Itch is not "closely related to mental health issues such as depression and obsessive compulsive disorder, "
No. Itch can NOT 'be alleviated through distraction."
Itching can be a sign of kidney disease, cancer, auto-immune disease or any number of serous medical conditions,
I suffer from chronic itching which is auto-immune in basis .
What is it that has led a cardiologist to believe that he is an authority on itching , or pain ?
Perhaps Dr. Warraich can explain to me how the itchy grooves and patterns that cover my body "can be relieved through distraction ", and how an abnormal anti- IgE level is "Closely related to mental health issues."
Perhaps Dr. Warrraich can tell me what the itchy impressions and patterns are. . None of the dermatologists allergist, internists or rheumatologist who have seen the grooves and patterns, or to whom photos have been sent by the baffled doctors who have seen my skin has ever seen anything like it.
I have heard :"I have never seen anything like that in my life."
and ""I have NO Idea what that is !" by some of the top doctors in New York. I have had a professor of dermatology at N.Y.U. run out of the office and grab a colleague. "Have you ever seen anything like this ?" "No I have never seen anything like that in my life."
Why hasthe New York Times published an Opinion Piece
written by a cardiologist regarding pain and itching ?
Why has Dr. Warraich confused himself with pain, itch, and mental health experts?
10
The evil of the Sackler family is unrivaled.
1
Empathy as treatment was offered to the victims of the Tuskegee experiment. Meds please, appropriate meds.
6
With that's said here and in the article it is utterly beyond understanding that marijuana is still Federally illegal. Millions have used it for ages to alleviate common pain. The NBA, NFL, NHL, MLB all prohibit it's use for pain, though many players have reported relief. How can right wing politicians and pastors justify such ignorance while they protect and defend Big Pharma. Marijuana is a leafy plant that God gave us, fools.
5
You've got to be kidding! I find this article incredulous and insulting as I sit here tonight in terrible pain awaiting a hip replacement in April and a spinal fusion to follow. I survived a botched back surgery and oxycontin addiction/withdrawal 15 years ago. Life since has been an ongoing search for relief and increasingly crippling pain. This article is irresponsible.
12
Yes, by all means, let's look to the ancient Greeks and the Middle Ages for our medical advice. They believed that pain was "an emotion." The also believed that our bodies were comprised of four humor and that you could bleed people to restore a healthy balance. I say, let's bring back leeches as a cure for depression! Also, bathing can kill you . . .
8
Try giving birth, Dr Warraich.
My grandson recently, for the 2nd time in 5 yrs, tore off a big toenail while playing exuberantly.
The pain is real. An actual sensation. A burn is an actual sensation. It is helped by applying a lot of ice for a long time, because the nerve endings are numbed, but even a kitchen burn can be extremely uncomfortable -- full of pain -- for over a week.
The damaged epidermis will continue to experience pain until all protective layers have been fully restored. Especially as you bring warmer temperature substances in closer proximity to the damaged area. Nerves have a memory function: if they didn't, we could not learn to type accurately blindfolded, or play a musical instrument in a darkened room.
Your debate about the meaning of "feeling" (or the Greeks "passion") is more rooted in language & semantics than any actual consideration of pain per se. When Greeks use the equivalent of 'passion,' they refer to 'intensity of suffering.'
We say the same thing in English, when we quote the song: "Love hurts."
Some claim giving birth is like "a huge orgasm stimulating all the nerves." I have birth 3 times & watched my daughter in labor for 30 hours as well. There was nothing 'orgasmic' about it. It was life-threatening agony, complete with convulsions & seizures (eclampsia), leaving scars, painful internal adhesions & requiring re-hospitalization for hypertensive crisis, at which time the head 'felt' like it might explode. Death is not 'a feeling.'
4
@Maria Ashot
Giving birth is acute pain.
This article is about chronic pain, which creates very different reactions in the brain - including specific emotions and thoughts, and what this op-ed remembers is that studies show that those emotions then end up CHANGING our brains and increase physical pain.
That means that drugs, which tackle physical pain in its "horizontal" dimension, aren't enough, for chronic pain patients, you need a horizontal approach, that directly tackles those emotions too.
1
@Ana Luisa
I put it to you that many more births are traumatic than most people realize -- including doctors (of both sexes) who have not themselves given birth, ever, yet are in charge of the management of labor.
It is not fair to tell women contractions are "uncomfortable" or "pushing doesn't hurt."
Women who give birth many times in their lifetime, or have more than the rare abortion (I know a churchgoing teen who had had 10 abortions -- in San Francisco -- by the age of 20), are exposing themselves to the risk of tissue damage that can lead to chronic pain -- or corrective surgery that can also lead to chronic pain. (The pelvic mesh scandal, for example, leads to chronic pain. So do endometrial diseases that are poorly understood. My daughter was told by a prof of Gynecology that she "has something in the uterine lining they have never seen before." She has chronic ovarian pain. It is life-altering. She does not take anything for it except for the occasional ibuprofen, although occasionally she has begun relying on something to sleep that combines pain med.) If medical science continues to treat most ob-gyn symptoms as 'normal' & 'non-chronic' (even though severe cramps are chronic & have been shown in some cases to be possible precursors for oncology later) we won't be making progress.
Adhesions (scarring) from sloppy C-sections that attach to ovaries or intestinal tissue can lead to diverticulitis & worse... and again, Chronic Pain.
Being sick is not an emotion.
3
@Maria Ashot
1. The distinction between acute and chronic pain is crucial, as it creates different brain responses.
2. Nobody is claiming that "being sick is an emotion". As I just wrote, this op-ed refers to neurological studies that have proven that chronic physical pain creates specific emotional reactions (= chemical substances) in the brain. And drugs to not address them, so we need more than drugs to treat chronic pain patients you see?
2
Physical pain is a signal that something is wrong with body functions. Holistics and drugs mask this but do not solve the problem. If drugs cause addiction one can also become addicted holistically because neither can cure, only conceal something emotional or physical from the brain. And it isn't nice to fool Mother Nature.
1
We are in a collective uproar about college admissions cheating, yet not nearly enough of an uproar about the cynicism and greed of the pharma company that sold all those opioids and a negligent FDA that passed all those approvals of these drugs. One casual mention in this article about this massive cheating that has caused death to Americans does not do nearly enough - we Americans need to demand that our government start acting like the 800 lb gorilla that can stop these companies from poisoning us for profit.
Emotions aside, sometimes pain is just pain. Ehlers-Danlos Syndrome (EDS) is a genetic connective tissue disorder that causes both chronic and acute pain. I know people with EDS who, for years, have been taking low dose opioids for chronic pain. It has worked well for them and improved their quality of life immensely. These people use multiple methods to control their pain, but the hysteria against opioids threatens to restrict their use of drugs that work best for them. It is terrible that illicit drug use is defining the standard by which these drugs are prescribed and thereby limiting their availability to suffering patients with legitimate needs.
6
There is a really good database of research that shows how effective appropriate pain management can be. With the right team and program a person with chronic pain can find a way to a better life. Financially a higher investment up front shows a savings in medical usage down the line as well. There is blame; and the executives of health care management, pharma, and medicine should be held accountable. Then maybe there could be hope for a better system.
1
Societies have leveraged God given opioids for centuries to help people manage pain, and the Greeks are no exception. Somehow, and quite suddenly, authors like you are seeking to distinguish between their use in acute and chronic pain. That is an academic distinction. For those who experience it, pain is pain. You either have it and it goes away. Or you always have it. For those that always have it, and often have alot of it, pain is one of the most debilitating sensations a person can experience, capable of ruining their ability to function and ending their life. The idea that anyone is looking to restrict a tool, and in this case such an important tool, from being used to help people who are suffering on the basis of biased data, or because they or someone they know has managed to do without this tool is irresponsible, and unfortunately for those in pain, genocidal. People who take these medications often take them as a last resort, and have tried to do without them (who wouldn't witht he stigma that now haunts this society?) Even if this were a generous society, with ample support for those disabled when their pain is not sufficiently treated, most would not choose to be disabled instead of taking a medication that can help them function. People with NO other condition would do or would be expected to do this. Restricting access to pain medication is nothing short of a death sentence. Shame on those who feel entitled to deliver it.
7
@CSA
He isn't trying to restrict a tool, he is trying to show that studies have proven that "pain" is NOT just physical pain, but causes complex emotions in the brain, which then actually increase the physical pain.
And studies show that unfortunately, opioids taken day after day, month after month, actively produce those emotions too, which makes them less effective over time.
At the same time, this means that the only effective approach is a comprehensive approach, which takes both the origin of physical pain AND the brain's emotional reaction into account, in order to reduce both aspects of pain.
And one of the first things that doctors can do here, in order to integrate the emotional aspect into their approach, is to take people's suffering seriously, which means actively cultivating empathy and compassion ... something that today we know can indeed be trained, but isn't part of most doctors (and psychologists') trainings at all.
All the best to you.
3
I am a lifelong athlete. (Ironman distance triathlon.) I know I have fortitude. I know I can force my way through pain.
I have had back injuries from sports and I've thrown a disc into my spinal canal. At one point I couldn't walk.
It is true that I feel emotional when I am in pain.
It is true that I am pained by emotions.
It is true that if I use multiple modalities my pain is managed and and I have less of it.
The problem is, my insurance company favors pills over any other treatment, they'll happily help pay for my meds. As a cancer patient I rely almost solely on my insurance company to pay for my treatment.
I continue to take pain meds and I continue to move as much as possible. This brings me joy. As long as I can move and experience the magical world around me I am happy. Not a junky.
6
Pain is real enough to the sufferer; suggesting a relationship between pain and emotion as a way of alleviating suffering needs to be explained in practical terms. We can improve our relationship with pain in a way that lessens the associated distress, which is no small thing.
We compulsively try to escape pain and discomfort, whether emotional or physical and regardless of severity. Boredom and the loss of a loved one compel us to action, as do a hangover and a slipped disk. Pain's onset causes distress and the desire to escape, which compounds our suffering.
Working consciously with the compulsion can lessen this distress and make pain somewhat more bearable, although it won't end it or remove all need for medication.
Buddhism teaches a practice whereby, instead of reaching automatically for a remedy, we first look into the pain and into the one who appears to be suffering. It's just looking intently for a few moments instead of reacting -- as you would look at an object that suddenly appears before you, without any mental discursiveness. We do this for as long as we can each time physical or emotional pain arises, without pushing ourselves too far, and then let go and return to our current activity, taking our medication if needed.
We may not see a difference at first, but if we look into pain and the impulse to flee each time they arise, some of the intensity and distress will gradually diminish.
2
I am a personal injury attorney who, fortunately or unfortunately, has represented clients for 36 years seeking compensation for their pain. I am not a doctor, but I often believe that I speak with my clients for longer periods of time (and often with more empathy) than their doctors do. I have also have had long periods of time where I have had my own "chronic pain" from a significant back injury. In my experience, the author of this article accurately points out that there is a relationship between pain and emotion. Pain is subjective. One person's "3" is another person's "10". It is no surprise to anyone reading this that the more likely one is to receive money for their pain the more prominent their pain will be (known as secondary gain). I have observed that Type "A" personalities experience pain with more intensity than those mellower types. Each of us has to decide how to handle our own pain. I know, for me, that my unrelenting neuropathic pain disappeared after taking nortriptyline, an anti-depressant, for a few weeks. Pain is processed through the brain and this is a worthy topic for research. Keep an open mind readers.
4
They took my oxycodone away and hgave me Tramadol. So I lived on Naproxin as Tramadol wouldn't work. Then a small occlusion burst in my left optic nerve, which they said was from the high doses of Naproxin and took my eyesight. So now I'm on a heart pill and blood thinner. I am abusing Tylenol because it helps and they won't treat me with Naproxin due to the blood thinner. I will probably ruin a liver but at least death will end my pain even better than Tylenol. Which is a side effect of their plan for senior population control I guess. I did so much better on that opioid and never abused it. So much for government medical regulation.
7
My back has hurt me for 50 years, and in my 60s I had several back surgeries. For 20 years, I have been on the same amount of opioids, and they have worked for 20 years, so although I do not question all the studies about opioids' lack of effectiveness for chronic pain, I and others clearly experience matters differently, and our lives would be much the worse without these now-reviled substances.
I have two suggestions for those being thwarted by our medical profession's new bogeyman.
First, try the Kabatt-Zinn MBSR program, now online at palousemindfulness.com. It will help you, Buddhist-like, to view pain as just another sensation.
Second, try kratom, which can now be bought online just about everywhere. It works better, at least for most, than opioids and is far less dangerous (if you read the science rather than the Gottlieb-inspired attempts to ban the substance, attempts that couldn't even convince the DEA). Fortunately, Gottlieb will now likely return to Big-Pharma and perhaps the FDA will have someone qualified to run it.
2
I'm reminded of the old advertising campaign for Certs Mints Lozenges --
"Certs is a candy mint! - No, Certs is a breath mint! -
No - it's both! - Certs is a candy AND and breath mint! - It's two mints in one!"
So -
"Pain is a sensation! - No, pain is an emotion! - No, it's both! - Pain is a sensation AND an emotion! - It's two feelings in one!"
There are people who suffer from chronic pain and take drugs to medicate the pain - and it also causes them to experience depression, anxiety and a sense of hopelessness --
There are people who suffer from overwhelming depression, hopelessness and psychic pain - and take drugs (both legal and illegal) or alcohol to medicate their psychic pain - but who also suffer from physical pain as a result of their severe depression --
2
Doctor:
I came to this piece looking for some relief for my husband. Instead of relief, I came away furious. What kind of healing do you practice, in stirring up such discord among us readers?
Who are you to tell us how we experience our own pain? And yet we are at your mercy because you write the prescriptions.
And you ask for a raise? So we can sit and talk? Unbelievable.
7
@AuntyLane
And what exactly in this op-ed would "stir discord among us readers"?
This doctor informs us of crucial neurological studies about pain, and of the fact that there ARE new and better approaches to chronic pain possible today.
How come that that makes you furious rather than curious?
My guess: because of what he writes, namely that chronic physical pain itself CAUSES lots of negative emotions and thoughts to flood the brain.
All that he's saying is that doctors have to take those emotions into account too, rather than ignoring them, because studies show that when they do, they do a better job of providing relief for physical pain.
And today, many programs who exactly that already exist. Just look up "MBSR" for instance, which has been used for thirty years now at MIT's Medical School, and with amazing success. Then you'll understand what he's talking about here.
In the meanwhile, all the best to you and your husband.
4
Marijuana!
I'm 74, active, fit and healthy - except for the pain, of course. Multiple sports-related surgeries + age = constant pain. The pain from my repaired back/knee/hands/shoulders… is experienced in my mind and, as a Type-A, "if I try hard enough I can make it go away" personality, I tend to get right up against the pain - metaphorically attacking it. That's exactly the wrong approach - duh! - since it causes the pain to be always present. Pain-killer meds don't cut the mustard for me for various reasons.
However, marijuana (I make my own tinctures since I don't like to smoke it) in small, steady doses helps me relax and mentally/emotionally step back from the pain. It's always there but not always present. As I cruise through a long back-country canyon hike, I'll often be surprised at the flash of realization that I hurt. The dope helped me to forget it and to just Be Present. No addiction, no stomach pain, no constipation/diarrhea - No worries!
Legalize it!
4
As a Retired Indiana Certified Marriage and Family Therapist, i agree with Dr. Warraich’s conclusion that empathy is “perhaps the most important tool physicians need to manage pain.”
Moreover, when in the midst of pain personally, my mind often goes to then Mother Teresa’s words to a U.S. nurse: “You can get so close to God that nothing will hurt you.” Fortunately, decades ago, this particular nurse related this welcome idea to readers of the inspirational magazine "Guideposts."
Each time, after reflecting on Mother Teresa’s words, my prayers are usually in this vein: “Thank You, dear God, for the gift of prayer. May we get so close to You that nothing will hurt us. Thank you, O God, for all opportunities to get closer to You. We pray to learn all that You, dear God, want us to learn from physical, emotional, mental, and other kinds of pain. Amen.”
1
So much to correct in this and the comments.
Perhaps the most important one is the implied dualism, and what seems to be an odd brand of illusionism.
To say that pain is "all in the head" does not imply that pain is non-physical, for presumably, our heads are those knob-like things with eyes and ears sitting on top of our shoulders, and what's "in" those heads are our brains. Last I recall, heads and brains are physical things.
If we retranslate a central claim to "it's all in the brain" we make progress. If we further recall that opioids affect neural processing of pain signals in the brain, in contrast with NSAIDs which treat inflammation at the felt location, we make further progress.
Warraich can then be understood as claiming that pain is like an illusion, which is also, very much, something in our brains. If you look at pictures with static lines and they look like they're moving, the appearance of motion is "all in your brain" but again, that's a physical phenomenon.
Finally, what is right, and supported by scads of studies, is that our brains "interpret" various bodily signals where the result is a feeling of pain, often despite a lack of any physical trauma or malfunction.
If so (if the explanation isn't chronic malfunction or inflammation at the felt location), we need an effective way to retrain or dislodge the interpretation system so that it doesn't cry wolf when there is none. Empathetic stoicism seems to be a poor method for accomplishing this.
2
@M Peirce
Uh ... "empathic stoicism" ... that's an oxymoron, remember.
Stoicism advised learning to become indifferent towards suffering. Empathy is defined by allowing yourself to feel someone suffering.
And the only effective ways of treating the minds' emotional interpretation of physical brain signals in such a way that pain goes down, all happen to include self-compassion training as one of its key practices.
So Dr. Warraich IS being perfectly right here, and as a consequence rejects the usual stoicism with which doctors were learned to approach suffering, as that was long supposed to be the most "scientifical" approach. Today we know that it isn't, and will need a paradigm shift in our medical schools if we want to considerably improve our pain treatment. Which is actually very good news, that we should celebrate rather than reject ...
2
Have you noticed how every government report and, thus every major article, regarding how the US is doing regarding the opioid epidemic is measured in the number of fewer doses taken? I am certain this precise number is generated by the number of doses they are taking away from people in chronic pain. The problem is the people in chronic pain are not the ones who abuse their medications or overdose. Addiction is brought about my the sensation of euphoria. Euphoria is completely absent when you take opioids for chronic pain. Therefore, we experience only relief from pain.
Since my doctor's practice is following the FDA recommendations, she has had to lower my dosage though she knows well the greater degree of my suffering. The FDA guidelines do not allow for the individual natures, causes or quality of life that define our pain. And I speak specifically of those of us who have no hope of our pain ending, not short term pain where hope of abatement is present. (I have two chronically painful diseases and blood cancer or allergies that make all other types of pain meds like NSAIDS, aspirin, Motrin, etc. deadly for me.)
**Our government has decided that it is easier to take medication away from the people who need it, rather than do the harder job of identifying, treating, and supporting the true addicts that just keep dying. Now those of us in chronic pain are dying too. At our own hands, because life like this is not living at all.**
10
In Spanish, it is both:
"Dolor" = physical pain
"Pena" = mental pain
1
Humans seem condemned to be always on a pendulum. And here it is, swinging to the opposite extreme. The opioid crisis is real, inflicted on the public by the drug companies and doctors who were willing accomplices. But to go back to the 'it's all in your head' philosophy reeks of ignorance about the mechanisms of pain. It reminds me of my mother's horror when told by her vet that animals don't feel pain. Ignorance...period.
3
The best book I've ever read on this topic, and that completely confirms this op-ed, is Vidyamala Burch's "Mindfulness for Health. A practical guide to relieving pain, reducing stress and restoring well-being".
It is based on what Asian psychologists call the distinction between first and second arrow pain.
First arrow pain corresponds to what this op-ed calls "acute pain". It is the direct, physical sensation of something in the body being hurt or damaged.
Second arrow pain is all that the mind subsequently does with that sensation: all the thoughts (oh my God, what if this will last forever? I have to do something to stop this NOW! Why did this happen to me, why me? Did I do something wrong? Am I in part guilty here? Will a find a good doctor? How stupid of me to not have bought better health insurance! Etc.), all the emotions (despair when the pain doesn't immediately go away, panic caused by the idea that it will stay forever, fear of losing your job and then your income, sadness for all the things that this pain forces you to give up in life, etc.).
As neurological studies have shown, it turns out that with the right mind and EQ training, you can actually eliminate most second arrow pain, whereas 90% of your pain IS second arrow pain. You do need those trainings though, so it's not your fault if you can't do so yet.
And yes, one of the key aspects of this training is self-compassion (not self-pity).
See also www.breathworks-mindfulness.co.uk.
1
@Ana Luisa: You may be on target with many types of chronic pain. But there does appear to be types of chronic pain that is just as severe and unrelenting as “acute pain”. One example is a cancer that metastasizes to the bone which my father suffered before his death and he was in no condition to work on his EQ
2
Is pain a sensation or an emotion? Clearly the writer is someone who has never experienced childbirth.
3
@Abruptly Biff
He doesn't write that it's either a sensation or emotion, and even less that it's "merely and emotion", as your comment suggests.
Instead, he writes: "chronic pain is an emotion as well as a sensation".
So it's both. And he's addressing CHRONIC pain here, not the acute pain of childbirth.
I assume it’s both.
We itch so as to scratch, the pleasurable reward for an irritating sensation. We suffer like we grieve, to be relieved afterward in a way not unlike the masochist’s reward that is the end of pain — it alone offers the erotic thrill of vital force. Those who fear death can’t bear the end of memory when it is only unconsciousness we undergo and so there is instantly no one to undergo anything. Unless neutrinos and electrons can be said to know.
1
just want to highlight that empathy and compassion are not the same. They are really quite different and should not be confused. Pain and suffering are also not the same and should not be used interchangeably. These phenomenon are at the core of the human experience. Though the writer is doing his best, it's telling of our society that a medical professional writing in the NYT is making these basic errors. Can I suggest learning something about Buddhism? It will help one understand pain and suffering, and it might help alleviate some of it too!
@Oliver Simpson
He's not claiming that they are the same.
And if today neurologists (thanks to Buddhist psychology indeed) have proven that compassion can be defined as noticing someone's suffering (= empathy) and being able to see whether you can do something to alleviate it (= compassion), then maybe the most "compassionate" way to react to the fact that Dr. Warraich doesn''t define these notions ... would be to define them yourself ... ? ;-)
And this doctor's distinction between pain as a sensation and pain as an emotion, as described here and as referred to by the studies that he's providing a link to, actually perfectly coincide with what Buddhist psychology defines as the difference between pain and suffering (= "second arrow pain").
So here too, don't you think that the most helpful and as a consequence most compassionate reaction would have been to clarify these definitions yourself, rather than to read this op-ed too fast and then merely criticize people's ignorance .... ? ;-)
The author does seem to ignore scientifically proven programs that relieve suffering for people with chronic pain, such as Jon Kabat-Zinn's MBSR program. But ... he's a cardiologist. And MBSR trainings aren't part of cardiologists' trainings today, so we can regret this absence of knowledge ... all while celebrating the fact that at least this cardiologist seems to have found out lots of things all on his own already, AND writes op-eds about them.
Namaste.
When the good doctor tells us, "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", it should be noted that this is how clinical psychologists and psychotherapists are taught from the get go. There is a strange inversion in medicine in which they are trying to learn the basics of the psychotherapist approach to other human persons.
But there is a lot at stake in terms of political power and money, so doctors always present with the white lab coats on and the whole marketing wing ding that they are the "real doctors". But they are actually more like workers on an assembly line putting together carburetors than healers.
Medical education as currently done actually makes people less capable of empathy, compassion, recognition of suffering, etc.
There is a simple statistical fact found in the opening pages of intro text books to Abnormal Psychology which points out the upwards of 80% of complaints that come to GPs in medicine are emotional or psychological complaints. The fact is that if we went by the nature of the complaints that walk through a physicians door the general practitioner, the first doctor you would see would be a psychologist not a medical physician. Then instead of the latter consulting a psychologist when they think the problem is "mental" it would be reversed and the psychologist would consult the body doctor or mechanic as the case may be. It's a travesty.
1
@IntheFray
With all respect, I studied both medicine and psychology, and then left both schools precisely because none of them had ANY compassion training for students. Not ONE course. The very notion of compassion was even totally absent.
Today, thanks to the gigantic progress in neurological studies about compassion, some schools finally start to train their students in the development of these innate skills, through proven practices and techniques. But it's still the minority.
So when I personally feel a pain, I go to a doctor, all while using my own compassion training to be able to both cope with his lack of empathy and compassion, and my pain ... ;-)
1
This article is brilliant and nuanced in so many ways. And if providers in the system can barely tolerate talking about physical pain, then we all know that most will not dare approach the unfathomable subject of the catastrophic death of a child, or multiple children, a sibling, partner, or parent. And this results in additional suffering and misdiagnoses, rampant in society.
We know that most providers are either too terrified to stay present with those experiencing traumatic grief or too busy to give grievers the time they need and deserve. And most providers receive no pedagogical training in traumatic grief or compassionate care. They then further add trauma and suffering to grieving clients when they misinform, criticize, or use ridiculous treatments to "treat" grief (i.e., CBT- as if taking a traumatic memory and replacing it with rainbows and unicorns works. It doesn't). The entire system is a psychological opiate pusher.
The system is long overdue for an overhaul.
1
An effective and available natural alternative is available and helpful for many: Acupuncture. While it will not help everyone in all cases, of course, it is a woefully under utilized treatment here in the USA.
1
The opioid addiction is caused by a serious disconnection and displacement from each other, especially in Western societies, but it reaches globally as well. When people aren't loved and do not have a sense of community, and have no access to mental health supports, then what is left? Greek philosophy?
To jump on the bandwagon that opiates are bad is akin to supporting "The War on Drugs." Don't fight a war you cannot win. It's a waste of time. Not everyone who takes opiates is a heroin or oxycontin addict. Some are in dire need of narcotics. Think: Stage IV Cancer, Think: End of life care. Think: Chronic pain sufferers. Sometimes opiates are the only way to relieve their pain. To stigmatize the use of opiates could leave an already fragile population without pain relief.
It's dangerous to simplify the nature of addiction without first considering other theses and studies on the subject. Take a look at RAT PARK, a series of studies into drug addiction conducted in the late 1970's by Canadian psychologist Bruce K. Alexander. It's an alternative look, but filled with evidenced based solutions that are attainable.
3
Having a bad case of Shingles, (for three months), I was prescribed opioids, but never took them. I can also say that every other pain killer, (over the counter), that I did take, had zero effect on my pain. I found that if I got into a certin prone position, with a soft tee shirt on, and didn’t move at all, I could actually experiance moments of no pain. But, any movement at all, was agonizing. Then, after three months, in 48 hours, it left my body like a Medieval curse.
Now, why didn’t I take the opioids? I had the hope that evenetually I would be okay, so I was willing to suffer weeks of sleepless nights and agonizing pain to not have to deal with a potential debilitating addiction. Without that very realistic hope, and the average general history of outbreak duration, I’m not sure what I would do.
The take away, first of all take all vaccines, (it can happen to you.)
Next, be physically and emotionally as strong as you can be, excersise, diet, don’t smoke, wear a seat belt.
1
This piece makes a convincing argument for using cannabis as one element of a pain management strategy, because it works in the brain to make the pain more tolerable, rather than masking it. Illinois has just made it legal to use medical cannabis as an alternative for anyone who has been prescribed an opiate for pain, and many are taking advantage of that.
1
How convenient that the author's pain came when he was young, and it was fixable with physical therapy. Some people live with pain that isn't fixable... not even with empathy.
9
As someone who developed chronic pain in both knees and hips AS A RESULT of bad physical therapy, I resent the implications of this article, especially when there are millions of people like myself who are simply trying to survive on aspirin...HIGH doses of aspirin, to no avail. Pain CAN exist due to injury and disease that goes untreated or is untreatable. Perhaps the author has a suggestion of how to exercise when both knees and both hips with movement AND rest. It's too bad the author lumped all pain sufferers into the opioid group.
7
@GariRae
He didn't.
Your comment, like an important part of the other comments below, is reading the exact opposite of what this author is writing into this op-ed ...
Pain Physician Here:
-
The International Association for the Study of Pain defines pain as follows: "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."
Thus, pain is neither just a physical sensation nor just an emotion...regardless if it is Acute (short-term, associated with damage and within the normal healing time) or Chronic (greater than 3 months and no longer strictly associated with tissue damage).
Take the lowly paper cut. Imagine getting it when opening an overdue bill. How much does that hurt? Now imagine getting that same cut opening a $1 million lottery ticket. Same damage, but how does THAT feel?
So, a person in pain is a whole person and not a hurting body part. Treating pain as “either/or” is wrong. Relying on opioids, distraction or any one thing is wrong. People who say, "I can’t live without…” and follow that with anything other than nutrition, hydration, or oxygen worry me. I care for patients with some very severe, complex conditions. Those taking opioids benefit greatly. NOT ONE takes them without doing something to help their minds and spirits and to improve their physical function. Society has developed a quick-fix mentality and the medical and insurance industries support that for profit. Chronic pain can debilitating, but NO ONE will get better and regain maximal function without investing in treating themselves as a whole person, not just a hurting body part.
7
@KG
That perfectly sums up this op-ed, thanks.
Too many doctors treat symptoms because it is symptoms which bring patients to doctors. I suffered from undiagnosed celiac disease until I was 53 years old. I went through a strict parochial school education from the age of 4 being told to sit still and getting poor "deportment" grades when I did not because I could not. At the risk of providing "too much information," I felt often constipated and it's opposite, struggling to control an ill digestive tract. (Most serotonin is in the gut.) Internal pain distracts from learning and leads to dissociation when one tries to imagine one's way away from real pain. Those in continually untreated pain lapse into learned helplessness. Following that, one find oneself labeled with cognitive, emotional and physical behavioral issues. Early on, we itch and scratch when we see others do probably because of the same mirror neurons which also result in young children mimicking the facial expressions of their parents. Everything, including, how we report our physical feelings and emotions is all learned behavior. My experience is that doctors geared to seek concrete diagnoses don't/can't/won't always listen to people with pain problems that are deep seated and multivariate. The doctor patient relationship is fraught with parent/child power dynamics.
5
Following a botched arthroscopic elbow surgery that led to elbow reconstruction surgery, I developed a rare condition called Complex Regional Pain Syndrome (formerly called RSD). It is one of the most painful conditions known to mankind and is very hard to treat. This pain disease did not stay just in one arm, it spread to all my limbs, my face, my neck and my eyes. I was diagnosed relatively early and treated with every interventional procedure available and various non-opioid drugs without any relief. After 18 months, I began taking a low-dose short-acting opioid (Dilaudid). This drops my constant baseline pain of 7 down to a 5, sometimes a 4, which allows me to function and have improved quality of life.
I am frustrated by reading over and over again articles like this and the constant story of opioid addiction that leads to limiting access to pain medication for people with my condition and many others; often, these articles don't separate the street heroin addicts from pain patients when reporting overdoses and deaths.
Deaths are real in the CRPS community also...from suicide because of the unrelenting suffering of extreme pain.
12
( this is sohy posting ) As a retired RN, I can promise the author of this piece that my older patients who suffered in chronic pain were almost always relieved of their pain by the opioids that they took.
In the distant past, I've taken opioids for my chronic pain as well as a few times for acute pain. They gave me much better relief than the PT that I've had, the NSAIDS that I can only take at very small doses without considerable side effects, or the acetaminophen that is only effective if combined with another drug, but also elevates my liver enzymes if taken in a higher dose than 500mg. per day. The aerobic workouts that I do help slightly but I mostly due them to keep me from further physical deterioration.
I remember the early days in my career when physicians would allow their patients to suffer in pain rather then offer them even a small amount of opioids. It always horrified me to see my older patients suffering relentlessly.
The perception of pain certainly varies from person to person, which is why my late father needed high doses of opioids fro the last 20 years of his life, while my mother who is still alive at age 93, almost never has needed anything for her chronic pain. My father died at age 87 so I doubt all those narcotics shortened his life. All they did was give him a little more quality of life in his old age. Help the small percentage of people who abuse opioids instead of taking them away from those that need them.
15
@Fred
This op-ed doesn't deny that opioids relieve pain.
It merely shows how they only bring partial relief and come with lots of negative side effects, whereas physical pain itself causes a specific emotional brain state, and it has been proven that that brain state actually increases the pain sensations, so as long as we don't treat the effects of pain in the brain, our treatment will remain much less effective that what we already know today IS possible.
More info: see for instance www.breathworks-mindfulness.co.uk.
3
@Ana Luisa Lololol. No one who has lived with chronic, extreme, irreversible pain would suggest breathing as a solution.
2
Pain, like torture, is something every sufferer wants to stop. If you put your hand on something hot, the pain tells you to move your hand to save yourself from getting burned. Your mind will have you move it faster the hotter it is, If burned, the pain continues until you get it "fixed" or cured to remove the pain. The more painful, the more money you're willing to part with to anyone who can alleviate the pain. Pain also serves as a "painful" learning experience.
If you cannot remove your hand from the heat - fire - the pain is torturous, especially since the mind has no options to resolve the damage and thus the pain become intolerable. Hence torture and pain inflicted by others you have no control over results in confessions to anything - truths and lies - as a desperate last resort to escape the pain and damaging harm.
Persistent lifelong pain is like torture, except you can't say anything, even lie, to make it stop. That's why even slight persistent pain you can do nothing about can wear you down to mental and physical exhaustion - even desperation - even if it means taking opioids or taking one's own life to remedy the pain.
11
After several surgeries I've found that resistance to the pain, which is completely natural, really intensifies my perception of it. Having taken a pain med to no avail, I tried deep breathing and sinking into the pain as if it were a hot bath. I also repeated the word "welcome". It really worked and has continued to be a helpful technique in subsequent pain episodes.
2
How would that work with two injured knees and two injured hips? How would that work with pangs from movement and chronic burning at rest?
2
@GariRae
Neurologists have shown how this works.
Resistance is itself a negative emotion, so it intensifies the negative emotions caused by the physical pain.
By learning how to lovingly turn towards negative emotions, you gradually create brain networks that allow you to at least actively regulate the emotional response, and if you know that most of the felt pain consists of that automatic emotional brain response, you can start to understand what mswatkins2u is writing.
"Turning towards" is a very specific technique though.
It includes rewiring your brain, so learning:
1. to clearly see and name any thought and feeling that are going through your mind and body
2. to no longer identify with them. You ARE not your sensations and thoughts and emotions, you are awareness of those things, which happen to come and go quite independently of "you"
3. to learn how to explore all those sensations, thoughts and emotions with curiosity, rather than reject or hate them (= once you've learned to fully accept THAT this is how it is right now)
4. to learn how to actively sooth yourself (= though specific self-compassion exercises, which is something totally different than self-pity).
All these practices have been proven to reduce the stress hormones in your brain, whereas resistance only increases them.
More info: see for instance spinal injury and paraplegic patient V. Burch's website www.breathworks-mindfulness.co.uk.
Other, similar programs: MIT's MBSR.
1
How come so many comments here are projecting the exact opposite of what this author is explicitly writing onto this op-ed - even comments by doctors themselves?
There is only one possible explanation: our spontaneous, cultural prejudices about "emotions" and "compassion".
Most misinterpretations here clearly assume that:
1. emotions are "psychological", not physical
2. learning to deal with emotions means cultivating moral values such as "being tough"
3. compassion and pity are one and the same thing.
For two decades now, neurologists have proven these typical contemporary Western hypotheses to be wrong.
1. Emotions are events happening in the brain, not irrelevant side effects of being a human being
2. Happiness is a very specific brain state, where enough brain networks between the prefrontal cortex and the amygdala have been developed to be able for the brain to regulate its own emotional "default mode" and make sure that it is a positive state, as that is what creates resilience, NOT simply dismissing negative emotions as "sins" or things you "should" not be having.
3. "Pity" means feeling sorry all while imagining that that other person's suffering can't happen to you too, or in the case of self-pity, that your own suffering is "unfair" and doesn't happen to others too. Compassion means feeling someone's suffering and being able to see what you can do to alleviate it, based on the idea that we ALL suffer, and that it could have happened to me too.
(1/2)
4
(2/2)
What Dr. Warraich is saying here is that studies have proven that IF you take these facts into account, as a doctor dealing with chronic pain, then you can see that physical pain itself CAUSES specific negative emotion and thoughts in the brain, and that that negative brain state itself then causes an increase in physical pain sensations.
That means that more than ever now, doctors need to learn to:
1. develop their own empathy and compassion skills, so that they can learn to detect the full "pain" event in a patient's body and brain, rather than to falsely imagine that all we can do is giving drugs that numb out the physical sensation, and
2. develop their own emotional management and compassion skills, as specific trainings reducing the negative emotions that are caused by chronic physical pain, EXIST. And those trainings include developing self-compassion brain networks - both as doctor and as patient. As patient because the more you can embrace those emotions with self-compassion and self-love, rather than turning away from them OR trying to "tough it out", the more you'll notice that that in itself, over time, actually reduces both the physical pain and the power of those emotions caused by it. And as doctors because studies show that the extent to which you can behave in a compassionate way towards others is directly determined by the extent to which you managed to develop self-compassion (= the ability to sooth yourself when suffering - empathically or not).
1
Let us remember Louis Pasteur's (great physician and microbiologist) motto: "To heal, exceptionnaly; to treat, as often as possible; to listen, ALWAYS".
Empathy and the judgement NOT to apply any "cure-it-all" recipe or remedy, unfortunately so often absent in today's medecine, as I have have painfully experienced in my body and soul.
2
I am an emaergency doc and I research pain & addiction. Often we hear those suffering from pain take a defensive stance because of fear losing access to opioids. We hear of their suffering and how they have legitimate pain and those "drug addicts" are ruining it for all of us. I challenge them to see the situation differently. Research now shows that opioids provide no benefit over non opioids therapies in chronic pain. This means your chronic pain may have been the same or better on non opioid therapies. Why is this? Your brain releases it's own opioids to control pain called endorphins and these are down regulated when you take opioid pain relievers. Multimodal pain therapy helps the brain to release more endoprhines to control pain. Now there will always be exceptions and some chronic pain patients will need opioids, but these people should be the exception. What happened over the past 20 years is we used opioids aggressively and escalated doses rapidly in many patients. Once on opioids, your brain changes and the pain is hard to control when you try to come off the opioids. If you are on chronic opioids, the goal should be to stay at a stable dose. What us docs too often see are patients escalating doses because long term opioids do a bad job at controlling pain. Nobody wants to take away opioids from pts who are stable on a dose, we want better pain control and to expose less people to opioids particularly those who are susceptible to opioid use disorder.
5
>>> "Nobody wants to take away opioids from pts who are stable on a dose . . ."
That's simply not true, Chris (although it may be true in your case). Our medical-regulatory system is operating in a mode that absolutely *does* want to deny opioids -- to patients in general and to the greatest extent practicable.
At the moment, the single most effective way to achieve that dubious goal is to scare the living daylights out of providers, threatening everything from their DEA numbers and licenses to their very freedom, to prevent them from prescribing opioids if they can possibly avoid doing so. It's working.
As for the oft-repeated contention that opioids are ineffective for treatment of chronic pain, it is rather striking that one seldom hears that assertion from pain sufferers. Rather, it is almost always heard from the same providers who live under threat of regulatory and legal consequences.
As Upton Sinclair famously wrote, "It is difficult to get a man to understand something when his salary depends upon his not understanding it."
The obvious corollary to the above is that it is relatively easy to get medical providers to believe those things they are "required" to believe in order to protect their livelihoods.
11
@Douglas Well said! Thank you!!!
2
All pain is not the same, as you yourself argue. At the same time, when opiods are taken, you don't know the kind of pain being alleviated.
I think opiods are effective for certain kinds of chronic pain, as long as they are taken just for that pain and nothing else.
I think physical pain pales to emotional pain (the pain in your mind when someone you love dies, the pain of failure/breakups/heartache, tragedy in the world, etc.). Unfortunately I think opiods are far more effective at treating emotional pain than physical pain and so people who become addicted I think are self-medicating in different ways. And there is a lot of of emotional pain to go around in society today for a variety of reasons.
Of course, opiod addiction ends up causing further emotional pain which becomes a destructive cycle, just like alcohol addiction used to dull emotional pain can become a vicious cycle.
20
I'm in my 60's and have had (at last count) 18 surgeries. I was born with a kidney defect, and have had a number of other ongoing physical conditions, all of which have caused me chronic pain throughout my life.
And I cannot take aspirin or NSAIDs (because of that miserable side effect, anaphylaxis). So how have I had to handle pain? I've had to tough it out, all these years, with no medication for pain relief.
But I'm not claiming any superior moral fiber. If there were any medications I could have taken that didn't cause me anaphylaxis or that weren't addictive, I would have taken them in a heartbeat. And I know I speak for tens of thousands of us who know that pain is real, it is not an emotion, and chronic pain is just viciously corrosive to one's physical -- and mental -- health.
Perhaps the good doctor ought to experience what many of us have to go through without any pain relief before he decides that we are simply expressing an "emotion".
70
As a seasoned Geriatrician, chronic pain is more than emotion for my patients. In Dementia, the patients don’t know what meds they’re taking. Commonly if agitation symptoms with a history of severe arthritis or spinal stenosis are treated first with pain meds - per WHO we use long acting Tylenol, then Gabapentin or Lyrica, then 1/2 tab Norco or 1/4 tab methadone for spinal stenosis ( which compresses nerves) and often can stop the psych meds, when the pain is relieved. These folks don’t ask for higher doses. But treatment helps keep them walking. We try to taper, but many still need a low dose for relief. Motrin increases the risk of heart attack, stroke ,hypertension, kidney damage and GI bleeding. Last, itching at least in elders has been shown to often be neurologic and relieved by Gabapentin or Lyrica. All specialists for adults would benefit from more Geriatric medical training.
39
@Kyle Reese In my darkest moments, I find myself wishing that doctors, as a part of their training, had to deal with what some of us deal with for a week. Their attitudes might change a bit.
I've seen a doctor take a patient off his pain meds and put him on another one for no other reason than he thought the pharma rep was cute. The patient suffered so he could flirt with the pill bunny.
10
@Peregrinus Pill bunnies are dangerous to our health in more ways than painkillers. Doctors get their drug and prescribing information for new medications from pharmaceutical reps who mostly have a four-year degree in biological science. And who spew the marketing pitch for a patented and more expensive version of anything.
2
I have taken an opioid only once in my life following having a tooth extracted. I'm a little embarrassed to say I didn't know it was an opioid when I took it. I found that it didn't actually get rid of the pain, it just made me not care that I was in pain. That caring was replaced with some truly loopy behavior which I did not like feeling and resolved to stick to ibuprofen until my mouth healed and not take any opioids again. I think it's still sitting in my bathroom mirror cabinet. The episode however made me really question the nature of pain, as Dr. Warraich is doing expansively here. How real it is and how subjective it is are very hard to pin down. It's clear that pain is a very necessary warning system for our bodies telling us something is wrong. But just like happiness and sadness it's processed through so many other factors in our brain chemistry that it's very hard to define as anything more than a feeling.
33
@O My
You had a tooth extracted.
Try having major surgery and getting through the days after surgery using ibuprofen .
I
18
@DJS: I believe the author of the article was talking about "chronic pain", not post-surgical pain.
2
@O My How about knee replacement surgery or a mastectomy or a hysterectomy or degenerative arthritis that leaves you three inches shorter in those "Golden Years"... see how "happiness" works for you then.
5
Family doctor here, 30 years.
1. The designation of pain as the "fifth vital sign" was a crucial error, prompting large numbers of doctors to over-treat chronic non-malignant pain with opioids. I never fell into that trap but have still had my hands full in the years since trying to clean up other doctors' messes.
2. If the author thinks the American medical system is going to pay more to have a family physician or other doctor "really talk with my patients about their pain," I think perhaps his understanding of the structure and function of the heart is much better than his understanding of the structure and function of the American medical system. In fact, the American medical system seems much more interested in having physicians type on keyboards in the examination room and then after clinic hours than it is in having us practice medicine at all.
3. Dirty little not-so-secret: Taking care of chronic pain patients is onerous. Very few doctors want to do it. You can train up the medical students on how to do it all you want, but they'll still avoid it it they can.
Medical students know about the ROAD to happiness: Radiology, ophthalmology, anesthesia, dermatology. Pain management doesn't make the list of happy specialties.
219
Excellent comment. Funny how we never hear the chant about the American healthcare system being the best in the world anymore. We’ve moved on to other self-delusions.
17
@vbering
Well said. Pain was never the fifth vital sign because it is neither vital (too high or too low low and you die), nor is it a sign ( something measured objectively). The pendulum swings back and forth, and eventually we will conclude that opiates are a reasonable option for chronic pain when nothing else is working. Sort of like it was 30 or 40 years ago.
8
@vbering
Well said! Right on.
3
Been a body worker for 45 years end observed a lot of responses to long term pain, including my own. Allopathic medicine (that which is practiced by MDs and most DOs) depends too lmuch on symptom suppression by medication and surgery. One only has to watch TV ads to see how one can take this medication or that and continue habits that engender troubles. Acid blockers, NSAIDs, and other drugs promise responsibility free solutions. To my observation the over use of corticosteroids as well as opioids are in the same pattern, allowing a perceived lack of pain to exacerbate various conditions. It is not the fault of individual physicians, it is a cultural phenomena, and none of us are easily separated from herd mentality, education does not better that human habit, only makes us think better of ourselves.
I have also long observed that attitudes towards discomfort (of which pain is an extreme) vary greatly. If the cause is structural some people figure out by experiment what causes and exacerbates it and take, or obtain, corrective measures, others retreat into inaction so as not to trigger response. The first group gets better, sometimes on their own, sometimes with the help of restorative actions, be they alternative, or mainstream. Those who do best are solutional responders, including advocating for complete care from the medical community and getting help with that if need be.
23
@Roxanne de Koning, As one bodyworker to another: well said. Too bad so few are listening (as evidenced by other comments and, especially, Reader Picks).
1
To reduce opioid addiction, notice the agony our society inflicts on millions of us--they have no hope for a decent future. Stuck in poverty or on its razor's edge, no living wage jobs to work toward, abysmal living conditions, no way out.
Republicans constantly sneer that they're not taking Personal Responsibility for having been born to impoverished parents, growing up in an underfunded school district, and not being geniuses. If they believe this, they hate themselves and also anyone different (darker skin, different religion, different language immigrant) they can blame for their lack of opportunity.
They are in pain. P.A.I.N. They'll take whatever drug promises to relieve it, even briefly.
Strengthen the social safety net, stop giving billionaires Very Special Tax Breaks, and invest in jobs to give every American a decent future. Watch addiction decline. Bonus: we'll be able to prescribe opioids to people in severe *physical* pain.
11
In my early 30's, after years of being extremely active in athletics and the military, my back "went out" during a time when I was ramping up at a new job and traveling all over the world. An MRI showed a disc bulge that could have merited surgery and pain killers.
After several years of occasional back episodes and alternative treatments, I discovered a book by Dr. John Sarno that linked pain such as mine to repressed emotions. When I opened my mind to Sarno's theories, my back episodes nearly disappeared completely. I later met a man who had the same disc bulge as mine. He was in dire pain that he treated with opioids that led to his early death. I often wonder why his pain was so different from mine. Could he have heard or applied what had worked for me?
Sarno's approach is not for everyone but it works for some. I am always respectful of the pain of others and never lead with Sarno or discount another's experience. On the other hand, I have shared Sarno with close friends & family who have benefited.
2
This article seems to assert that pain is all a matter of perspective and that the best way to handle it is to tough it out. That will lead to moral strength and a brain that feels less pain with chronic conditions. Interesting point of view.
As an older person with a body that heals far more slowly than when I was younger and more is susceptible to painful temporary conditions, I have learned that if I wait for pain to go away to carry on with normal activities, I will end up weaker and less able to move easily. However, I also know that pain above a certain level causes my body to involuntarily fail to complete normal movements. In other words, sometimes to continue to function normally painkillers are necessary.
125
@Casual Observer
With all respect, I truly saddens me how so many people can read the exact opposite into this op-ed of what this author is literally writing.
He's calling for more empathy and compassion, and you interpret this as calling for "toughing it out" ... ?
Compassion, BY DEFINITION (and contrary to pity) is all about ALLEVIATING someone's suffering, remember?
What this doctor is telling us (and correctly, I can affirm, having been a chronic pain patient for years myself) is that as long as we treat chronic pain as MERELY physical pain, without taking the fact into account that such pain actively produces lots of negative emotions and thoughts and the brain, which then increase the sensitivity to physical pain signals, then we're condemning people to stay stuck with treatments that merely numb out the conscious sensation of pain, without treating the impact of chronic physical pain on the brain.
So what is needed is a more holistic approach, that alleviates BOTH the physical pain and emotional pain created by physical pain, you see? And that's needed because today neurological studies have shown that this emotional component itself increases physical pain sensations, whereas drugs don't take it into account at all (and have horrible side effects).
Go to www.breathworks-mindfulness.co.uk for instance, if you want to learn more about how such more scientific and holistic approach of pain management and relief works.
In the meanwhile, all the best to you.
10
@Ana Luisa If so many people are misreading the author then perhaps it is the author who is to blame. People who have gone through all the treatments, holistic or otherwise, to no avail or their condition has progressed are sick and tired of having their suffering discounted by those who had a tooth extracted or episodic pain or think compassion is curative. I would happily trade my pain for the kind that can be fixed by breathing, but life doesn't work that way. The only people who truly understand living with chronic, severe and intractable are those who live with it... and for whom all other treatments up to opioids have failed.
11
@Ana Luisa And we have all of that and very little access to it as Dr. Warraich has noted. The VA happens to have (at least in Philadelphia) a very comprehensive pain program whenever opioid use has become dangerously high and extended. To bad it isn't the start rather than the end.
2
Only a physician would have the chutzpah to publish so confident a statement based not on professional specialization and experience, or research and study. A vague reference to what I'm guessing must be Stoical philosophers is supposed to suffice to ground the assertion in ancient wisdom? I wouldn't accept such sloppy work from my pre-med students. The doctor would likely not accept such quality in his area of specialization.
The problem of pain is spiritual, physical, medical, personal, social, and inadequately addressed in our country. When I worked in oncology decades ago we knew there were highly addictive painkillers: they were the ones that relieved pain and also lifted one's mood. Why is there no federal program to find better pharmaceuticals for pain relief in, say, ten years?
My personal experience includes having been NSAIDs suffice for a chronic congenital lower back condition. I've found steroid injections along with physical therapy are the only sources of relief when the pain becomes severe. And yet there are studies that show steroid injections are of no value, and the effect must be in my head. Studies are of varying quality, and their results need to considered with great care.
The problem is serious. We need better thinking about it.
7
Yes. Pain is certainly a complex, multimodal phenomenon and requires multimodal treatment approaches. As a psychologist who has treated a multiplicity of chronic pain patients, I have come to believe that much of the time, open ended taking of opioids is rarely going to be helpful except in acute pain situations (e.g. post surgery). For the chronic pain patient a combination of psychological
and mindfulness approaches seems to work well. However, we do definitely need more evidence based research to guide clinical practice in the area.
2
My brother is also a doctor, and recently had a complex fracture of his leg while skiing, that caused him to be immobilized with pins through his leg for several months. There were a lot of aches and pains, and he refused to take opioids. I think most doctors know that opioids are a very risky proposition and would rather endure some chronic pain than run the risk of addiction.
15
@Jonathan, months vs rest of your life, never to travel by plane again, not go to theatre, ballet, never sleep through the night. no walks along beach. guess which is chronic?
9
@Jonathan
Your brother did not suffer the level of pain that countless doctors who use these meds, properly, on a short-term basis, use them.
But don't generalize from his stoicism.
Yes, some poorly treated doctors, especially self-medicators, have ended up opioid addicts.
It happens - but the answer is not to generalize.
Maybe I'm "oversensitive" to pain - my receptors work better than his do. Maybe he's "undersensitive" to pain - something that cannot be measured beyond asking "are you hurting" and "how badly are you hurting".
Until we can get snapshots of neurotransmitter/neurotransmission levels, and precise data on how given levels effect individual pain sufferers, don't give me "if my brother was tough enough to take it, you should be too."
Also, please consider, he knew his pain would go away when the fracture healed. I know the nerves that are randomly put under pressure when/if I even slightly shift a given muscle, will cause some point along the neural path to become indescribably painful - and will for the rest of my life. I am at the point I'm willing to try (after the now-prohibited testing on chimpanzee models) replacement of my spine with elements cast, in gel and ceramic, from ultra-detailed MRIs, though running a 25% chance of quadriplegia. THATS how much I'm suffering.
Now shut up about how your brother can beat up my brother and other such trash talk.
Sorry for the lack of civility.
It's hard to be civil in this case
13
A nurse colleague had a shoulder fracture and could not sleep from the pain. She was given Norco, then low dose OxyContin that allowed her to sleep and heal. She tapered the meds off in 9 weeks when it healed.
5
I am an orthopaedic surgeon who has spent the last 40 years treating patients, most of whose primary complaint is pain. I don't think that many orthopaedic surgeons really thought opioids were much a solution for chronic pain. We have all dealt with patients for whom we prescribed narcotics for acute, severe pain, and who did not want to get off them, when we thought they should. Unfortunately, the laity were told by a variety of entities including the National Academy of Medicine that pain was being "under-treated." One of the insidious aspects of opioid consumption, is that it may turn a reasonably normal human being into a manipulative and almost sociopathic person. Given a patient perspective that (s)he should not be experiencing anything more than slight pain, I have experienced many a patient demanding to stay on narcotics, and suggesting that withdrawal is indicative of my not caring abut their pain control. I have spent a lot of time and effort talking with patients and being empathetic, but it only goes so far when someone is hooked. This problem is not all of doctors' making; it is largely societal, although it has certainly benefited the pharmaceutical industry and the medical specialty of pain management. If funding was immediately forthcoming to cover treatment for the afflicted, it would probably take another decade to train the cadré of medical personnel necessary to attempt to treat those in need. It is a horrific problem.
43
@M. Tooke And how much pain should the patient be willing to experience?
9
It's no coincidence that the whole problem started when the AMA made its pronouncement. The way back requires a new pronouncement.
5
Thank you for this comment. I think the response here of the people who take opioids is a little frightening and indicative of the addiction problem.
1
An ode to pain 'I feel, therefore I am, whether my pain is sensation or emotion, I am alive to do with it as I may'.
2
Well, we should follow the Greeks? Really? Suffer like a Spartan? Well, you are welcome to suffer all you like. I just moved my plants indoors my back was really bothering me, now after a couple of Tylenol with codeine, I can get some rest. But both my feet are numb. It won't get a lot better even with surgery and the surgery is rarely a success long term, no I'll keep my pain meds thank you.
Don't get me wrong I know they impair me but why suffer? I have been taking the same pain meds Q.E.D. for almost 40 years. I am not a junky just a guy with a bad back. Why should I suffer because you think it is wrong to take drugs.
62
@GladF7 Same here. I have tried all the other things he talks about, some made my pain even worse. Surgery not an option. My pain meds make my day livable. Glad he's not my doctor.
7
@GladF7
This op-ed says the EXACT OPPOSITE of what you're writing here.
"If chronic pain is an emotion as well as a sensation, then it is unlikely to be managed successfully without compassion."
Compassion is defining as noticing someone's suffering (= empathy) and being able to see whether you can alleviate it.
And as neurological studies have shown, empathy literally means that "mirror neurons" in your brain start firing, which puts your brain in a similar emotional state as the person in front of you. So you LITERALLY feel his pain, once you have the guts to start training your empathy and compassion skills, as Dr. Warraich proposes EVERY doctor should do.
And there's even more.
Exactly as Dr. Warraich is remembering here, many studies have already shown that chronic pain causes the brain to produce very specific, negative emotions and thoughts in the brain - which themselves cause the brain to increase the physical sensation of pain, etc.
That means that ANY serious medical approach to chronic pain should take these facts into account, rather than to imagine that pain is "just" a physical sensation.
Drugs cannot take this dimension into account, only fully present and emotionally highly developed human beings can.
The good news is that programs such as MBCT precisely increase EQ (by training awareness of thoughts and self-compassion), which then acts on sensations of pain and can take away about 90% of them. So we really have to take this op-ed seriously.
6
@Ana Luisa
Compassion is defining as noticing someone's suffering (= empathy) and being able to see whether you can alleviate it.
"is defining?" really ??
Well, I guess being from Belgium English might not be your 1st language but I got no idea what EQ means in this context at least. See @vbering
he wrote the best comment that I agree with. I'd love to quit drugs and now I take about 1/3 of what I used to take I will hopefully get down to just dosing 2-3 times a week early next year.
I am a physician who treats a lot of people who present with pain.
While I realize that they are truly suffering and that they come to me for relief, I also know that it is not important to them whether pain is a sensation or an emotion.
In fact, if I were in a lot of pain and someone asked me this question I would probably get up and walk out.....and refuse to pay their bill.
I might also be tempted to yell at them and let them know that I think that they have no business preaching to me or practicing their woo woo philosophy. I want relief.
However, since I am a physician of last resort with many patients, some of whom are on many medications, I will say that they come to me because I truly examine them and attempt to figure out if there is some way that they can be helped with less meds or no meds.
What I have found is that a lot of musculoskeletal pain is due to structural issues. Diagnosis and treatment of them using osteopathic manipulation, acupuncture, for example, may provide significant relief for many.
There are also many patients who have psychosomatic pain. Read the work of John Sarno, MD ( 5 books on this). Much of my work comes from patients in this category. No med school teaches this approach so most of these patients end up on drugs.
And some patients just must stick with pain meds.
It is not black and white.
Each patient is different.
99
@simon sez
This op-ed isn't advising you to start theoretical explanations about emotions to your patients, it's advising doctors to start developing their own empathy and compassion skills, as studies prove that the more you do, the more effective your attempt to heal and reduce pain becomes.
Moreover, studies also show that chronic pain literally produces much more negative emotions in the brain, AND that those emotions then actively increase the physical sensation of pain.
Taking these facts into account means starting to invest time in studying EQ increasing tools, as a doctor, and then helping your patients in developing these tools too.
See for instance breathworks-mindfulness.co.uk for more information.
Nobody is claiming that chronic pain isn't triggered by a physical problem. But we do know today that chronic pain itself creates a very specific emotional context in the brain, which CAN and as a consequence SHOULD be treated too, as doing so takes away up to 90% of the sensation of physical pain - and without any of the horrible side effects that come with taking drugs for the rest of your life.
So yes, each patient is different. But no, compassion and empathy and EQ training (both as doctor and as patient) isn't something that only certain individuals can learn, as we all have an innate "compassion instinct" (D. Keltner, Berkeley), just like we all have amygdala and their stress hormones. So we should use it.
5
The article correctly suggests that pain is felt and interpreted emotionally and psychologically is correct.
The source physical pain indeed is the bone fracture or herniated disk or some other unfortunate physical problem. The article is about pain and how it has been dealt with in the past and treated poorly in the present. BTW, narcotics is not a recent thing but dates back to the Greeks and have been available for centuries before us.
The mindfulness meditation studies at the Massachusetts University have already proven that mindfulness training alleviates pain that even large dosages of narcotics no longer can.
After several Oxys that worked a little for my broken pelvis, I started physical therapy. After several attempts by physical therapists ranging from “pressure point and release” to aggressive versions of acupuncture, I settled on a kind woman whose first words were “we have to get you a good night’s sleep.”
Her physical manipulations were subtle at first until I felt that she was caressing the painful area like putting a baby to sleep, the baby being the muscles impacted by the fracture.
My exercise regimen was to move very gently even as little as half an inch. I said why? She said “it’s not for the muscle but for the brain.
5
These concepts are interesting, but the reality in our country is that for most, even the cost of physical therapy is out of reach. Working with fresh out of college physical therapists or their interns, can cost as much as seeing a psychiatrist, given our tortuous health insurance system. Looking for better ways to treat pain by searching for help from different doctors, also costs more than most of us can afford. The U.S. system is rigged to make the average patient in pain feel ashamed and helpless. Medicare for all!
7
After nearly 5 decades in medicine my impression of most patients is that that they want to be told what they want to hear or think they know because “...I know my body.” A recent patient in a clinic that manages chronic pain or in most cases opioid-induced hyperalgia told me she”likes doctor’s who do what I say.” Meaning just prescribe the oxycodone at a stratospheric MME(morphine medical equivalent) level along with the benzodiazepine(Xanax), muscle relaxant(Soma) and the hypnotic(Ambien) and I will be on my sedated way. And that was the first patient of the day it only got worse after that.
I agree with the this physician that chronic pain is a learned behavior and the medical profession has turned into a national health crisis.
3
Those offering NSAIDS such a ibuprofen as a safer alternative should also discuss the 30 percent higher risk of heart attack and stroke if you use these medications. In short, there is no safe medication for pain management. Empathy is unlikely to be a satisfactory replacement.
10
You are most fortunate to have suffered for only a year with a treatable physical malady.
If your spine had been more damaged or sustained a slightly different injury you might not be so confident about treating chronic pain as an 'emotion'.
Millions of Americans have relied on opioids for decades to help them cope with broken bodies that cannot be healed by exercise, surgery, a TENS unit or positive thinking. We shape our days around our next dose and pray our physicians will be allowed to continue prescribing the narcotics that help us function.
Spend your days confined to bed or a couch dreading the moment you'll have to walk 30 feet to the bathroom – you'll rethink your opinion.
13
@Kris Aaron
Please read Vidyamala Burch's "Mindfulnes for health".
She herself had a spinal injury but contrary to the author of this op-ed, never fully recovered and as a consequence HAD to find a way to live with chronic pain.
The book teaches that method step by step, but you can also work with experts trained in it (see breathworks-mindfulness.co.uk).
The method is entirely science based.
And it turns out that the author of this op-ed's findings and intuitions are exactly right: chronic physical pain CAUSES lots of negative emotions and thoughts in the brain, and learning how to turn towards those thoughts (which is quite difficult, in the beginning, and requires some fierce self-compassion, rather than trying to distract yourself with "positive thinking") actually reduces 90% of the sensation of pain, which then allows people to have a much more normal life again, and to reduce the intake of painkillers with inevitably have lots of side effects.
If this seems weird to you, at first sight, just think about this: today, in many Western hospitals, surgeons operate without using any general anesthesia for surgeries that normally absolutely require them in order to avoid horrible pain. How can they do so? The anesthesist uses hypnosis instead.
So yes, our mental and emotional capacities are actually much more powerful than we tend to assume. We just ignore this, because we were never trained to develop them.
All the best to you.
1
@Ana Luisa . Do you have any idea how insulting it is to tell someone who has described her pain so eloquently, and has ALREADY SAID that "positive thinking" doesn't help, that she should just turn to "mindfulness"? This comment section is full of testimonies from those who have tried every non-pharmaceutical treatment possible, including "mindfulness," and are telling us that nothing apart from opioids helps. Why are you so determined not to believe their testimony about their own experiences?
2
@me
With all respect, MBSR has nothing to do with "positive thinking".
And Kris clearly didn't try it out yet.
I'm not questioning any of her experiences, I'm just trying to show that what she fears this op-ed says is actually not what it says at all, it's rather pointing to totally new, AND scientifically proven approaches.
V. Burch is a paraplegic spinal injury patient herself. So this is not "just" mindfulness ... ;-)
I remember when pain was the fifth vital sign. Evryone was given limitless amounts of opioids then bam...we are not allowed to perscribe opioids in the practice. Patients were taken off meds cold turkey with no help in the withdrawal that was bound to happen. Therefore, patients looked for alternatives and bam, illegal Fentanyl and heroin became endemic. Stealing drugs from family was a common occurance and we know the rest of the story.
There are times narcotics are needed and when they are not a patient should have medical help to find an alternative of which there are a few out there.
Doctors need to remember, NSAIDS are great except for the kidney failure from too many and tylenol by mouth is an OK drug, increasing that too much can give you kidney failure.
I am in healthcare and have been developing work related pain and right now it is very difficult to find a doctor who even recognizes it. I would never resort to illegal drugs but do know, chronic pain needs to be addressed not ignored.
8
"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."
So you are saying that doctors knowingly prescribe pain pills because that have to pay for their boat? We need to change much more than the way physicians are paid, we have to change the way they think too. For starters.
@Aurace Rengifo They do not even get the boat, they are paying bloated 'Malpractice Insurance' payments instead, and that is if they are being perfect with their work, one mistake in the medical group and the insurance goes up radically for the whole practice.
Decades ago when Hospitals were allowed to become profit making, rather than the non-profit status required of pharmaceutical and medical facilities, the costs of medicine and care were tolerable, and care was widely available.
Then the Profit motive took over, and while doctors may have a nominally high income, they also get dinged at higher levels, and for more things from whole business plans that are nothing more than a parasitical arrangement on the doctors and hospitals, with Insurance, Investors and Lawyers being the ones to make the money instead of it going to patient care.
We need to re-think the entire 'Profit Motive' across our entire range of businesses: where it conflicts with Ecological or Human living standards, such as pollution, or lack of access to medical care, schooling and proper diet and shelter which are problems of Inequality that are reinforced by the Already Wealthy so as to have to pay less and less for Labor as the poor will compete against each other for the few meager jobs that can be had.
Sounds like a 'third world nation'? Well, that is because the Corporations have already extracted all they could there, so now they are extracting ALL the personal wealth of the developed Nations
1
@Aurace Rengifo Errata
"because that have to pay" should read "because they have to pay "
1
Jon Kabat-Zinn has been a pioneer in this field for almost thirty years with his clinics and his book Full Catastrophe Living which provides a Buddhist and meditation view to the problem of pain while not ever using the word Buddhist.
1
@Chuck Burton
His - indeed scientifically proven method for treating chronic pain - doesn't need to use the word "Buddhist" because even though it's Buddhist psychology that invented these tools and trainings, Western science today has proven them to work perfectly well in an entirely secular, non-religious setting too.
And it turns out that Dr. Warraich's intuitions here are perfectly right: contrary to Western psychology, that treats negative emotions as illness to get rid of, Buddhist psychology has studied what it takes for human beings to thrive and be deeply happy (even in difficult circumstances) for more than two thousand years now. Happiness doesn't require the absence of negative emotions, neurology has now proven too. Happiness is a skill, which can be trained, and is the result of systematically cultivating and practicing what we in the West thought of as "moral values" but that are actually innate "instincts" (as Dach Kelter, Berkeley, has in the meanwhile shown): empathy and (self-)compassion.
So contrary to what we in the West tend to think, the best way to alleviate chronic physical and emotional pain is not to try to numb it out or distract ourselves from it (even though in acute cases that's necessary, of course), but to learn how to turn TOWARDS it and be with it. The more you become able to do so, the more it literally disappears.
1
This is one of the more sickening articles I've read recently on this important subject. The good Dr. Warraich is leading the charge in a movement that will have one very certain result - suicides will spike because people can't stand to be in severe pain all the time. I think it's already happening.
This past January I slipped on the ice and landed on my back. Intense pain the next day sent me to an urgent care clinic for x-rays etc, which showed no broken or cracked bones. The Dr. treating me told me to take muscle relaxers. I asked for percocets, and he said that would be overkill. The muscle relaxers did zero and I simply suffered with the pain for about a month.
I've used precocets off and on my whole life for pain. They work great, and I've never had any desire to use them as a recreational drug. I always keep a couple on hand for that, and to help with the side effects of migraine medication I take. Most people use these drugs with no problems, and it makes it possible for them to lead productive lives. In mild doses, they should be legal.
Dr. Warraich would have us believe that "we just think we are in pain", which is complete rubbish in most cases. He also amazingly does not mention the new, amazing results from people using CBD for some types of pain and other ailments.
Does Dr. Warraich drink alcohol, a deadly, potentially addictive drug, that is infinitely more "dis-inhibiting" than opiates? We have a long way to go making our drug policies sane.
11
@Paul Shindler
Except that Dr. Warraich did NOT write that "we just think we are in pain", and contrary to most doctors today instead writes that:
" 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".
Many other studies have confirmed this already.
Chronic physical pain actively produces certain negative emotions and thoughts in the brain, and it has been proven that those emotions and thoughts (= the brain networks associated with them) in turn actively increase the physical pain sensation.
Programs such as MBSR (developed at MIT specifically for chronically ill patients) or its "breathworks" variant have been proven already to be highly successful in alleviating physical pain, THROUGH mind and emotional training.
So the mistake you're making here is to assume that somehow chronic physical pain would NOT have any effect on emotions and thoughts, as if those emotions and thoughts weren't products of the exact same brain as the brain that is experiencing physical pain in the first place...
1
I read a related article this A.M.on a financial site, CNBC . Tech companies trying to solve pain with neuromodulation instead of pills Does it work ? Most products still in trial stage but it certainly deserves researching .
1
Anyone who has ever gone through a bad breakup or the loss of a loved one - ie, all of us - know without a doubt that emotional pain is real and can feel like physical pain. I wonder that the author doesn't mention this.
5
Life - its “all in your head”
Actually the suffering was all in his tooth in the movie "Marathon Man" during Olivier's questioning of Hoffman - "is it safe?" Yup, one of the most painful scenes to watch in cinema. Even more so for those watching who have suffered under a poorly trained dental butcher.
Isn't pain our mind's way to signal the alarm of not imminent potential harm (itching) but actual harm that needs to be stopped at any cost for the most severe pain? Scratching an itch is confirmation the itchy sensation is not dangerous - like a tarantula crawling on you.
After a spinal cord injury leaving me in unbearable pain I could not sleep at all for over a week in the hospital - morphine tapered the intensity of some "flavors" of pain but not all - until spinal surgery resolved the worst of the pain, leaving a blend of pains and paralysis likely for life. The experience shifted my pain tolerance much higher - able to tolerate more pain. Unfortunately the residual pain over time is limiting and exhausting - I could only man up for so many years.
I've refused opioid pain killers - if morphine didn't fully work, why would an opioid? After years of pain and complete skepticism I tried a new TENS unit that's placed around the calf below the knee. It's been the only thing to mitigate or turn down the volume of pain from my back to the sole of my feet. Expensive, but worth it.
For doctors, empathy does not pay a kickback from the pharma industry like a prescription does.
5
Pain isn’t all in our bodies, nor is it all “in our head,” but it is all about…our emotions.
As a professional "life" coach for almost 20 years, working intimately with doctors, attorneys, teachers, salespeople, parents. CEO's, CFO's, etc. - in major cities all across the United States…
…I can tell you that most often the pain - allergies, anxiety, eating disorders, sexual dysfunction, sleep disorders - most adults are experiencing, is about the emotions they are suppressing, repressing, and subjugating.
Put more simply...it's about the unresolved issues - the truths and realities - in their lives and their relationships they are not addressing; the anger, bitterness, frustration, fear, sadness, hurt, loneliness, and anxiety they are suppressing and/or medicating, in order to subjugate their emotions.
Now we’re using meds, marijuana, media, marketing, advertising, alcohol, and technology to numb ourselves to the realities of our relationships…and real life.
These substitutes “feel” like the real thing, “feel” like real relationships, “feel” like we’re being productive, “feel” like we are connected, “feel” like they are fulfilling…
…but they’re not. They are no more genuinely fulfilling than eating a bag of chips instead of a well-balanced meal. But…we keep on bingeing on them.
We have so much pain…because we are so disconnected from ourselves; from our intrinsic wisdom, curiosity, creativity, wisdom…and humanity.
6
@Kelly Grace Smith
In other words, we are so disconnected from ourselves and as a consequence others because we have very low EQ.
And that is because we never thought about teaching how to develop our EQ in schools, at work floors etc.
One of the best ways to learn how to connect: www.self-compassion.org.
@Ana Luisa
Thank you Ana, but I don't align with "EQ" or "emotional intelligence," or any of the made-up marketing hooks we've created to obscure what this is really about...
...emotional maturity. It is about emotional maturity.
Let's start calling it what it is, so we can start helping and healing the problem.
Finally we’re beginning to develop some balance in our understanding of pain. It is indeed neither “all in your head“ nor “all in your body“. This sort of balanced thinking is sorely needed in many many areas. It’s heartening to see it emerge in the matter of pain.
1
“That PAIN, notwithstanding the Opinion of the Vulgar, is one of the best Symptoms which a Physician can wish to produce. That a very wise SECT of ancient Philosophers maintained it was no Evil, in which Opinion the learned Faculty do concur; with this Difference only, that the Stoicks speak of themselves, and the Doctors of their Patients.”
--Henry Fielding, ‘The Charge to the Jury: or, The Sum of the Evidence, on the Trial of A.B.C.D. and E.F. All M.D. For the Death of one Robert at Orfud,’ 1745 (PRO KB28 187/6)
2
As a professional "life" coach for almost 20 years, with many years of intensive training, not to mention working with doctors, attorneys, teachers, salespeople, stay-at-home mothers, CEO's, CFO's, etc. in major cities all across the United States...
...I can tell you that more often than not, the pain - allergies, tension, anxiety, eating disorders, sexual dysfunction, sleep disorders - which most adults are experiencing right now, is about the emotions they are suppressing, repressing, and subjugating.
Put more simply...it's about the unresolved issues - the truths and realities - in their lives and their relationships they are not addressing; the anger, bitterness, frustration, fear, sadness, hurt, loneliness, and anxiety they are ignoring and/or ignoring via medicating, in order to subjugate their emotions.
We’re using meds, marijuana, media, marketing, advertising, alcohol, and technology to numb ourselves to the realities of our relationships…and real life.
These substitutes “feel” like the real thing, “feel” like real relationships, “feel” like we’re being productive, “feel” like we are connected, “feel like they are fulfilling…
…but they’re not. They are no more genuinely fulfilling than eating a bag of Doritos instead of a well-balanced meal. But…we keep on bingeing on them.
We have so much pain…because we are so disconnected from ourselves; from our own, individual intrinsic wisdom, curiosity, creativity, wisdom…and humanity.
2
People with serious medical conditions that require these medications, have taken them successfully for decades, are not addicted, and are now being denied treatment from their doctors and forcibly tapered are in so much pain that they see suicide as their only way out. Your article is a slap in the face to people who might otherwise be bedridden without these medications and are under siege. The opioid epidemic is an illegal drug problem, not a prescription drug problem.
27
@Melissa kudos to you, melissa. your article response is spot on. i suffer from chronic pain and take morphine, thanks to my compassionate and understanding primary physician. i have never thought of myself as an addict. it's amazing that most all of the pain clinics here where i live are staffed with doctors who will not prescribed opoids, but rely on PT, implanted stimulators, cognitive behavioral therapy for their pain patients. i have been on morphine for years and it is helpful. glad i read this.
14
@Melissa thank you for stating clearly what many of us know. In our rush to combat drug abuse we are stepping between doctors and patients who suffer from unbearable pain. Many doctors know this and are afraid to speak the truth for fear of retaliation from drug enforcement agencies. Much needless suffering is being forced on many very ill people. These patients are not seeking drugs to get high; they are simply trying to survive, and they do not abuse their medications.
13
I also have chronic pain and right now am in bed struggling to move my stiff painful body.
I have been on low dose codeine for many years. I only take it when paracetamol and ibuprofen are not working. I use heat and TENS too. I am on nerve pain meds too.
When nothing else is working and the pain is getting too much for me, I take my 60mg of codeine. Around half an hour later I am mercifully pain free. I can get up and get some chores done, potter slowly in the garden. That period of mercy transforms my life
The article doesn't seem to have personal awareness of chronic pain. It is every day of your life, for years, and many of use use opiates safely and find they give respite from terrible pain.
It is 1pm. The only pain relief I have had today is a heated blanket. I want to be up and about but everything hurts. My routine begins again. Paracetamol first and wait an hour to see if it's working. Sometimes it does. If not then ibuprofen. Wait an hour. Most times this works with the prior paracetamol to enable me to get down the stairs. I will slowly do chores but will be in significant but manageable pain.
I choose pain over codeine but if it gets impossible I will resort to the 60mg codeine. The pain will vanish in an hour. Some days I need none. Some days I will need 60 mg 4 times a day.
The same routine if pain wakes me in the night.
Please please remember all the people who only have quality of life because of the opiates they use safely.
10
Completely annoying that regular folk trying to manage their life now have to jump through all kinds of hoops because of bad behavior in the part of drug companies, over prescribers and addictive personalities.
14
"All this is not to say that there is no physical component to these feelings."
Thanks, Doc. Glad you have a little sympathy in your heart.
12
Why do articles about opioids and pain always come down to money and doctors? There are too many suppositions in this article. Too many ifs. Face it. Doctors are never going to be able to read people's minds. They're not omniscient gods. They can't tell if the pain is fake or not. Neither can the DEA. So how about giving "us" patients all a break and let us live our lives as we wish. Decriminalize drug use. Our immigration crisis is an inadvertent consequence of our War on Drugs in Central America. These efforts are a waste of money.
7
@Bill
Actually, science has proven the exact opposite already.
All mammals' brains have "mirror neurons". Those neurons put our brains into an emotional state similar to that of the person in front of us. It's what we call "empathy".
And in the meanwhile it has been proven that "compassion" (= empathy plus the ability to alleviate someone's suffering) is an innate skill too, and highly trainable.
What Dr. Warraich is saying here is that by systematically shutting down their empathy and compassion brain circuits, rather than cultivating and training them, doctors tend to actively ignore the entire emotional context created by chronic pain.
Moreover, studies show that chronic physical pain ITSELF produces much more negative thoughts and emotions in the brain, AND that those emotions themselves increase the sensation of pain.
This process is happening both in the body and brain, so is entirely "physical", if you want. That's the very opposite of your notion of "fake pain", whereas it's precisely doctors without any serious empathy and compassion training who tend to decide that if they don't find a clear physical cause of pain, then it must be "fake pain".
What Dr. Warraich is proposing here is to stop imagining "fake pain", and to start taking seriously the pain patients tell doctors they are feeling. And studies show that just doing so, rather than judging patients, already turns you into a more effective doctor (whether you decide to prescribe drugs or not) ...
1
@Ana Luisa
A little "new age" don't you think? Any double-blind studies? No. Because none of these assertions can be proven, not scientifically. Legally, as in covering one's backsides is the way medicine is practiced, protecting that most valuable of privilege - the DEA license to prescribe, which means you can't give out too many pain pills because Big Brother is watching, which means you must diminish the validity of a pain sufferer's relationship to his body.
The recent hysteria over drug price gouging informs me that there is no money for leisurely doctor-patient relationships unless you're a politician with a gold card to Walter Reed. After two years, a congressman is vested in Congress' retirement and health care plans, which is why healthcare isn't going anywhere. Read all the heart procedures VP Dick Cheney enjoyed at taxpayer expense at Wikipedia.
End Nixon's War on Drugs, and get the DEA out of our bodies!
1
The opioids are merely the big tip on the iceberg. For the huge numbers of addicts, there are thousands of physicians willingly and concurrently filling out dozens of prescriptions for each of their addicted patients. Thousands and thousands of scripts are generated for opioid's best "buddies"; Gabapentin, Klonopin, Lorazepam etc... etc...Big pharma has its claws in our physicians and our addicts. It is a bigger problem than anyone thinks. I can assure you that most of these MD's who wrote these description where I worked were well aware of their patients opioid addictions.
I found this article to be filled with purely opinionated judgemental statements, but little factual understanding of chronic pain or its impact on a human being’s ability to lead a productive life. Unbeknownst to the author it seems, there have been some major improvements to the science and technology of pain management since the days of the ancient Greeks. For example, a judicious combination of interventional methods with pharmaceutical management can be highly effective in restoring mobility and quality of life in the case of long term chronic pain. Chronic pain is not only debilitating but a mind-highjacking affliction. Oh, and by the way, do not translate “pharmaceutical” as “opioid” or “antidepressant”.
13
There's nothing noble about being stuck in your room for a year with agonizing pain.
11
Really? No mention of marijuana here?
It doesn't make the pain go away, it allows you to acknowledge it and then not care too much about it. Marijuana provides the mental tool or state of mind useful for enduring pain.
WAY better than opioids.
Absolutely ridiculous that it is illegal.
The pharmaceutical companies are the real drug pushers, pushing really awful drugs. Our bought and paid for government is in on the take, and responsible for allowing the companies to provide lethal substances while criminalizing one of the best natural drugs for pain management. It has been used for centuries without the death and devastation that opioids deliver.
Grow your own. Vote out the troglodytes that won't legalize it.
2
Comments on articles about pain, like this one, are always remarkable in that there are always people who insist that they absolutely need their opioids and how dare you suggest differently.
The US comprises only 3-4% of the world's population, yet Americans take a third of these addictive drugs.
Drug company executives are laughing all the way to the bank.
2
“While the expression that suffering is “all in your head” is too often used to diminish others’ agony, ...” but isn’t that what this article is about? Doctors who irresponsibly gave out opioids to all and created the current crisis are now faced with vexing paperwork to do if they prescribe appropriate painkillers. So now those few of us for whom OTC painkillers do nothin can just scream in agony while being told to do deep breathing exercises, told that it is just emotional and ‘all in our heads.’ So much easier than getting to know a patient’s individual needs.
7
Sounds to me like yet more Office of Drug Control Policy propaganda. What we really need is an Office of Gun Control Policy.
6
A few years back feeling a pain in my left hip, I went to see a doctor in Miami Beach as we were vacationing there. At the end of the visit, besides giving me some advice on how to deal with the hip (exams and the like), he prescribed OxyContin to help with the pain. It was the weirdest situation as after the first two days the body was telling me of the pain, but the brain decided to ignore it, I stopped immediately and it took me almost a week to “calm” down. The pills? Addio forever down the drain......
2
Somehow Dr. Warraich brings to mind those physicians of a century or so ago who thought women in labor shouldn't get pain relieving drugs because the Bible said women should suffer in childbearing.
12
The worst med mistake of our era is NOT prescribing opiates for pain. At all. THE WORST mistake the US has made since slavery is the drug war. Portugal decrim'd all drugs a decade ago, they have almost no ODs. Ditto Switzerland. Our war on drugs is what kills people. D.A., J.D., NYC
12
@David Anderson
You are 100% correct David.
1
The purpose of pain in primate African apes aka bonobos, chimpanzees and humans is evolutionary fit biological DNA genetic survival. A warning. You are hurt. Withdrawal is instinctive. Invoking the immune system is automatic.
Opioid drugs alter and interfere with the natural physiological, emotional and mental responses to pain. The purpose of opioid drug makers and dealers is to enhance their profits. And the biggest opioid drug makers and dealers are legal such as the Sackler family Purdue Pharma.
3
Money will be made by individual doctors tending caringly to patients, or it will be made by manufacturers of pills. The pill people are organized to get their way; the individual doctors arent. So doctors must see many patients to make money, and this means that they can do little except prescribe pills. The pill people spend much money and schmoozing to keep it so.
If medicine is a business, then all this is OK. If it is more or other than a business, all this is ugly and immoral. Now, in this country, medicine is a business. Government can make medicine more or other than a business, but only if we elect people who want to do this and do not worship business.
3
Unsurprisingly, each top comment is an impassioned defense of why they absolutely, positively need to take powerful prescription narcotics.
2
The pharmaceutical/government/healthcare complex continues to support the interest of shareholders, and sacrificed the Hippocratic Oath on the altar of profit long ago. Pain management----whether physical or psychic----is a lucrative business and it matters little to them if the “cure” is worse than the disease.
There have always been alternative approaches to pain management such as medical marijuana, meditation, acupuncture, meditation, as well as many others that have been marginalized, stigmatized, or outright banned without justification other than to protect corporate profits.
The entire healthcare system is dysfunctional and needs to be rebuilt from the ground up.
1
This article seems to have worked up people too well acquainted with pain to risk having their drugs taken away. Don’t go scaring those who live with pain or anticipate it will kick in any moment. Yes, be sympathetic. Yes, hear pained people out. But, helping people to not suffer is paramount. If it takes drugs, manage them.
I wonder about the mentality being honed in Americans by years of pharmaceutical TV commercials bypassing the medical professional and instructing people to “tell your doctor” you need their drug. I wonder about people using pain killers to get high. For pity's sake, let’s first look at such abuse.
15
I stub my toe. Now it's broken. What I feel is an emotion and not a pain? The examples are innumerable.
Personally, I suffer from chronic pain (as well as periodic cuts, burns, and contusions), and in every case the pain lessens if I experience some strong positive emotion.
However, for some of my worse pains, I take opioids with a positive benefit. I have been on some dose of opioids nearly all the time for 20+ years (although I have stopped several times for periods in excess of a year). Neither I nor any of my doctors have every considered me to have an opioids problem.
Aren't endorphins the body's own paid medication? They are, in fact, a chemical that works with receptors in our central nervous system to make us feel better. This "feeling better" can easily be interpreted as an improved emotional state, but it is a biochemical phenomena, as is the effect of pain medications.
Can't two different systems (our sensations and our emotions) interact without that fact necessarily defining that our sensation of pain is part of our emotional experience?
I have two siblings who are long-term invalids due to their perceived pain and who take the amount of opioids that far exceed what most doctors would ever prescribe. They are either addicts, or they are chemically dependent, but either way opioids have not helped them.
This article doesn't reflect the complexity of the issue as I have seen it.
3
Thank you for starting a very useful discussion - is pain a sensation or emotion. Sensation is natural response to sensory stimulus reaching the mind for the protection of the self. The old scriptures of East talked about the human capacity of moderating these incoming stimulus by many mental functions like - forgiveness, unselfishness, shyness, and concentration. Indian yoga practitioners can allow doctors perform minor surgery without anesthesia by withdrawing mind from the body. The first thing, Western medicine has to come out of its ivory tower and accept that human aliments are not only chemical process, there is role of mind that is more than a chemical computer. Underlying algorithms of mind is different from cause and effect of chemical reaction. There is intelligence that is both objective and subjective. It is necessary to bring MIND in the medical science to treat human conditions.
1
"The only demonstrable effect of two decades of widespread prescription of opioids has been catastrophic harm."
Absurd.
Fifteen years ago, my wife was prescribed opioids in the last month of her life, and it made that month bearable despite the cancer throughout her body. That was a demonstrable positive effect within the last two decades.
Dr. Warraich should be ashamed of him/herself.
11
@Dan Styer There is a difference between acute and cancer pain and chronic pain. Opioids are good for the first two and don't work for the last one. I don't think anyone would say that your wife should not have had them, I am sorry for what you both endured. I had fentanyl when I fractured my ankle and had surgery - it was wonderful.
2
@Dan Styer. Thank you Mr. Styer! This new age holistic approach is so old. Many people like Mr. Styer and I were advised to invest in expensive, worthless time at these sports medicine clinics, physical therapy services which were not only ineffectual but often made pain worse.
Nobody should have to get cancer in order to have adequate treatment of pain. This histrionic witch hunt is a cruel punishment of innocent people. Addicts and alcoholics have always been with us. They should not be used as an excuse for prohibition. Yes, Dr Warraich should be ashamed but I bet he/she is sitting smug and pretty.
2
I suffer from chronic pain since 1985. I will say that if I didn't receive pain meds I would have never been as productive, or have been able to save for retirement. I've been on pain medicine for 25 yrs. In that time I've had a number of doctors try various medicines. When I retired I was quickly able to reduce my pain meds by half within 6 months. I was taking CBD oil, but had to quit due to it not being allowed. When I moved from CA to TX I had to quit taking pain meds as I couldn't find a doctor. I was less than half the person I had been. Then I found a doctor, I'm on a very low dose, just enough to eliminate the pain and neuropathy in my feet. I can't believe that I'll need a higher dose. There'll be days where I'll have it rough, but that's with everyone. So the dose I take now will just have to work. Life has moments of pain. I do wish I was allowed to have the CBD oil again.
6
Since the dawn of man people have been selling cures for pain guaranteed to cure your pain in three weeks. Remarkably they usually work in three weeks or less but if not you get your money back. The ingredients can be literally anything that won't kill you but should include a small amount of alcohol and a blue or green coloring agent. Packaging is also important as is TV advertising.
An externally applied device with copper woven into it is also a near sure three week cure and has the side benefit of drawing the attention and false sympathy of others.
2
My wife has chronic pain from a back injury over 30 years ago. She has good days and bad days. When she goes to sleep, she either gets lucky and is able to sleep, or she wake up in the middle of the night, writhing in pain. When that happens, she takes ibuprofen like vitamins. Sometimes it works enough to get her back to sleep. Increasingly, though, she continues to be in severe pain for several hours until it subsides. This leaves her both physically and emotionally drained.
We know that opioids are contraindicated for long term pain management; however, even if some of it is in her mind, she awakes suddenly with excruciating pain. Without a physical component, she would not be suffering and waking up in pain (probably because when she is asleep, her body moves without conscious effort to avoid positions that cause the onset of her pain.
For my part, I have developed(?) a form of psychopathy to deal with my response to her pain. What I mean is that I love her, but have learned to do what I can to help alleviate her pain, while disconnecting my emotional response to her sharp cries and moans. If I didn’t, I would be emotionally incapacitated, as it is ever present. Some days, her nightly bout seems to have hollowed her out. Other days, she is present and also experiences joy. When these days with joy become fewer, we will come to a point when death is a better alternative than constant pain.
At that point, perhaps, opioids will allow her a comfortable existence for a time.
5
"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."
Unbelievable--I knew the statistics were high, but this is astounding.
This physician makes excellent points about how pain, and the patient's perception of it, can vary based on a ton of factors, not the least of which is medical compassion.
Dr. Warraich hints at the answer that his column asks; is pain sensate or emotional? To which I-- a chronic pain patient from multiple fractures suffered in a freak accident almost six years-- respond, both. Chronic pain affects mood and mood affects pain.
I've read about an elusive "substance P" in the brain that modulates patient perceptions of pain. No surprise substance P was locate in the same area of the brain managing emotions--Merck hoped to find the holy grail, a treatment for both depression and pain in one compound.
No surprise there--older antidepressants such as elavil are still occasionally used for pain.
But if researchers do find a miracle cure for pain, can Americans regain trust an industry that so dramatically failed them with opiates?
5
My daughter began dealing with chronic pain at a young age. Although the doctors couldn’t foresee her future, I still feel they did a disservice to her in that for years she was told repeatedly that her pain would go away. She was given medication so she wouldn’t have pain anymore. She would have been much better served if a doctor had taken the time to discuss the nature of pain with her and with me as her parent; that maybe she would have to learn to manage a certain level of pain. Our society is obsessed with this idea of no pain, emotional or physical, and we are even more obsessed with getting rid of it. For some, like my daughter who have to live with chronic pain, they would be better served to learn how to manage life with a certain level of pain instead of this all or none mentality.
1
Another step away from overuse of pain medication may be banning drug companies from marketing directly to consumers. Encouraging people to imagine their discomfort as a symptom of official-sounding diseases ("low testosterone," "halitosis") and then to "ask your doctor about" whatever drug will provide a treatment is not only unethical, but likely a factor in why doctors' offices are so inundated that doctors have less quality time to spend with patients.
7
@Greek Goddess
If the drug companies are going to be allowed to market direct to consumers, they should have to pay a percentage of profits to a fund that provides health care for the uninsured. I'd also like to see a tax on their nonstop television advertising that would go to a similar fund.
1
@Greek Goddess...thank you. An oft-ignored byproduct of the "healthcare crisis." In actuality, we have a self-awareness crisis. Self-imposed Hypochondria and obesity are cultural byproducts of entitlement and me-ism and are what's helping to tip the scales (pun intended). Any discussion of our collective societal dilemma---and more to the immediate point, pain---without acknowledging and navigating these hasn't been, and isn't, based in simple logic.
1
Perhaps your pain was psychologically based doctor. Perhaps yours had a back story.
Not everyone’s pain is in his head.
Perhaps some compassion is in order for people with physical suffering greater than you can ever imagine.
Burn victims have no mental defect or back story.
But they can suffer additional trauma in the hospital at the hands of people like you who suggest breathing and meditation and psych drugs as the patient screams in agony from physical pain that has no back story.
I might add that people who have suffered physical trauma are not responsible for the opioid epidemic and should not have to suffer for the mistakes of those who are responsible.
18
Whether the good doctor likes it or not, while pain is a given in this existence, suffering IS optional. That's an axiom inherent in all ancient traditions, now lost in the modern psyche. We no longer know how to NOT fixate on pain, because we insist on believing (useless word) that our existence is in spite of its inherent existential condition, and not as a part of it. See birth and death. Early Vedic teaching was in tune with this millennia before the inception of Western philosophy, and my guess Non-acceptance of pain is the threshold at which pain becomes emotional. And our modern attempts at escaping it--futile at best.
Mind over matter; pay it little mind, and it doesn't matter. As someone with chronic pain, funny how it's "not there" when I'm not. My grandchildren will attest to that.
2
Is pain a sensation or an emotion?
Pain is a sensation but humans are deeply invested in reducing it to an emotion. Physical reality often hits the body, and the more the body is flayed the more it tries to crawl into the brain, identify purely with brain, call the pain emotion rather than sensation which can be turned off, strip itself from the body even as it watches its body flayed and knowing if the body dies there goes the brain.
The less physical reality hurts the body, the fewer instances of sensation of pain, the more the brain extends into the body, identifies with it, puts out its sensitive tendrils by which in fact the brain gathers its information about the world (the five senses), and the less pain is reduced to just an emotion among others and one which is needed to be turned off. A decent analogy is to the actions of a roly poly or flower which opens and closes depending on stimulus.
But things are even more complex than that: Trying to find an optimal pleasure state for a human to oppose to pain, and even more difficult, to have a person optimally open and close to pleasure and pain while going through various environments and across the lifespan is one of the greatest philosophical/scientific questions of all time. Pleasure saturations are as dangerous as pain experiences to humans and humans try to reduce both to emotions which can be turned on or off at will, like a higher sleep/wake cycle beyond sleeping and waking.
A rare pleasure the world.
Here's what I learned from the school of hard knocks when my back started to crumble. Hate guides our health care if you are not one of the %1. Our rotten health care system runs on what's cheapest for the insurance company with no thought about the patient's health hence pills. They more often than not refuse to address the actual cause of the pain and address that to stop the pain instead for the last 15 yrs they gave out pills for the symptoms and sending them back to the job that is killing them in the first place. Add to that employers illegally no longer pay worker's medical bills if they are hurt on the job all because our leaders take bribe after bribe from big pharma.
12
For mild to moderate chronic or acute pain, buprenorphine in its suboxone formulation works really well IMO especially if it's the first (and only) exposure to opiods. It is very very unlikely to lead to addiction (I've yet to see a controlled study on pure suboxone addiction - usually it's someone addicted to opiods who abuse buprenorphine because either no alternative or to get clean and reuse again).
2
I suffered a severe fracture to my arm. It was the upper part of my arm that fractured across and up. They couldn't cast it and I had to wear a sling with an ace wrap around my body to keep it from moving. Every time I breathed the pain was excruciating.
I was given opioids and anti-inflammatory meds. It didn't relieve the pain. Ice became my best friend as it was the only thing that relieved the pain but I couldn't keep ice on my arm all day and night.
I meditate every day and had heard that meditating can help with pain. I meditated looking for the pain and to my amazement couldn't find it. I was pain free while meditating. Like the ice I couldn't meditate all day but between the ice and meditation my pain was manageable. I continued the anti-inflammatory but cut back to taking an opioid only when I went to bed but as the bone healed I stopped taking that also. Today I do a meditation that suggests I watch my pain and not react to it. I have arthritis and it certainly helps not to feed the pain with reaction.
I am not suggesting that opioids not be given for acute or chronic pain but other avenues to understand and treat pain should be explored.
19
Pain is real. Emotions are real. That they work together makes perfect sense.
I've had both knees replaced, 2 surgeries on my shoulder for a torn labrum, etc, ...
I could not get enough opioids for my first TKR first knee replacement because I was moving to Switzerland 2 months after the surgery and was in a panic. My second--14 months ago--required almost no opioids for pain as I recovered in my home with no timeline to return to work much less move overseas.
Those commenters who wish to believe that their pain is purely physical are missing out on a wonderful pliability of the brain and their psyche. Too bad, it is a leap of faith, of course, but I am an atheist unused to leaps of faith.
To those commenters who believe that their pain is purely physical, I say open your mind to the spectrum of possibilities because your mind holds more buckets of happiness and dread and joy and pain than you could ever use, and most importantly, we can choose--to some extent--which bucket we dump over ourselves.
6
I remember 20 years ago when someone was put on morphine, it meant that they were on their way out.
3
Pain is discussed in this article as physical. It also can be psychological. Shouldn't we be discussing the intersection of physical and psychological pain as an area that may produce the highest risk for addiction and death as these become inseparable for an individual?
4
Debating the relative degrees of is all well and good. Suggesting non-pharmaceutical remedies also has its place but at the end of the day acute sensation of pain is as real as the bone protruding from one’s skin. If all this pseudo-philosophy around pain medication leads to me being denied an opiate as I lie either in agony or near death, I suppose I will have to start brushing up on my Ancient Greek philosophers now so I will know the correct arguments to get the opioid that will relieve my suffering.
Joking aside, a simple argument to explain the explosion of the population of Lotus Eaters can be made by invoking the Rotten Apple Postulate. We are at End-Stage Barrel, IMHO. To paraphrase a modern philosopher, “Time for a new barrel.”
3
What is, is. Pain, whether emotion or sensation, afflicts us all in the tribe of human beings on earth. We are animals -- mammals in fact -- and we suffer from real and imagined pains all through our lives. We pay for the moments of joy in our brief lives by undergoing the kaleidoscope of pain and suffering in all its forms. Prayer won't cease suffering nor will the good Dame of Norwich's "all will be well, and all will be well, and all manner of thing shall be well". Acceptance of pain lessens it. And the realization that everything passes and transmutes from living flesh of flora and fauna to death helps, too. This isn't mournful or depressing thought. It's just the reality that things are what they are in our human lives. Thank you, Dr. Haider Warraich, for your musings on the ancient understanding of suffering, which gave birth to our present day understanding. Pain and release from pain are phenomena of breathing in and out from our physically beating hearts on our planet. Doctors who pay attention, who empathize with their patients suffering pain. who take time to speak with them and listen to them, are healers in the best sense of the word. Words matter, words heal, and we attend to your wise words.
2
This is a very thought provoking piece. I wonder if this question, "what is pain", is not sort of equivalent to asking, "what is the meaning of life". It seems to me like pain can be, one or the other, or a bit of both. If my injured knee hurts I feel the sensation of pain, but how many times do we hear, read, or ourselves describe an emotional state as painful? Consider phrases like "I was reminded of the pain of my father's death", or "it pained them to see their friend in that kind of pain." Personally, I'm satisfied with defining sensational and emotional pain as sub-types of pain, both of which have common properties.
Respectfully, Dr. Warraich, I am put in a bit of pain when reading this article. Specifically when reading a line such as, "pain is part of the STORY of the person who suffers from it, not just a separate physical phenomenon.", or "The concept of pain as a purely physical phenomenon reached its zenith in the 1990s". These lines cause me pain in the way the story of Sojourner Truth and her mother causes me pain. I am reminded of Truth because what she was lead to, and allowed to, believe caused her harm. I think those that are allowed to believe in, or fed, the nonphysical, the unrealistic, are in many ways similar. Perhaps its my Christian upbringing, one which stressed compassion toward others, but I think compassion can mean requiring others to accept that "their story" is purely physical. To hopefully make my point clearer, what is the structure of ..
1
In the USA, "Pain and suffering" has become "Pain equals suffering".
Always, in all situations.
Suggesting that someone calm down when they are hysterical following a minor scrape is considered heartless instead of helpful. I am not suggesting that people ignore pain from serious injury. I have however noticed that pain + fear or pain + hysteria is much worse than the pain itself.
When my infant child fell and got a mid scrape I picked him up and hugged him till he was calm. When (as an adolescent) he was slightly injured during a ball game we would clean and bandage the wound, he would close his eyes and breathe slowly and deeply. Others his age would moan and groan and cry and scream for scrapes not even visible. The parents were also hysterical.
When you are taught that the slightest amount of pain is a horror and potential lawsuit - then all pain is unbearable.
5
While many doctors are good and help their patients the majority have over prescribed medications in the US for the last fifty years. The US over uses medications as though the side effects will be handled by the population . Trust has completely disappeared with respect to accepting medical advice. Study after study shows that the US population is over medicated. What is really surprising is that with the addiction of these medications and illegal drugs at an all time high that the addicted are not helped in a more progressive manner to help them beat their addiction . A heroin or cocaine addict should be able to get their need for their drug from a professional doctor without recourse. How does it help society for organized crime to profit by selling illegal drugs to the record population of addicts. In the future those addicted to drugs should be able to use medical centers to fill their need. They would no longer fill prisons. Statistics would show the real size of the problem. Crime would fall dramatically for those addicted would get treatment. The laundering of drug money would end. Fentanyl is the new crisis. There will always be a new drug to cause a crisis. If we leave the self destructive system as it is will it get better?
6
I believe the standard American diet, (often referred to as S.A.D.) largely explains the chronic pain Americans suffer, and those from countries adopting our bad example. Try eating a healthy diet of mostly vegetables and fruits for a few weeks and the unexplained pain will very likely vanish. The emotional component comes from our addiction to S.A.D. eating -- rat lab tests show it may be as potent as opioid addiction -- and that's the challenge.
3
@R1NA
And if you don't go the vegetarian way in a few weeks your pain will also likely disappear. While I don't argue with some benefits of the increase in vegetables pain relief isn't likely to be one of them. In any case last I checked opium was a purely vegetable product. Time may not heal all wounds but it will heal many.
@Bunbury
I suggest you read the numerous scientific findings on the adverse effect of bad diets, like inflammation that has been scientifically proven to can cause chronic pain and can be reduced, if not eliminated, with a low sugar, high nutrient diet, particularly of beans, berries, green vegetables, mushrooms and onions. It doesn't just magically happen and this is one non-drug way that can work. I also recommend Dr.Campell's book, "The China Study", which explains this in more accessible laypeople's terms.
1
Americans consumer 95% of the world’s hydrocodone. Opioids are extremely rare across the rest of the developed world.
It is not possible that the US has as much pain as it claims compared to the rest of the developed world. Something else is afoot. It could be that pain is a bit like the immune system: you need to be exposed to discomfort in order to learn how to deal with it. Perhaps Americans live in such sanitised/pain-free environments that their bodies become incapable of dealing with normal life experiences without medical intervention.
2
@KW What some of those other Nations have, such as many in Europe, is a good medical system that treats symptoms before they get to the point of needing the heavy pain meds.
Would be nice to have that kind of medical care here, prevention and catching low level problems before they become major problems would cut a lot of the cost of our medical system.
Too many people profit on the death, disabling and discomfort of others and lead very comfortable lives themselves. Time for some serious, non-captured regulatory actions to get to the heart of the matter and if stockholders have held stocks knowing crimes were committed by those companies, then they should have all of their investments and wealth removed, let Them live on the Dole and Govt Assistance, since they say it is so wonderful for people to live on that they refuse to work to get there...let THEM try to 'live' on $771/mo cash and $175 in food benefits.
Let THEM try living on the 'cake' they so deride.
But it all comes down to having good medical care and not being treated as a replaceable slaves by our industries, which chew up and throw away a lot of highly trained talent that then is wasted when the unsafe company overworks their labor and permanent injuries happen.
The workmen suffer for the rest of their life.
Those who profited, with the cost of injury on Insurance and go unpunished living their lavish 8 & 9+ figure incomes while the permanently injured are also impoverished on top of it. Talk about Pain!
1
It is most interesting that Dr. Warraich is referring us to the Ancient Greeks's characterization of pain. After all the culture and civilization of the Ancient Greeks are at the very basis of our modern Western culture in all its aspects.
But it would have been even more helpful if he had been willing to quote his Greek sources and give us either the text of his quotations or the references to those ancient books, possibly with the mention of the modern editions he is using and favor.
6
an emotion is a specific type of body state that has crucial survival benefits in having it's emergence shared with the group. Fear helps the whole group by telegraphing danger. Pain is more body state and not an emotion because it has less utility for the group. Once you are injured you are more likely to be eaten and it makes no difference to group survival one way or the other .
Seeing how useless we are with dealing with other peoples pain and in inflicting it on others I would add us to the animal Kingdom without hesitation
1
To those who believe that pain is all in the mind - do you believe that animals feel pain? If not, have you run that by a veterinarian? If the idea that opiates relieve pain is only a comforting fantasy, why do opiates work on animals?
12
As expressed by other comments below, much of the problem with opioids results from a failure to taper off the scrip.
And like whatever drug, there is always a black market.
When a patient suddenly finds himself still in pain, without access to the drug, the illegal option is out there.
And the time pressure on Docs, to see as many patients as
humanly possible, discourages a slow taper-off approach.
Abuse is always suspected, and without attentive care,
you end up where we are now- pain meds without oversight,
leading to high overdose fatalities.
2
My chronic pain from arthritis only responds to opiates, not to over the counter pain killers.
Without opiates I couldn’t move around the house!
14
In Vipassana Buddhism, acute and chronic pain are considered nothing more than sensations — sensations we move away from versus those we move toward (such as those that provide pleasure). But according to Buddhist philosophy, sensations are always temporary; they never last. Through careful observation (meditation), one learns to appreciate that sensations are elusive, blinking in and out of existence — an illusion. In other words, in a sense, sensations are not real.
To anybody experiencing terrible acute pain, such pat ideas about the all too real pain they experience will sound at best uninformed and at worst, dispassionate to the point of heartless. And yet, there is something to those who through meditation observe the fleeting nature of sensations that does allow for transcending and/or transforming the experience of what is conventionally considered pain, even unbearable chronic pain.
Research into this approach has been done with success, and various folks have arrived at this approach from a Western angle, not via Buddhist philosophy. It does require a commitment, patience, and even in many cases, a personality willing and capable of applying the practice diligently, which many Westerners, depending on age and other factors, may not be capable of doing. In that sense, it won't necessarily work for all.
But the fact that it does work is proof that pain can be transcended without drugs and with proper training of the mind.
3
@John Crutcher...right on the mark. With all its achievements in cosmic knowledge, modern science's greatest irony is its contribution to our estrangement from self-awareness. Review some of the other posts this morning for clarification.
I think I need this concept demonstrated. Here. You meditate while I saw off your leg.
2
In my mid 20's I started practicing martial arts
Mostly as a way to stay in shape.
One of the things that amazed me about it was that as I learned and practiced more several things became obvious to me.
The ability of your mind to control "pain" either way good or bad was probably the biggest "thing" I learned from 10+ years of practice. If you thought it hurt it would - and if you refused to let it bother you -> it still hurt just not as bad.
Fast forward 20 years and I break a tooth on something hard I was chewing
Go to the Dentist and she fixes the tooth (crown) and hands me a prescription
What's this? I ask
A prescription for a weeks worth of Vicodin... It wasn't Oxy but it wasn't needed either...
I looked at her like the drug pusher she was and never went back to her.
6
There is very little argument that the opioid epidemic is a huge problem in this country - and the overprescribing of them has exacerbated certain societal problems. I don't think the goal should be to reduce the prescriptions to zero. Comparing the efficacy of opioids to ibuprofen is a bit patronizing. Indeed, many people have been - and will continue to - suffer unnecessarily because their dosages have been drastically reduced to satisfy some arbitrary quota. The author offers a personal anecdote; how he overcame an injury by sheer willpower and grit. I don't have that kind gumption and mental fortitude. That's why I'm not a cardiologist. A few passing remarks were made to mental health and the role it plays. Rates of mental illness have are also positively correlated to opioid deaths. Could lack of economic opportunity, wage stagnation, political polarization, and social media create the conditions that could cause someone to numb their pain with opioids? How's that for a feeling, doc? Should we go back to the good ol' days when they did surgery without anesthesia, too?
17
@Randeep Chauhan So, according to you, the whole developing world should be a bunch of opioid addicts?
Of course there are more conditions that would cause someone to dump their pain with alcohol, opioids, tobacco, or other stuff. But accessibility, promotion, or pushing of these can only make things worse.
Besides, the article is not discussing what are all the reasons people turn to opioids. It's discussing about the culture of giving opioids as prescriptions for everything, increasing the chances for an addiction.
@GA
"The whole developing world should be opioid addicts." Not sure how you got to that conclusion. In what way do I advocate "pushing" opioids? The point is, many people benefit tremendously from the pain relief of opioids and do not abuse them. It is cruel to penalize them because the medications have been abused by others.
3
@Randeep Chauhan"
"Should we go back to the good ol' days when they did surgery without anesthesia, too?"
Good point. I'd like to see some of the sanctimonious meditation snobs here "mindful" their way through surgery without anesthesia.
"I study the ancient [fill in the blanks] and have learned the elders' wisdom … I am better than you who takes ::gasp:: drugs for pain" -it's one of the utter worst memes we have to listen to in Western society today. Please let it end soon.
3
The funny thing about pain is that at a neuro-biological level it is just some biochemical activity in a part of your brain that we interpret as pain. As the author points out, some other neural activity is interpreted as an itch. The first is perceived by us to be agony, and the second to be just an annoyance. It seems plausible, to me at least, that the brain should be able to be retrained to interpret the pain nerve activity not as agony, but something else, like an annoyance.
The other funny thing about pain is that it seems to require cognition for the brain to fully interpret pain nerve activity as agony. This seems to be how general anesthesia works and is why distraction also lessons pain.
Between these two observations, it seems that pain control should be focused on our minds rather than on deadening our nerves. Let the nerve impulses come at the brain, just retrain our minds to how we interpret and react to those specific impulses. It is really all just biochemistry at a fundamental level.
I wish the term 'empathy' would not be thrown around like an obvious fix for so many problems which are, at their root, caused by a difference in point of view, not a lack of empathy.
People cannot know what they don't know. And empathy, like all meaningful things, must be earned and exchanged in the context of a relationship and being known to another.
Empathy is what the self-esteem movement was in the 1970s. On-demand empathy is no less empty than on-demand validation.
5
Pathos, which is translated by the author as “passion” does not necessarily carry this meaning but rather implies “effect” in general. Any sense-perception can be regarded as an effect on the soul/mind (psyche). Passion (whose origin is Latin, not Greek) for Pathos is more like a Middle Ages Philosophy version of the term.
5
@Lale Levin Basut
Bravo. This is why it would have been important to give us the original quotations with the Greek words actually used, and not the Latin words, with some explanation of their flexible meanings. Because ancient Greek words cannot be translated with some kind of one-to-one equivalence in our modern English, as they covered a much wider range of meanings.
Which is what makes them so tricky to translate, and also makes them more profound than their Latin or English translations.
1
Great piece. Important addiction to the pain discussion. Don't read the comments.
6
@Caroline
Absurd. The comments are fascinating and they develop the full scope of the inquiry. Socrates and Plato both recommended a full discussion for any subject to become if not fully, at least better understood.
4
So many of our ills can be soothed and healed by caring practitioners with the time and inclination to actually, well, care. But American medical solutions always seem to involve a poke, a prod, a needle, a scan and a bag of pills, when most of the time loving concern would do more for us than all of that. Maybe we need a new field of medicine, with Doctors of Listening and Empathy, whom we could visit and actually feel better after we left. I remember when pyschiatrists had compassion instead of antidepressants and their focus was to listen to find out what was actually troubling you. And most other doctors had bedside manners. Today we're mostly treated as objects instead of vulnerable humans. No wonder our life expectancy is decreasing in this country.
9
It's a serious problem when professionals, like this author, make wide sweeping judgments that raise research findings to the rank of holy writ. Regrettably I use opioids on an occasional basis after massive spinal surgery and many complications. I take them for no longer than 3 months at a time (a self-imposed limit) and have never experienced withdrawals. For the rest of the time I try to make do with non-opioid painkillers, but there is sometimes a point when the lack of sleep and constant severe pain takes a toll that outweighs the problems of taking opioids. It's a judgment call for me that my doctor usually trusts (not without their own investigation). The author sounds too self-righteous for me to take them seriously. Provide an effective alternative, rather than moralising, and I'll use it.
33
@jtmd
Agreed. Moralizing seems to be the main point, for many commenters.
I keep wishing we could hear what Susan Sontag would have to say about all this (opioid crisis, etc.). Something about how for many of the so-called "woke," management of chronic pain without drugs is what now makes a person "enlightened"?
1
Severe Spinal pain may be relieved by Gabapentin, Lyrica or if severe small dose methadone, suggest you find a pain doctor.
@Elizabeth Landsverk MD What does one do after 50 years of spinal injury/pain? The original injuries have gone extremely arthritic, the Fusion ended up failing at multiple points, and the stenosis is increasingly ongoing.
I did the Methadone, Gabapentin, muscle relaxers and various supposedly appropriate antidepressants. 20+ years ago now.
Now I am on morphine, and at a level that is actually reduced from what Was giving me 'moderate' relief. The doc said that the Govt decreed the cuts of my morphine and breakthrough pain meds and for me to 'use more pot instead'.
Smoking is not so healthy, so I began eating the cannabis concentrate a few months ago, and since then have noticed a Major decrease in the full body inflammation, and that has knocked the real pain levels down to a 4 on my scale, rather than a 6+.
Having developed such an extremely high pain tolerance due to having neck broken as a kid, and then not diagnosed properly, I lived with a broken neck all my life, until at 42 the stenosis was so bad I almost lost use of my hands/arms so they rebuilt C5-6-7.
I grew up with the "Everybody Hurts" and "I will give you Reason to cry, now get Busy" and other things, even from doctors.
Yet when I had a major gallstone it was only 'discomfort' for me, when the doctors found it, and realized that I have a wildly altered pain tolerance, that such pain is considered a full on '10' by most normal folks, and that my constant pain IS Real, and much worse than they had thought.
2
This article is so full of misinformation it’s hard to know where to start: “it was recently reported that, for the first time Americans were more likely to die of opioids than of car accidents.” That was in fact first reported in 2011. Or "The only demonstrable effect of two decades of widespread prescription of opioids has been catastrophic harm.” Apparently he doesn’t consider such trivialities as showing up for work to be worth mentioning. Or "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.” It’s always nice to throw in a little science with the anecdotes.
But the real grating thing is the suggestion that opioids work for acute pain but not for chronic pain. Why? Does pain change when you have it for a while? And why do they work for chronic cancer pain but not for other types of chronic pain? Or, why does acetaminophen work for chronic pain if opioids don’t?
The upshot is, an influential political group that unfortunately includes some doctors has decided that we need a certain outcome, and they think we won’t notice if they lie to us. Opioids do in fact work for chronic pain. The problem is they work too well, and some people get addicted. The only reason doctors admit they work for cancer pain is that cancer patients are expected to die anyway. In any event, I’m glad this guy is not my doctor.
43
@Bob - just out of curiosity, what do you suppose is the ulterior motive of the "influential political group that unfortunately includes some doctors" that are trying to limit the prescription and use of opioids? To me, it seems very clear why someone (i.e., drug companies) would have an interest in promoting opioids. It's less clear to me what interest anyone could have, except public health, in trying to reduce their use.
Also, at the neurological level, acute pain and chronic pain are in fact different and this is precisely why opioids work well for the former and not so well for the latter.
2
This author reads like an alcoholic ranting about the evils of demon rum. I have suffered from chronic, often severe pain from back problems for the past thirteen years. I have used opiates off and on over that period, often for prolonged periods and to my great benefit. I can easily say that without them I would have blown my brains out years ago. When my back reaches a certain level of pain, I thank god I have pain meds to turn to. When the pain lessens, I back off on the meds or stop. I have probably stopped 8-10 times over these past 13 years after having taken them for as long as 15 months at a time. Sometimes I have gone through withdrawals. But doing so is well worth the relief I get and these pain meds remain a powerful tool that allow me continue to live a worthwhile life. True believers like this doctor, who are sure they know the answer if we will only give up those demon opioids, are what I fear most in this world. I have tried chiropractors and PTs and accupuncture and hypnosis and congitive therapy and probably a dozen other traditional and alternative treatments. None worked. Opioids do. Of course they need to be used intelligently by both doctors and patients. And drug makers. But that doesn't mean those of us who are help by these meds shouldn't have access to them. So please, Dr. Warraich, no matter how well-intentioned you are, take your little crusade somewhere else and leave those of us in chronic pain who are helped by pain meds alone.
56
Other commenters have mentioned the medication gabapentin. I find gabapentin to be a very dangerous drug. It has side effects and rebound withdrawal effects that last for months. This is something about which the pain physicians seem to have little understanding - probably because they don't ever try the meds they are prescribing to patients. It took me many months after stopping gabapentin before the rebound diffuse neurogenic pain subsided for me. The first time I was prescribed gabapentin, the MD gave no instructions for tapering the dosage when I was ready to stop the medication and the withdrawal pain was quite remarkable. I was shocked that the MD was so clueless about the drug.
I learned for myself that I needed to taper off the dose so the next time I had an orthopedic injury requiring surgery and had an Rx for gabapentin, when I was ready to stop it, I tapered the dose myself. This required opening capsules to cut the dosage. Pharma didn't make available the medication in a form that was taper-able.
Certainly there has been a revolution in our understanding of pain over the last 5-10 years. Dr. David Hanscom (Back In Control) has done a nice job of summarizing our current understanding of the different types of pain, and has a method for addressing chronic pain.
7
@NS
One of the unrecognized dangers of gabapentin is that it often interacts very badly with marijuana. If doctors fail to recognize this or patients are evasive about their usage things may not go well.
3
@NS you don't have to take months to get off gabapentin unless you have epilepsy. I use it for nerve pain that is chronic and will never go away. I suddenly got off gabapentin because I thought I was having an Algerian reaction to it. It turned out to be something else. I had no problem getting off gabapentin and I was taking 2100mgs. a day.
@ms you misunderstood me. The physical withdrawal/rebound effects lasted for months after I ceased taking the medication. Good for you that the drug didn't have the same effect on you.
1
Acute pain indicates immediate body malfunction attention. It is life or death body alerts. Those have been my experience.
2
I have watched my kid suffer unbelievable agony when breaking a collarbone, and being refused any useful painkiller. I have lived through herniated disks with out painkillers (after living, much more comfortably, through the same with 3-5 days of narcotic pain relief). It is cruel and unusual punishment to deny pain treatment. The vast majority of us do NOT get addicted to opiates just when given a short course of therapy for acute pain. Heck, most of us over a certain age had opiates in our cough syrup when we were kids, and there was no huge addiction crisis.
Medical practitioners no longer practice sensibly where acute pain and opioids are involved. This causes an immense amount of completely unnecessary suffering.
Perhaps rather than depriving those in need of some relief from blinding pain, those who seek to actually do good should focus on the underlying issues that drive so many to seek escape from dreadful lives via opiates and other drugs. But, it is always so much easier to focus on what is easy to control (in this case, our doctors).
34
“the mind does play a pivotal role in the experience of pain”
The mind also plays a pivotal role in our sense of touch, smell, hearing, sight, and taste.
Showing that the mind is involved in a person’s experience of suffering is not exactly a groundbreaking idea. If you consciously experience something, your mind is involved. This is not big news.
Also seems like the distinction drawn here between the physical and the emotional isn’t clear enough to be helpful. Emotions are physical. The fact that the mind is involved doesn’t make them less physical, because the mind is physical too.
19
All pain is a physical process. That includes "psychological" pain and as well as the so called acute pain.
.
All activity pertaining to homo sapiens is physical. It is a mechanistic universe. That includes everything in it - including us.
.
5
Could someone explain why the opioid exception is always made for cancer pain? What is so special about cancer pain? There are other conditions that hurt as bad as cancer. Can't cancer patients "get addicted" just like we're told everyone else does?
11
@Madeline Conant
I think it's still part of the moralizing thing. I think we feel (perhaps unconsciously) that cancer is usually the very worst thing that can happen to a person, and the fact that they have cancer is already punishment enough for (fill in the blank for whatever we unconsciously think terrible diseases are punishment for).
Also, many cancer patients are going to die one way or the other. There's a sense, I think, that if they get addicted, it doesn't matter anyway; it may be a moral failing but, as I said, they're already being punished with a death sentence anyway so we'll let the addiction piece slide. In other words if a person's a lost cause we can ease off moralizing over how the pain is probably their fault.
(to clarify: these are not my views, I am attempting to characterize a sin and punishment mindset, religiously oriented, that still permeates our society.)
2
Many cancers have lower survival rates, so the doctors reason they wont live long enough for addiction to opiods to become a problem.
1
I wonder what people did for pain100, 200 years ago or since the dawn of man. I can only imagine the extreme and constant pain these poor folks felt every day as they cut wood for fires, hauled heavy water buckets from far away streams, caught and butchered animals, cleared land, built homes with little or no tools etc. all while probably malnourished and ill clothed. Some did all of this while pregnant! How did they manage all of this without opiates? They managed because they had no choice. They managed because their will to survive was stronger than any pain. They managed because they knew that giving in to the pain meant certain death. They knew nobody was going to rescue them because everyone was in the same pain ridden boat. I wonder how quickly we, as Americans would "heal" our maladies if our lives truly depended on it? I think survival is a pretty good distraction from pain, don't you?
7
@Madilyn Greiner
But, we DO have a choice. We do not HAVE to suffer in the ways that were unavoidable in the past. If you want to suffer, go for it. But what right do you have to make that decision for me, or my kid with the broken collarbone who sits in agony?
29
@Madilyn Greiner And sometimes these forebears of ours did NOT survive. Sometimes they did NOT manage. This assumption that they were stronger, perhaps even better, human beings than we who do have the medical advantage of pain relief, seems oddly moralistic. . . and false.
16
@Madilyn Greiner The fortunate people from hundreds and even thousands of years ago used opium when they were injured or ill. And they did so without stigma. The less fortunate ones mostly died before they were forty years old, often in unimaginable suffering. But even then, there were undoubtedly some with a higher tolerance for pain, and correspondingly less empathy.
10
In fact, there have been very , very few, high quality, studies of alleviating chronic pain. What we have too much of is low quality opinon pieces from non-scientists with no peer-reviewed research to back up their opinions.
Of course there objective measures of pain—blood pressure and muscle tension, for two. Treatment for chronic pain can be studied and refined. But vidently it is more politically convient to blame the patient than fund the studies.
29
I am a just retired neurologist. I feel my perspective, therefore, is valid. All animal life forms have pain including one celled amoebas, etc. it is the ubiquitous sensation, whatever else one thinks of it. This type of pain is called acute pain. Everyone knows it, has experienced it, etc. The pain that is harder to grasp is chronic pain. Unremitting back or neck or head or other parts. This is the pain that is the conundrum. How much is physical pathology, how much is emotional overlay, how much of a role do analgesic med withdrawal and rebound play. Doctors who attempt treatment may simply supply analgesic meds including opioids or attempt to dive into the weeds with multiple tests, therapies and psychological approaches. Each patient is unique. Sometimes a miracle treatable diagnosis is found. But mostly, chronic pain is one of medicine’s intractable problems. As another doctor respondent wrote, these are the patients that doctors keep referring to others, for want of any help. These are the patients that should not be treated with opioids. Opioids do not work for these patients in the long run and many become addicted.
12
I share the frustration of the retired Neurologist. As a group of medical practitioners it must be difficult to solve the riddle of painful conditions that don’t show themselves on endless diagnostic tests. I have also felt the frustration, judgement, discounting and abandonment from “Neurologist” community including the famed Mayo Clinic. MEL from NJ not so subtly implies that the patients have “intractable problems” (pain) that should not be treated with opioids. His blanket judgement is that these patients most deserving of chronic pain relieve should not be aggressively treated to relieve their suffering because they might become addicted. If it sound like I have an agenda - I do! I was diagnosed with “psychogenic pain”- a catch all, wastebasket diagnosis for difficult patients. When I asked for referral to a psychiatrist that specialized in treating “psychogenic” pain none was forthcoming. My sense is that MEL would not know if his patients could benefit from opioids because many Neurologists don’t prescribe them. Rather, I was told go “find” a pain management doctor” (not “a referral” ). Finally, my GP had the courage to buck my label of “difficult patient” and arrange for “Whole Exome” genetic testing. Of course this story ends that I was diagnosed with a (rare) disabling and painful neurological disease. Pain hurts and suffering is overrated. With mobility aids and the long term and EFFECTIVE use of opioids I have returned to work and lead a full & vibrant life.
16
Please re-read the article, it did not say pain was not real. And, as a part, research shows that overtime opioid use can turn counter-productive due to the way our various biological systems interact.
I'm sorry for your chronic pain. Having broken my thigh bone, collar bone, ribs, and back, dislocated one shoulder and separated the other, along with other soft-tissue injuries and head trauma -- all in separate instances -- I can understand your very real pain. However, as with the MD in the article, I've found that only nominal use of drugs, one shot of morphine to reset my shoulder, has better long-term outcomes for me. I limp on occasion from pain in one knee that has no cartilage (another injury), but I manage it better without medication -- which I realize may not work for everyone.
6
I'm sorry, but although I appreciate compassion in the doctors I see, Dr Warraich's argument doesn't hold true. I am currently on opioids, and have been for more than 20 years.
But until he goes back to the story of the previous 8 years, he seems to think that I didn't really need such treatment. I was hurt 8 years prior to my getting pain relief. While stationed in the middle of nowhere (Diego Garcia, BIOT) I fell while managing an urgent cargo movement, improvised because the required vehicle wasn't available. The initial visit to the station doctor yielded inconclusive results. It wasn't until I returned to the States where the Navy Hospital Long Beach found three compression fractures in my spine--4 months after the injury.
For the next 8 years, in Germany and the DC area, I lived in agony. I DID get a physical therapist in Germany who did some help, but at 1 visit every 2 weeks, was not enough. Standing watches around the clock at DIA after returning to the DC area. Some nights I walked for 12 hours, because I couldn't sit, and standing didn't help. I finally took early retirement because Motrin just didn't do anything and the Navy had nothing else to offer.
Percocet and Oxycontin, FINALLY after 8+ years got my sanity back. Since then, I've been on the meds successfully, not a single issue with them. I don't expect 100% remission; just enough help so I have a life back. I am still that way today.
Pr Chris
55
Thank you! I know someone who has been on an opioid at the same unchanged dosage for almost 15 years now. That and a muscle relaxant for her neck spasms, help her manage on a daily basis. Her chronic condition will never get better. Without the opioid she wouldn’t still be with us. But it’s a constant battle to be able to get a secure, regular supply these days with so many doctors and pharmacists fearful of losing their licenses for simply treating her pain as needed. She is under supervision by a neurologist, a psychiatrist, and a pain management specialist.
12
Try reading one of Dr John Sarno's books. He covers this topic extensively.
There is a phenomenon known as TMS, Tension myositis syndrome that Dr Sarno explains intensely.
All I know is that I had very bad lower back pain and now it is 100% gone and has been gone for years.
Many celebrities have used these methods and had great success as well,
Good luck!
3
Bravo to Jon Han for the artwork.
Hurts just to look at it.
7
We as a country need to wake up. The financial crisis and the opioid crisis both were slow rolling disasters that were apparent years before the financial crisis happened and years before any serious attention was paid to the opioid crisis. There's something rotten in Denmark and we better figure it out and deal with opioids and before the next crisis happens.
3
I believe that looking at sports can give us important insights into the nature of pain and how to manage it. For example, running fast (especially for long distances) is an intensely painful activity. The runners who win are not necessarily the fastest, but those who can manage their pain the best.
It is not unusual to see a winning runner collapse at the finish line. The question then is: Where would that runner had collapsed if the finish line had been 100 meters further down the track, 200 meters, 1000 meters? The answer is he would have collapsed 100 meters, 200 meters or 1000 meters further down the track. Where ever the finish line is located and whatever it takes to win.
I have experienced this myself after an unusually intense effort. I don't recall any lack of strength or unusual pain until reaching the finish line. I was strong and moving well and fast. However, at the finish line, I recall completely losing control of my body and involuntarily collapsing in writhing pain.
3
Dr. Warraich, a cardiologist who overcame a painful condition himself, understands much about pain and suffering and he offers hope and insight into the nature and treatment of chronic pain.
As a psychiatrist, I have worked with patients over the years for whom chronic pain (both mental and physical) and suffering are major problems.
Pain of any type, acute or chronic, has at least three or four components; physical, emotional (add psychological), social, and spiritual.
To relieve pain and suffering, understanding and empathy are essential as Dr. Warraich eloquently notes. Opiates are helpful for acute pain but basically ineffective, at best, and harmful way too often for people with chronic pain.
9
@Daniel No. Opioids are not ineffective for chronic pain. Ask a hundred chronic pain patients and they will all give you the same answer. Harmful way too often, yes. But come on. We are not children here. We can handle the truth, which is that the medical community has largely decided the risk profile of opioids is sufficiently negative that they are willing to sacrifice large numbers of chronic pain patients rather than take the risk of more addiction and overdoses. It’s that simple.
13
Your last sentence is simply not true and rather self-serving given that returning to adequate treatment without the hysteria would dismiss the need for people to see you in your own professional capacity.
As someone with the genetic disorder Ehlers Danlos Syndrome, I suffer from chronic pain. I previously went without pain medication for years, and yet my quality of life was severely impacted. Without medication, I was literally unable to function and unable this work.
With a highly managed, small dose of opioids, I have a thriving career and happy home life. I am routinely tested for drugs and quantities of opioids, and am, according to my doctor, a “model patient.” It is incredibly unfortunate that those with actual pain suffer the consequences of those who don’t.
51
There’s no doubt that the opioid epidemic is a horrible disaster and that addiction for some started with over-prescribing of opioids, but it is equally clear to me that the pendulum of opioid prescribing is now swinging nearly 180 degrees to the point that responsible doctors are fearful of losing their license by prescribing ANY opioid to chronic pain patients, and those patients are seriously considering suicide for an even further reduction in their quality of life. I know because my wife (age 58) has been one of those patients for 5 years now - a very conscientious and disciplined user of opioids, not wanting to become an addict.
This is too complex an issue to simply create policies or legislation that address one end of the opioid spectrum while ignoring the other, law abiding, legitimately prescribing/using end. You are taking away what little hope many of those people have for a tolerable life.
It’s not just the chronic pain; it’s also what that chronic pain steals from the sufferer. In my wife’s case that includes needlepoint, gardening, working (she is disabled - a teacher who cannot carry books, cannot climb stairs, cannot stand or sit for more than 5-10 minutes (she must lay down) and must nap every afternoon), visiting our grandchildren (cannot tolerate the 90 minute drive), going to movies or performances, and being intimate, to name a few. She has given birth to our 4 children and has dealt with pain successfully in the past - this is on another level.
18
@MJH I am so sorry to hear of your wife’s disability. I understand—that was me in my thirties and early forties—from needing to rest to not being able to handle car rides to not being able to do simple, every day activities.
Your assessment is on point. Responsible doctors are fearful; responsible patients hide their suffering and the relief they get from managed opioids due to the stigma of taking life-enabling medication.
Even the insurance companies are now involved. I recently changed heath insurers and the new company denied coverage for my medication, saying I could only have a seven day prescription instead of my usual 30 day prescription. My doctor’s office told me they spent close to an hour on the phone to convince the insurance company that I am, indeed, a responsible chronic pain patient.
4
Highly managed, small dose (or smallest possible dose) is a key concept for opioid use. Chronic pain sufferers know their pain and know their bodies better than any physician. I carefully titrate my intake, sometimes even prophylactically, when I know I will be engaging in an activity that can aggravate my condition. I am fortunate to go to a fine pain clinic where PAs and doctors listen to their patients, respect them and work with them to achieve the best possible outcomes.
I believe that despite the criminal marketing and prescribing of opioids, patients must be educated about the costs and benefits of taking these drugs. If not, they become addict/victims because of unrealistic expectations. They also bear some responsibility for misusing these drugs.
That said, all these articles that present a black-and-white analysis just continue the constant feed of misinformation.
2
Have opioids been over-prescribed? There's no doubt about that. But saying pain is purely an emotion is dangerous and a sign that our society doesn't know how to properly prescribe opioids for those in unrelenting chronic pain. I would say that pain is both sensation and emotion. I know from experience how depression deepens pain, but the pain always started as a sensation. I also know that having an elevated mood makes pain easier to bear. In my opinion, medical professionals are far off in being able to take the time to show empathy and kindness. Going to the doctors is like being processed in a factory. I'm not surprised by our opioid crisis, but holding them back from people in chronic pain isn't the complete answer. I read an excellent article in Scientific American that said only 1 in 10 people with.chronic pain became addicted to opioids. A lot of research still needs to be done, but "throwing the baby out with the bath water" isn't the answer.
32
Absolutely right. I learned this dramatically in the course of childbirth; at the moment my husband/coach left my side for a few minutes, my discomfort increased significantly, and was alleviated as soon as he came back.
3
It seems to me that pain is a sensation and the suffering it causes is an emotion.
17
@Adrasteia, I agree that pain and suffering are two different things, as I mentioned in my comment on childbirth.
@Margaret Hasselman
Pain is inevitable, suffering is avoidable. Pain happens in the body and suffering is in the mind. While it may be true though, that we cannot identify any difference in the location of the mind and the body.
2
I can buy that pain is both a sensation and an emotion. I have chronic pain from multiple herniated discs with stenosis and I know that as the pain increases depression and anxiety set in and worsen. I have tried a plethora of ways to control the pain over the years with some temporary success. I use opioids at times and find that they can help. They do not relieve my pain and I don't expect them to; what they succeed in doing is to lower the pain level to a point where I can function and remain active. The medication is a last resort for me after heat, ice, massage, hot baths, etc. have failed. I don't want the government or a physician telling me how much pain I'm having and what does and doesn't work. It has taken 30 years for me find a regimen that works for me and medication is part of that regimen, but only part of it. Until you've walked in my shoes don't tell me what will or will not work and do not tell me it's all in my head.
38
I graduated medical school in 1989. It was obvious to most of us that the pain academics and the policy makers who listened to them were misguided. Now the pendulum is swinging the other way. For goodness sake, learn this lesson, people: Stop telling doctors what to do. You do not know more than we do!
10
@Daniel Waxman There is no one size fits all solution. I am involved in the training of MDs and as a scientist can say that there's a huge amount about the human body we don't know. So you can't just discount individual patient experiences either. Doctors and humans in general don't know as much as they think they do either.
On the other hand, it's quite obvious when someone is addicted. It's the gap between the start of treating pain and the addiction that may or may not arise that needs to be addressed properly.
8
Staying as ambulatory as your body is capable of and living with whatever pain is associated with that effort is the goal. How you navigate those waters is a unique experience to each individual.
13
The designation of pain as the fifth vital sign appears specious. Breathing, maintaining normal heart rate , blood pressure and temperature are all vital for life. Is the pain free state vital for living? The answer for many with chronic pain is probably no. The pain scale, however , may be a useful tool for the assessment and management of acute post trauma or surgical pain.
@NJ observer And the answer for many with chronic pain is probably yes (I'll even give you that it could be a minority but it's a significant minority). So here we are...
3
How one deals with pain today should have absolutely no connection to how the ancient Greeks, Romans, Babylonians, Assyrians, Persians, Medes, Egyptians etc. etc. etc. dealt with pain or related to it.
These are matters best left to historians.
As for compassion as a factor in the fight against pain, that should be a factor in all aspects of medicine, and by all dealing with a patient.
Alas, compassion does not always do the trick.
Lastly, age and general health are a factor.
Stoicism seems to work best with the medically fit facing a problem, like the author in medical school.
It is less successful with chronic pain and disease coupled with age.
34
Pain is a physical reality, a multifactorial symptomatic experience, driven primarily by noxious stimuli, and partially modified by psychosocial and personal cognitive mechanisms. Pain does not arise in the mind alone. Nor does hunger or thirst.
No two human beings are exactly alike, not even "identical" twins. Physicians seeking to ameliorate pain must determine the actual noxious source, individual by individual. It is an arduous task, as is the choice of medication and detailed follow up.
Opioids of various types do, in fact, control chronic, intractable pain, properly diagnosed and followed up, and in appropriate patients, for decades, and without "addiction," i.e., without uncontrolled, deleterious, misuse, and without cardiac damage, liver failure, or hemorrhage, the price of long term administration of NSAIDS.
Timed-release opioids are useful in controlling the intermittent pain resulting from shorter acting agents. The timed-release feature has been illicitly broken to facilitate addiction.
The causes of addiction to opioids, as to alcohol, tobacco, and cannabis, are, as yet unknown. Further dedicated research, will, one hopes, solve this problem.
In the meantime, patients in pain must not be trivialized by psychobabble.
The current "opioid crisis," is the result of misuse of the agents, not of their appropriate use, and is the result of the importation of synthetic opioids (e.g., fentanyl), a matter of border control and law enforcement.
32
@ATMDPHD Thank you for your wise and, spot on post, as I have experienced life as a chronic pain patient. After three different vertebrae were compression fractured, and the Navy doc didn't pick it up; I spent 8 agonizing years, ended up in the hospital after futile efforts to solve the pain issue with increasing quantities of prescribed Motrin, since the Navy wouldn't go any further, with a case of bleeding ulcers, and, ultimately, was forced to retire early, and thereby lost most of my Navy retirement.
THAT's the price I paid for my being able to FINALLY obtain opioids for pain management. Now, over 24+ years without ANY negatives, I live in fear because many of the patients in the pain practice are having their opioids cut drastically by their insurance company...and they're blaming it on the CDC/CMS directives.
Why in the world do they feel they can take away someone's treatment that is working when they have no treatment to replace it with? That is cruel and inhumane.
Pr Chris
I appreciate the force of the argument, but "the ancient Greeks" did not equate physical pain with emotions. Aristotle, in the Rhetoric, states clearly that emotions (pathe) are accompanied by pain and pleasure, which are themselves sensations rather than emotions proper. There were, to be sure, other views, but the most sophisticated ones (in my view) did distinguish between raw sensations such as pain and the cognitively more complex feelings that are emotions
10
@David Konstan
Bravo for going back to the authentic
Greek wordings. But, since you mention "There were, to be sure, other views", why not go the whole way and give us the various references to the texts, or if possible the various quotations. It is sure that the Greeks had a more direct perception of the phenomenon of pain and their descriptions more immediate than ours that are irremediably cluttered by too much knowledge and memory.
Excellent essay. I agree with you with one exception: I don’t believe it was physicians who succeeded in having pain declared the fifth vital sign, it was the pharmaceutical industry that enthralled venal and unethical physicians with vast amounts of money and perks. Part of the remedy to this sorry mess is to hold physicians, as well as the drug companies responsible for the damage they cause.
7
Please leave my opioids alone!
When I don't take them, I hurt.
When I do take them, I'm free of pain and able to work.
By the way, have you noticed that the subject of opioids helps numerous opinion writers meet their production quotas?
40
Huh? Just broke my hip and pelvis. Pain is definitely a sensation and real.
28
As an observer for 60+ years, I can now report:
When pain is an emotion, it is somebody else's.
When pain hurts, it is mine.
111
What this Op-Ed is about, I cannot find out. The conclusion seems to be that resilience and mental health are good, more patient-doctor time would help and opioids are bad for people who are supposed to live after treatment. So far so good. Every argument between that is fuzzier still than the line between itching and pain. If you have a position on something, please state it.
12
@elmueador
Very true. The good doctor promises in his title to offer us a presentation of the ancient Greeks' observations, and he does not deliver a real full discussion of their texts and wordings. That is my main beef with this article.
1
This article says things like "knee pain" or his "back pain that went away". Then he talks about cancer patients that do need opioids.
Well, what about those of us with degenerative auto-immune diseases. We are also being swept up with addicts and people with "back pain, sometimes". This article totally forgets about those of us with chronic, life long pain, with no finish line. True diseases that are attacking our bodies - not some figment of our imagination. I had a fractured tailbone that hurt for a year, it was nothing at all like dealing with two auto-immune diseases.
I don't take opioids and I do take all the preventative meds (like Cymbalta, Gabapentin, DMARDS plus a biologic, and prescription anti-inflammatories) but sometimes I am in so much pain I'm not sure I can survive it. And with degenerative diseases, chances are it's not going to get better with time. I only hope those of us that need them, will start to get some sympathy back before the time comes that I need them daily.
37
@Mona My daughter has a chronic pain condition like yours, and holding her last night as she cried without relief was absolutely, I-can-hardly-go-on agonizing.
(And yes, we see all the top doctors.)
2
@CK I'm so very sorry. The absolute worst is when I'm woken up in the middle of the night with a pain that seeps into my very bones.
The general consensus now to chronic pain - live with it. But even this doctor, writing about pain, has no idea what that does to us, that there will be no relief.
I hope your daughter finds some relief.
1
While I don't like to call myself an old man, I have been to this circus several times in my lifetime. Each time, the disturbing feature has been the real world application of our American, puritan stoicism to a real, or to an imagined, drug crisis. Each time, no problems were solved but puritans did feel better about themselves.
Perhaps this crisis is real, but in the unlikely event my health care providers announce one morning that I have six months left and the cancer will be painful, I have every confidence that palliative addictive substances won't avail from my doctor. I also have the confidence that I or my designee need only step into the street to buy the drugs the puritans deny, from the black market. If history is any guide, they won't really care about that, unless someone can be sent to jail.
Certainly there is an over-prescribing problem. The numbers in West Virginia make that abundantly clear. It is quintessentially passive-aggressive when Americans solve that problem by torturing some emaciated hospice patient down the road, or advise Tylenol for chronic acute pain.
35
Acute pain is not chronic. Chronic pain is not acute. They are opposites by definition.
4
Acute and chronic are not opposites. They describe duration - they are time expression. This is why people claiming to be physicians should stay away from blanket statements in humanities fields.
9
@Richard P. Kavey,M.D. Acute pain is when you put your hand on a hot stove. Chronic pain is when you leave it there.
One could argue that pain medication will do more good in the latter case, since there will be no healing, or removing of the cause of the pain.
3
When I was much younger I was prescribed an opioid (percocet) after an accident in which I had much second degree burns, and, even taking twice the prescribed dose, could not detect any effect. Since that experience, I've just tossed the pain prescriptions in the trash if arguing with the doctor was to no avail. I can certainly believe that they don't work any better than NSAIDS or aspirin, which don't work either. I feel bad for anyone with chronic pain, since there isn't anything except placebos that are toxic and addictive.
1
Most people who use opioids for pain do not become addicts. In any case, treatment for opioid addiction is improving. Funding has increased since white people starting overdosing and dying. Treatment includes psychotherapy (which would have prevented addiction and saved money if it were easily accessible to begin with) and prescribed use of rehab meds like Methadone and Buprenorphine. Widespread availability of Narcan to treat overdose is also helping. We should see fewer deaths and less street drug addiction in the near future, especially as we move away from abstinence-only programs like AA and punitive interventions by law enforcement. Let's not get hysterical (again) about pain meds. Judicious prescribing is needed; a pendulum swing to the bad-old-days of tough-it-out is not.
23
@David Howard. Plus at 78 w a 50/50 chance of making it to 80, using about 6-10 opioid pills a year when pain is unbearable, would addiction be so bad?
1
@David Howard. Thanks for that.
I wonder how much of this "pain" is self-inflicted. There are so many ways that could happen. On the other hand so many seem to almost worship the healthcare business, doctors, nurses, etc, etc. Take their comments at face value. I, for one, only go to a doctor is I really have to. I know of so many that rush to the doctor with the slightest sniffle or the most minor ache. Maybe if they spent more time paying attention to their own selves a lot of this pain might go away or maybe not even happen.
1
Pain is a subjective experience. I find it irritating that Dr.Warraich, in a subtle way, suggests that pain is something to override or treat with love and compassion, rather than an opioid.
Sometimes, a person needs medication to take the pain away so that healing can start! It’s hard to even think about healing if you’re in debilitating pain.
I’d be interested to know if Dr. Warraich has ever had a kidney stone. Get back to us with your impressions, Doctor. Did the compassion of your wife and friends take care of that for you?
31
http://americanpainsociety.org/about-us/press-room/evidence-shows-benefits-of-psychological-care-in-pain-management
I saw the title of this op-ed, and before even reading it, assumed I was going to feel some pain upon reading the comments.
Ronald Melzack, over 40 years ago, identified pathways in the brain and overall nervous system that create a complex, multi-layered experience of pain made up of cognitive, affective and physical components.
My own interest in the role of the mind (cognitive, affective and motivational) stems from several years of excruciating dental pain, involving occasional periods when no medication was available.
I found through rigorous experiments that Melzack’s theory (not refuted in the decades since he first formulated it) explained a great deal about the variability of my pain experience.
During the years I prepared for and conducted dissertation research on mindfulness and pain, i met many people like the ones that commenters here describe in their attempts to refute Dr. Warraich. I saw people with chronic pain that varied, sometimes increasing with seemingly no hope of release.
The research was positive for positive changes in pain levels due to mindfulness. Now, over 1000 studies later (and with agreement by American and international pain associations), the neurological evidence is conclusive - pain is a psycho-physiological phenomenon, and the sonner we treat it this way, the more people will be helped.
Www.remember-to-breathe.org
6
There are other non-cancer reasons for pain medication. Unfortunately, without a better solution for pain in 2019, and doctors unable to actually make new medications, then the only solution to conditions they can treat is to blame the patient. Sad.
10
As a Classics professor, I would be very interested indeed to see a citation for the claim that "the ancient Greeks" considered pain a "passion" or an emotion. I certainly don't recall any such statement in any of the Greek authors I've studied and taught -- nor, for that matter, in ancient medical writings. Too many garbled statements get attributed to "the ancient Greeks" all the time; I think this is one of them.
86
@me
Absolutely true. That is the major flaw of this article. A real discussion of the original Greek texts would have been in order, and might have offered some clue to the quirkiness of the phenomenon.
1
@me,
Good comment. And it strikes me as curious that people refer to "the ancient Greeks" as if they were very different from us.
Other than their technology, hairstyles, and religious customs, they were perfectly modern. Given a year to learn the modern dialect and social customs, any one of them could fit right into modern society.
Still, we call them "ancient". I guess I'll soon be ancient, too.
@me
Maybe because it was all greek to them when they were reading about it.....
So, I'm just imagining that my knee hurts?
11
Pain is a sensation.
We love to watch disaster.
We love to watch accidents.
We get a kick burning bugs.
We pull our hands out of fire.
OK I'll read the article now.
Don't get sore at me.
I had 12 teeth pulled on Thursday, and was told to take Tylenol for pain. Methinks that the pendulum has swung to far towards caution.
30
@David Stoeckl Ask your pharmacist about combining Tylenol with ibuprofen. You'll probably get relief from the advice you get.
1
@Charles Coughlin
While more easily obtained, NSAIDs are not without their own risks, and more so as people age. Kidney and liver damage are pretty common side effects.
For short term acute pain, opioids are often the best and safest option. This sounds like a treatment based on the legal fears of the health care provider and not the patient’s best interest.
10
Ibuprofen long term increases kidney damage, GI bleeds ,hypertension, heart attacks, strokes,congestive heart failure. Motrin and Tylenol together increase risk of kidney damage. Gabapentin likely helps more less side effects. Approved for post Shingles pain. Anecdotally used for arthritis, neuropathy, joint pain and anxiety... it’s non addictive.
The last time I felt true empathy from a physician was about a dozen years ago, when I was cared for by a very kind, elderly neurologist. He’s gone now, sadly, and with him went a lost art of true healing.
18
@Passion for Peaches
It's interesting how often I've heard people say that their neurologist is the only doctor who really listens to them.
6
@Childe Roland’s, it may be a chicken and egg thing. The field might attract more empathetic practitioners because so much of the work is with older patients, or the doctors may learn to be patient and caring through dealing with a largely geriatric population. Or maybe the analytical mind that takes an interest in brain science is more inclined toward empathy? I have seen a few neurologists who were quite cold, though, so I would go with the first possibility: if you are going to have a careeer caring mostly for old folks, you need to be an empathetic sort. Working with patients who have suffered brain injury required a warm heart, as well.
BTW, I’ve noticed that rheumatologists can be pretty warm and fuzzy, too.
4
So far no mention of giving birth without dosing with epidural or other meds
I had two 7 plus lb. babies without any form of medication for pain.
Both deliveries and my bundles of joy were textbook Lamaze 32 and 27 years ago.
Breathing and puffing and counting and swearing and sweating and shaking but I would not have changed a thing.
I always had a high pain threshold.
Some people do not.
My babies were alert and had great scores.
I was awake and relieved and ecstatic.
I never felt more powerful as a woman after they were born.
My experience was uncomplicated and appropriate for giving it a go without the meds.
Not every mom desires this or can do it for many reasons.
But childbirth is true pain.
Like a massive leg cramp. Over and over again and worse and worse.
For a majority.
5
@nurseJacki
"I always had a high pain threshold.
Some people do not."
1
@nurseJacki
I am pretty sure I am not the only one who does not recall childbirth being anything like a leg cramp.
I am happy it was relatively easy for you but … for heaven's sake.
This Opinion references "Pain from OIH is not necessarily located at the source of injury or disease. Instead, pain manifests as generalized, diffuse, and ill defined; all despite increasing opioid doses."
Sorry, this is wrong.
The pain from the 'source' (don't you mean 'site'?) of impact/injury, plus disease, is definitely located AT that source of injury AND disease. Yes, it can, and does, impact other parts of the body, but it doesn't neccesarily "diffuse." The actual 'source' of injury is indeed, debilitating in and of itself.
I disagree that all chronic pain is "ill defined."
A patient can define it quite clearly.
I don't think this author has any experience or interactions with true chronic pain patients.
37
Pain is a fifth vital sign because when a post op patient has pain the reality of the pain is expressed in rapid respiration’s and restlessness and blood pressure changes.
Given a medication for pain ... in 30 minutes .... most often positive changes in sensorium.
If the signs of discomfort persist postoperative
Look for more dire reasons as in post surgical shock from a bleed etc.
pain is fluid and real and a mind / body experience.
Inflammation is our body’s friend and foe as well.
17
@nurseJacki
While reading the article, I noticed he kept saying "physicians" this and "physicians" that. I thought "what about the nurses, they are pretty much closer to the pain on the whole than the doctors are.
And so I see in your comments evidence of what I was thinking. Also, nurses prescribe too these days.
10
Bravo. Denying the truth that pain is a combination of the physical infliction and interpretation (processing) by the brain is just false as some many comments seem to imply. Just consider that you can experience pain because your friend does so. Just consider that you will not experience it if your friend does not show it. And above all just consider that all these opioids have not reduced the amount of pain Americans say they suffer. Today opioids are prescribed for pulling a wisdom tooth. In the past people managed pain induced by sawing off a limb without anesthetics.
It seems to me, no offense, that lots of people seem to endear their pain. Perhaps because it is socially correct, acceptable, or of advantage. I am not denying that chronic pain does exist; but I struggle to see a physical reason for the chronic pain epidemic. Surely living longer plays a role — but surely it cannot be the answer. The answer to given by this article and I think it is correct.
3
When one feels another’s pain, it’s not an illusion. The brain contains nerve cells that respond to what a person perceives exactly as they would if that person was actually doing that same thing. If you do not experience pain frequently, you ought to consider yourself lucky not right thinking.
1
Ok, now it begins. First the NYT publishes two years of unrelenting articles saying no one should be prescribed opioids, opioids don't really work, and all people who take opioids are addicts. Now the campaign begins to try to indoctrinate us that if we could just learn how to think correctly, we could control our pain with our MIND. No doubt there are people out there who will give impassioned testimonials about how this worked for them.
Meanwhile, people are definitely dying of overdoses, but they are people who are buying street heroin and stealing prescription drugs for recreation. Meanwhile, the little old lady with intractable arthritis and the guy with the broken back are both just sitting at home suffering. And fyi, I don't have chronic pain and I don't take any prescription pain medication.
114
@Madeline Conant - There are good nonopioid medications for chronic pain - high dose anti-inflammatories for joint pain for example, or antiepileptics for neuropathic pain. No one is suggesting that people suffer, just that they not be given opioids (unless their chronic pain is from metastatic cancer).
7
No. There. Aren’t. For many, many, many, many people suffering from chronic pain, there are NO effective non-opioid treatments. For entirely too many there are no effective opioid treatments, either, sadly.
70
@GBR
What an ill-informed comment. Anti-inflammatories (NSAIDs), especially at high doses are not recommended for chronic pain because of internal bleeding risks which can result in death. Second, anti-epileptics carry so many nasty side effects that their (non-FDA-approved) use for chronic pain is a prime example of the cure being worse than the disease.
25
It is crucial to the point of this article to understand that, for the ancient Greeks, the operative term here is "passion." Modern readers might hink it is good to have passion, but that is a different meaning than what the ancients understood.
A passion is something that happens to one -- an undergoing, something that is not chosen, but "passively" takes one over.
Pain is an emotion, a passion, in this sense.
Some pain is very difficult to manage. But if we take the idea in general, pain as a passion leaves room for how one reacts to the undergoing of it. This is what the Greek philosophers, especially Plato, noticed. The passion happens, but what is important is what happens, and what we choose, in that event.
The theory is, one can modulate and control passions to a degree we may not fully realize. We are not locked-in to be victims of our passions. We have the power of how to react, and this power can be cultivated.
In other words, one's "reaction" can actually shape or even constrain what a passion "means."
So much pain in life, much of our suffering, might be a symptom, not of something inevitable, but of how far our skills at coping and reacting "lag behind" the wave of the happening of the immediate passion.
Those who are "slaves" to their passions do not understand this of course. But our culture, in denominating so many passions as inevitable, and encouraging people to never be "ashamed" of them, is perhaps equally setting us up to feel powerless.
10
As a palliative care physician who has a propensity to addiction, I have explored this issue both professionally and personally.
Most contemplative religions — particularly Buddhism, Catholicism, and Judaism — understand that suffering and pain are related, but not the same. Suffering is a universal condition made worse by the dread of losing something precious, often life. It is suffused with fear of the unknown. Pain is a complex physical phenomenon. One can suffer without pain, and one can have pain without suffering.
For example, when I have had surgery, the pain was, at times, tremendous. But I knew why the pain was present and that after about Day 2 after surgery, it would slowly ease away. Thus, while I confess that I enjoy the warmth of opioid pain relievers, I have tended to forego them because my pain was not accompanied by suffering.
We were all sold misinformation by drug companies in the 1990s. In fact, we cannot get through this life without pain or suffering. We were told to treat pain, which often was the manifestation of suffering and dread and fear of the unknown. To my professional and personal disappointment, we prescribed the opioids to people who lived with dread — those same people who tend to be prone to addiction.
How much better our nation would be today if we had simply been present to listen to the fear of those who suffered. Instead, we bathed them in drugs, and their suffering actually became worse.
16
@Joanne Roberts
I experienced EXCRUCIATING pain following surgery.
I did not "enjoy the warmth of opiod pain relievers."
Opiods barely made a dent in my pain. I was in so much pain such that prayed for death in order to escape the pain.
I wasn't suffering from dread, nor am I prone to addiction.
I was suffering from excruciating post-surgical pain.
I was okay by the end of the week, each time.
5
@Joanne Roberts
I have a similar history but my experience and the conclusions I have reached are significantly different.
2
Pain is a big problem. But opioids are just not the cure. Maybe if we work on a pathway between where the pain is registered in the brain to where it is perceived as suffering and block that?
1
Having suffered from chronic pain for 10 years now, I do not buy the current mania that opoids are the devil. I have club feet, a bad very bad back and destroyed cartilage and mininscus in both knees. NSAIDS were my drug of choice until they began killing me because of internal bleeding. Now, the only way I can function is to take the occasional opoid - maybe twice a week. I could use them more, but usually can force myself to just bear it. Tylenol does very little when things are bad. Sometimes I just get sick of hurting and need some relief. I swim, walk and lift light weights, but still just need something to get through the especially bad days.
107
@KatDog
And you should be able to get it. Good grief, we are all going nuts with all this obsessing. Opioids help people who need pain medication. People who don't....shouldn't take them. Period. Addiction? Shouldn't we ask why people are susceptible to addiction? And why they don't fight it? Opioids are not the evil boogeyman, but they should not be trifled with.
And they are also so very helpful to those in pain.
6
@KatDog
Tylenol will rot your liver, too. Show me an opioid that does that.
3
Which Ancient Greeks? Cite your sources. If this were an essay from one of my undergraduates, it wouldn't go over so well.
31
The word 'pain', much like the word 'love', comprises a vast inventory of meanings that results in miscommunication. Physicians are able to treat a small subset of the conditions that we self-identify as a source of pain. Broken bones, invasive cellular growths, infections may respond to treatment, but expecting doctors to perceive and address perceptions of sensory distress is routinely futile.
1
I have had chronic pain in my hip joints, knees, and one shoulder due to arthritis and bursitis for a few years. I have received cortisone shots in both my left hip and my right shoulder and I take an anti inflamatory medication twice daily. What has helped decrease my pain the most, though, has been the following: 1. I lost twenty pounds. 2. I started walking regularly. 3. I received physical therapy treatment for my shoulder. 4. I use an essential oil recipe for arthritis on my joints when they are achy. Due to these four reasons, I am no longer waking up at night because of pain, I can climb stairs again, and I am able to go to Zumba and line dance classes again. If you are having chronic joint pain, try remedies like these first before getting cortisone shots or pain medication--they may work as well for you as they did for me.
20
@Sophie, Achy? Achy would be a gift! I'm talking about wracking pain that is unbearable!
1
It is notable that the author of this op-ed has no credentials as a neurologist, neuroscientist, or as a physician specializing in pain. He is a fellow in cardiology (a sort of journeyman position on the way to a permanent appointment).
Pursuant to that, there is so much wrong with this op-ed that it is hard to know where to begin.
First of all, statistics about the number of Americans using opioids and the number reporting chronic pain are irrelevant. Statistics about opioid abuse have nothing to do with the use of opioids for pain treatment. When heroin was the choice for opioid abuse, I'm sure you would not have seen anyone (even a medical journeyman) attack the medical prescription of morphine, codeine, or related legal pharmaceuticals as an enticement toward abuse.
The experiential reality of pain is demonstrated by the presence of specific neural pathways that represent painful or noxious stimuli. In our nervous system, the lateral spinothalamic pathway specifically transmits sensory signals of pain (and temperature) to the brain.
Pain is the most reliable driver to send patients to their physicians. And when patients report pain, physicians should begin by assuming that their patients are honest. Abuse of prescription drugs occurs mainly by diversion of appropriate prescriptions (e.g., by other family members).
But it will not be solved by restricting prescription of opiods to those who need them.
107
I’ve always been a fan of the Alanon maxim “ Pain is inevitable, suffering is optional.”
This is a different outlook with the same result. IT’s what you do with pain . And what pain does to your mind.
3
My pain treatment physician tells this 100% work-disabled reporter he should run for Congress.
The reason? People in chronic pain need representation.
Folks who were once in pain don't remember it, he says, pointing to stacks of studies; it's a survival mechanism.
The average reaction to 'pain' from a third party is "I broke my arm, it hurt, took pain killers, stopped after it knitted - whadahell you need them for? I got better!" he says.
The feds, who first ordered him to give up dispensing me the Valium I have taken with opioids since 1999 failed to release impinged nerves, are now telling him I shouldn't be seeing 1 doc for pain, another for PTSD, depression and anxiety.
That's because opioid OD deaths, due mostly to imported-from-China street drugs are not being treated as a medical issue. The politicians have taken control.
And the victims are people like me - who need strong pain killers, and will for the rest of their lives.
Yet, that's not the "Popular Wisdom" - even at the NYT!
I've placed repeated calls to reporters on a beat I covered too, when the artificial stuff first hit the streets in the early 1980s, killing junkies because dealers, then and now, lack the equipment to properly 'step on' a gram of artificial super-heroin and a kilo of cuts to produce a standard street dose of smack.
Nobody's called me back.
it's not the story they believe, not the Official Narrative.
Somebody, please save me from the next round of prescription limits! I don't want to die.
29
I wonder if Dr. Warraich practices cardiology in the U.S. or elsewhere, given his comment about doctors taking time to show more compassion and understanding. My recent visits to doctors tells me that they are now compelled, given our model of Corporate Medicine, to type on computers with no time to even look us - the patients - in the eye.
71
@Ellen
MD here- Seems every year or so, reimbursements from Medicare/Insurers go down. Costs to provide services go up, documentation requirements go up. Patients get mad if you are not in their insurance plan. If you are not in most insurance networks, you end up just treating the wealthy. Terrible system, not what I signed up for.
10
@Brenda Moore
Brenda - I commiserate with my two physicians, as I do with you. Both are harried by the "system" but see no alternative, so they stick it out. I don't envy them. We need to get the profit out of healthcare with something resembling Medicare for All.
2
In clinical medicine doctors are taught that "pain" is a subjective symptom reported by the patient—
And "tenderness" is a physical finding on examination.
A physician MD
6
Pain may have a physical trigger--I'm not denying that a burn, cut, or broken bone hurt--but it also has an emotional hook. I have watched friends and family become emotionally invested in their pain and sort of lean into it, deriving identity and importance from it. I've seen others shrug pain off, taking things a little easier until they heal. In my experience, women are more likely take the former route, and men the latter--but particularly women whose emotional needs are not respected or met by their families, friends, and coworkers.
I am a woman, but I don't like pain and I don't have any interest in dwelling in it for long. I don't wallow, and I don't enjoy being babied or cared for. Mine fades much faster than most people I know once my physical wound begins to heal.
The terrifying thing about Oxycontin/Vicodin, in my experience of taking it after surgeries, is that it doesn't stop your pain. It just blunts the edge of it--and, more importantly, makes you not care about it anymore. Of course it's highly addictive. How could a drug that divorces you from care not be?
5
@Incredulosity,
You were overdosed - a proper level of oxicodone, or hydrocodone, taken when pain becomes intolerable, doesn't make you 'not care' except about chronic pain with daily acute flareups, is not "addictive", [except when given in the Oxicontin formulation - the continuous blood level formulation preferred by the FDA and DEA over dosing when needed, because the pills cannot be reduced to an injection] except in the "psychological addiction" category created by said agencies when cocaine was found to be not physically addictive at all. Hellishly attractive, users will suffer depression brought on when stopping, but suffer no physical withdrawal - that's what "addiction" means.
These meds don't, properly prescribed, divorce you from 'care', in fact, they give you back a good deal of the freedom to care that real pain steals from you.
You had poor physicians, you healed, and, according to all the studies, do not remember your real, intense, destructive pain that tore you apart until you took the meds - in your case, apparently too much.
Never tell someone they can't be in sufficient daily pain for opioids, as much as you did after your surgery - Unless you are willing to let someone come behind you and smash your back at some random time, two or three times every 24-hour period, to the point where you cannot sit, stand, lie down, sleep, stay awake, do anything at all without crushing agony.
Give it six months, a year, and while still taking place, you can talk.
11
@Incredulosity. "... taking it after surgeries" That's not at all the same as taking it for chronic pain and illnesses.
2
@Eatoin Shrdlu I love how you're telling me how much pain I was in, assessing the quality of my physicians, and analyzing what my dose was. Ridiculous. Your assessment of your own pain is your own. Mine is my own.
Again, I say: some people are deeply invested in their suffering.
"The ability to tolerate great pain and suffering is easiest when it is someone else's pain."
I wonder if Dr Haider Warraich would be as philosophical if it was his wife passing a kidney stone, His young son who has a comminuted elbow fracture, or himself with a dissection thoracic aneurysm.
After 40 years working in the medical field I can not remember an instance where a physician's stoicism about the nature of pain has extended to his/her immediate family.
136
@Mr. Louche But chronic pain is none of those things.
A suggestion: How about a war on pain instead of a war? Can we not divert money from the bloated defense budget and put it towards finding a painkiller that is not addictive? Or any other type of pain management that could truly cure the suffering of millions instead of inflicting it?Are our brains so primitive that we can't imagine a world without suffering?
18
@theresa
It would be nice - and I believe in such a work, but your goals are impossible.
Allow people who can function if given proper anti-pain medication and ONLY if given anti-pain medication, to have it, as prescribed by physicians skilled in deciding on doses.
Put the money into free medical/psychiatric treatment for those who suffer from pain, and for those who have self-medicated themselves into an addiction.
And training physicians to care about their patients beyond their own experience with getting hurt - then recovering, and forgetting the reality.
For them, I suggest the words of Phil Ochs, folksinger, in light of what happened when, vocal chords damaged in a "mysterious" possibly Nixon-era government-sponsored attack, then a
a suicide "Tell me every detail, I have to know it all/And do you have a picture of the pain?" ('The Crucifixion,' on the album "Pleasures of the Harbor")
2
It's not just the ancient Greeks. Buddhists have believed for millennia that suffering based on pain, and suffering in general, is mostly a perception-- a brief verbal description or mental image we fabricate ourselves and rely on to process the unpleasant experience and try to orient ourselves within it. We go back to it again and again, each time more deeply entrenching the perception and reifying the suffering.
It's a cycle that can be broken, according to Buddhist teaching, but that's too involved to cover here.
4
@Sixofone
Having practiced Vipassana meditation and having suffered from chronic pain, I know this to be true.
The story that the Buddha told about pain being like two darts is very instructive, even if it sounds a bit brutal. If someone throws a dart at you, there is an immediate physical sensation of pain that would be universally experienced. But the second dart is what the mind does with this sensation - and here there is a whole range of options based on one's historical emotional and cognitive pattern of reacting to pain, and one's experience and practice in trying to overcome it.
This is not to say it is easy. But it is possible.
5
@GoddessOfGreens
And in fact, both sixofone and Goddess Of Greens, modern neuroscience fully agrees with the Buddhist view.
It is fascinating to the the outrage directed at these very simple facts.
2
@GoddessOfGreens
That's all nice, but it depends upon the nature and severity of the pain. Chronic pain from your elbow is one thing; acute trigeminal neuralgia is something else. To the point that is can often lead to suicide. Even for Buddhists.
Please don't underestimate the power and importance of your somatic sensations, even as you meditate to reduce your attachment to them.
After all, without your body you will be dead. Yes we are all headed in that direction, but are you in a hurry?
1
Compared to a life tortured by real and unremitting pain, surely addiction is like heaven. No doctor has the right to make that choice for the patient.
40
@Fourteen14
On the one hand, you're right. On the other, it's a false choice. It's the patient's to make, if s/he wants, but those aren't the only two available paths.
9
@Fourteen14
From the article:
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.
8
@Fourteen14
No addiction is heaven; the two states are mutually exclusive.
By the way, spouse recently had pretty gruesome (well, to me, anyway) surgery on spine via front of neck. Was told to fill opiates prescription, took one as ordered, and then spent the duration on Tylenol. Worked just as well.
11
Some of what this piece suggests is really quite fascinating. As for the question of whether pain is a sensation or an emotion, it's interesting that....my understanding is that when we are given anesthesia, there's usually/always(?) a component that includes a drug (such as valium) to cause you to forget any 'memory' of the procedure, and possibly any pain you felt during that procedure. This notion in turn begs the question.... if some of us are indeed 'feeling pain' during surgery, is it more the memory of that pain that could be more 'painful', than the pain itself, as it's being experienced?
A number of years ago I had a period of about 5 months of intense, unrelenting stress at work due to my having to temporarily take on a second role (in addition to my primary role), plus the uncertainty of not knowing if I'd have a job in the end, due to management changes. At one point I began having severe neck pain that lasted for about a week, with tears sometimes coming down my face. I went to a number of doctors, acupuncturists, and even took half a percocet one day (it made me horribly sick). Nothing helped, so I finally caved and decided to shell out $150 to a neuromuscular masseuse I've used in the past (but who does not accept insurance). Laying on my back, eventually she began pressing on the back of my neck, base of skull, etc. Suddenly, without warning, I began bawling my eyes out, not due to pain, but the 'release' of all the emotions I was holding in. Amazing!
7
A lot is unknown about pain. There are many of us in chronic pain who don’t abuse their prescriptions nor do we ask for more pain meds because we’ve been on them a long time. My pain medication allows me to go to yoga, walk my dog, be a good friend to others, cook dinner and any other daily ordinary things that people take for granted. The pendulum is swinging too far in the other direction. The opioid crisis is penalizing people in legitimate pain. Until more is understood about pain, it does little help for those of us in pain to basically be told, “it’s all in our head”. Chronic illness is on the rise. I suffer from a chronic invisible illness. I look great but I’m very sick. Women in particular are constantly belittled.
163
@Nina Henderson. Thank you.
2
After both of my two major surgeries (a four graft cardiac bypass and abilateral nephrectomy with renal transplant) I discovered that I have a natural resistance or very high to opiates and opioids. Extra strength Tylenol works as well for me as do the "stronger" drugs. Happily, I am not diabetic, but the kidney disease left me with typical peripheral neuropathy for which I take no medication. I simply ignore the constant pain in my feet and tingling in my hands. This works for me, but I don't recommend it. Pain is very subjective, and my "3" may be another's "10." I guess that brings me down on the side of the Greeks!
Besides, I figure if I am still feeling pain, I must still be alive -- considering the alternative.
8
Read Dr. Sarno on mind-body connection. If his work on psychosomatic pain was more widely known, so much money and angst and agony could be spared. Of course, it might disrupt the pharmaceutical industry a bit. Watch the film about him, too. Howard Stern and Larry David are fans and appear in the movie.
8
@Louise Mitchell Agreed, everyone suffering with chronic pain owes it to themselves to at least try his method.
4
I have spoken about sarno countless times. 15 years ago I experienced constant excruciating pain for over a year. MRI revealed slipped disk and I had cortisone shots and physical therapy a few times a week. Nothing helped and I suffered.
A friend gave me dr sarnos book and while I was in the middle of reading the book my pain started to go away. With a week after reading it was gone.
From being a 30 year old invalid I was soon back to my normal self and more. I exercise regularly and have done 20 triathlons over the years since.
My trigger that started the pain was lifting weights at the gym. I heard a pop and was convinced my life was ruined. Sarno teaches that anything and nothing can be a trigger. It is not important. What is important is the mind uses this “incident” as the reason for the pain. Once it is established the mind goes to work to use the pain as a distraction from repressed emotions, rage and many other things the unconscious mind would rather not deal with.
The importance of sarno to me goes way past pain. His beliefs on the power of the mind to run the body is very powerful.
9
@Louise Mitchell
- YESSS! I was scouring the comments here, hoping so highly that someone would mention Dr Sarno. Completely changed my life. So powerful.
2
It’s true that doctors could take more time, but if patients could afford to wait, which most working people can’t, knee injuries (of which I’ve had two) can and do get better with time. The body has a great ability to heal itself, but it might take six months to a year. Meanwhile, docs are responding to the patient telling them they have to be back at work, hence the effort to medicate and at least numb the pain.
3
@NH While some injuries can improve with time after the injury, there are other things that worsen, like my hip and back arthritis.
These are not things in my imagination or will improve as time goes on, or other than self hypnosis, make the pain go away.
The bone on bone rubbing as my body's cartilage has disappeared makes those bone surfaces hurt.
I'm not asking for opioids. I'm asking for some common sense when it comes to believing old folks or those with severe scarring or limited tendon function tell you they hurt.
Don't go dragging some philosopher into this. And don't tell me I need to buck up and suffer more than I already do. I admire the Greeks for their work over the centuries, but they did not have the direct line on everything, either.
92
@reid Not to mention that "the Greeks" didn't even say what this article claims they said.
1
@reid
Sigh.
“These are not things in my imagination.”
Well, reid, in a sense that are. Have you seen Dr. Anil Seth’s Ted talks? Neuroscientists have known this for several centuries (and those “philosophers” you disparage have known it for several thousand years) - namely, that all the we perceive, the land, trees, airplanes, stars, planets, etc - are images constructed by the brain.
Where Dr. Seth goes wrong is in excluding the “brain” from this observation - in fact, all we ever know of the “world” is constructed images.
“What” it is that constructs these images no scientist knows. But most scientists are not humble enough to admit this, as Dr. Steven Weinberg almost did in his 2003 essay “Does Science Explain Everything? Anything?”
As far as how these “images” we refer to as the “world’ can be changed, teh scientific consensus, since the near demise of psychosomatic medicine in the 1950s, has gone from nothing, to, well, a peer reviewed journal of the American Psychological Association admitting - perhaps sheepishly? - that psychokinesis is a proven fact.
Meaning, folks, all bets are off.
As I just wrote else where, the Right wants to go back to the 19th century, and much fo the secular Left is stuck in a 19th century fundamaterialist mindset. We won’t solve chronic pain, climate change and other 21st century problems wtih a 19th century mindset.
Www.remember-to-breathe.org
1
Spinoza v Descartes was not mentioned here. The relationship of the mind and the body. I am for whoever defended the intimate relationship of the mind and the body.
I had a molar pulled and all that I got from the dentist was a prescription for pain killers. But he didn't give me anything. My mouth was anesthetized. Back at my office the anesthetic wore off. I experienced it as tears pouring down my cheeks. I associate tears with emotional pain. I went and filled the prescription. It did what it was intended to do.
Anecdotal.
3
Pain is transmitted as a signal by the nerve system to the brain. Little doubt about his. The problem is how the brain transforms that signal into a pain sensation and which emotion is elicited by that pain sensation. In fact pain sensations and emotions are strictly correlated.
Animals suffer pains but they are able to feel the pain without emotion in a brief lapse of time. Humans have more difficulties in detaching themself from the pain they feel.
Pain was associated to the delivery process in almost a scary and biblical way, but training and education can change the emotion associated with that pain and make it tolerable.
Thus I think that education, can play a great role in removing those emotions that make a pain more "painful" than what it should be. This is a role that must be played by the Society as a whole by building the "right" culture. Doctors I believe can have only a limited, although important, impact on this.
1
@Mur,
What makes you think that animals don't experience emotions?
1
@Mur
Iannetti, G.D., and Mouraux, A. The search for pain biomarkers in the human brain. Brain, 2018, 141:3290-3307.
https://www.ncbi.nlm.nih.gov/pubmed/30462175
I thought you were going to say something about physicians not being the ones to deal with pain so much given their failure with the opiods and all. Sounds like PTs would be better and even better than those folks might be ordinary Walmart workers trained briefly and cheaply by PTs.
1
“Long-acting opioids like OxyContin...” I found that the drugs life was three hours, regardless of the dose while I was awaiting surgery for a compound fracture of two bones in my leg. Prior to that, I had surgery once and left the hospital without a prescription for pain medication. When I returned to my surgeon to have the metal staples removed, my surgeon was head of surgery at the hospital, he just shook his head and said I was the only patient he ever had who left without pain medication. Emotion? Both injuries were unexpected, circumstances had not changed much. I found the OxyContin was so timed, you could set a clock by how long the drug lasted. That surely would be an addictive quality to a substance that has proved to be questionable.
3
Just a caution about pain and the reasons for experiencing it.
My sweet Aunt Mollie in her 70’s complained about back and shoulder pain.
Her PCP treated her with NSAIDS
for a couple years and the discomfort worsened.
He sent her to an ortho doc and her MRI results showed pervasive late stage bone cancer metastasis without discovery of a primary tumor.
My aunt cancelled her mammograms a number of times
The oncologist treating her found a primary advanced mass in her breast.
She passed 5 years later. In much pain until hospice gave her the correct dosage of fentanyl and she was comfortable.
Pain should always be thoroughly investigated.
157
Of course it takes a nurse to make the right statement. These days even in severe pain and damage from trauma , even at top doctors , you may be evaluated and diagnosed bye a PA in the doctors office. This is outrageous. The film MRI of complete torn rotator cuff not even observed. Only report was read bye the PA. People ought to tell their insurance companies not to pay the doctor bill stating the reason not seen.
6
Oof. The ol' "all in your head" story.
Like my mom's male boss told her about cramps.
". . . no blood test to draw, no imaging test to order" seems like an excuse for not knowing which imaging test to order.
This throwing in the towel on diagnosis is not helping patients and is contributing to opioid addiction.
I have had increasingly debilitating pain for over 30 years. Pain medications help for a couple of weeks and then it gets worse, as do the side effects. I told a doctor this 2 days ago. He responded by saying I should try Cymbalta again. No.
Physical therapy helps a little.
Mindfulness meditation helps a little.
Cortisone shots are a waste of time.
My mother and uncle have the same crippling hip pain -- my mother's hip replacement did not help -- my uncle vapes himself into oblivion with CBD oil.
A physical therapist said the problem is from a pinched nerve in my back.
Maybe so, but a surgeon said he couldn't do anything.
With appointments limited to 15 minutes by insurance companies, how can doctors perfect diagnostic skills?
Empathy is good, but it's not going to fix a pinched nerve.
Emotional stress (like from an impatient doctor) causes muscle tension that can trigger the pain.
But if there wasn't a physical cause (as there is not on the other side of my body), the stress wouldn't cause that kind of pain.
Maybe if the insurance companies ever decide this is not cost effective treatment, doctors will have time to realize it's not all in our heads.
61
Perhaps what is so haunting and hellish about Wharton's 'Ethan Frome' is how crippling pain transforms the personality of the loved one at the end of her novel. Henry James was to write that it was one of the most autobiographical novels he had read for Edith Wharton has been inspired by her tormented marriage.
David Brooks wrote earlier of the loss experienced by Agnes McKeen, when her son took his life a few years ago, and it took courage on his part to address this sorrowful topic, one that some of us have encountered on our life journey.
Some of us have a higher tolerance for pain than others. When I stub my toe, the New York Times gets to hear about it, and my friends in comparison are born stoics, able to function with chronic migraines, or far worse. There is even a note of satisfaction in their voice, in describing how they walked their feet off in search of fresh parsley at the end of the day, and their plans to take a vigorous class of Pilates the following morning.
A philosopher once wrote that he could not understand someone's toothache. He has a point because you can relate painlessly and be there, while standing aside.
Recently a young woman on crutches entered an empty office elevator, and I asked this stranger how and why she was able to manage. Hit by a taxi cab no less, leaving this viewer gawking in a state of admiration.
Pain can make you feel 'alive', but a pragmatic friend and I have asked in our living will to bring on the morphine.
29
Imagine having that back pain FOREVER, and then you will know what chronic pain actually is. Chronic pain is not pain that goes away after a year — it’s pain that lasts for many years or for a lifetime.
It is cruel and unusual punishment to make patients suffer with chronic pain because you were lucky enough to have your pain go away.
184
@Sarah. Thank you. Chronic pain also means it gets worse. Some think 'chronic' means a set state of pain, when in fact it worsens with time.
49
@Sarah AMEN to this: It is cruel and unusual punishment to make patients suffer with chronic pain because you were lucky enough to have your pain go away.
27
@Sarah: His pain didn't just "go away". The point of the article is that by using opioids pain sufferers never allow themselves to get at the cause, instead developing a "tolerance" that requires more and more opioids. The author states that his pain was "telling him something"; by listening, he was able to address the problem at its source, not cover it up and allow it to become something lifelong.
8
This article sets up a false dichotomy starting with the heading. Pain almost always starts as a pure sensation--find someone who is asleep, and shove a needle into their calf muscle, and they'll wake up with abrupt onset pain. Leave the needle in and wiggle it from time to time, and they'll also develop a fear response to seeing you. Of course one's emotional state can affect pain, and in rare cases even cause it, but it primarily starts as a physical insult to the body.
I feel strongly about this because the main thrust of the article seems to disparage the pharmaceutical treatment of pain. Have opioids been overprescribed? Clearly. But on some level the author makes himself clear by referencing his own struggle with pain, suggesting that others would do well to "tough it out." Chronic severe untreated pain is a significant cause of suicide.
I agree with other commenters that empathy, mindfulness, and other treatments are important. But I object to the false dichotomy set up in this article. It is basically a screed against opioids, which remain extremely valuable medications when used appropriately.
220
@Richard Mize
If “chronic severe untreated pain is a significant cause of suicide”, then why are there not high rates of suicide in other parts of the world? We use opioids here like no other country. I bet the rest of the world experiences as much pain as we do. How do you explain that?
1
@Momdog,
What makes you think that people suffering extreme chronic pain are not killing themselves elsewhere? Do you have a handy worldwide database of suicide and its causes? If so, I'd love to see it.
5
Both. The nerve ending type(A) and the feeling of loss type(B). (B) is probably the most long lasting and devastating.
5
Many years ago I read a book called “The Road Less Traveled” written by a psychiatrist. It changed my life and how I view subjects such as “pain.”
With each passing year, I see Americans devote more and more time and money to avoiding all pain and suffering. As a result, we are unable to handle physical, psychological or emotional suffering of any kind. We use opioids and other chemicals like candy to avoid physical pain; and we use chemicals or all types to address the symptoms of mental illness rather than endure the emotional suffering required to solve the underlying issues.
We’re a nation of wusses - and will remain a nation of wusses until we learn growth and progress require suffering.
5
@John I don't know about the wusses part, but enduring the emotional (and I would add physical suffering) required to solve the underlying issues.
I would add that physical pain is important information indicative of emotional issues and should not be suppressed.
Unless you just can't take it anymore. And that is the crux. How to know the difference.
5
@John
A doctor friend of mine did research on medical marijuana patients in California. He found that a significant number of them had hard drug abuse of multiple drugs in their life history. They also had a very high incidence of absent natural fathers during childhood, childhood abuse, early diagnoses with things like ADD, ADHD, and PTSD, and other related problems.
One survey I saw of female heroin addicts said that about 80 percent of them reported that they had been sexually abused as children.
The doctor's diagnosis was that they took drugs because they were suffering from anxiety-related disorders they had had since childhood.
So the "wusses" in question who need to toughen up are children.
Incidentally, his research also found that when they took up the regular use of medical marijuana, 90 percent of them greatly reduced their use of hard drugs and ten percent quit completely. Marijuana gave them the anxiety relief they were seeking without messing them up so badly they could not function.
13
@John
'The Road Less Traveled' was a great success and I believe it was helpful to some readers as yourself. This is all to the good, however, we are not all the same when it comes to pain equalizers.
When a friend, a doctor, had a liver transplant, she visited afterward, and brought a tray of necessary pills required. There she was at dawn, dressed and sitting uncomfortably on a kitchen stool, reading the New York Times, while I was loafing about on the sofa like a Victorian debutante.
We are living to a greater age where health is being discussed more than ever, and gone are the days where on T.V. you saw an Ad for an aspirin brand. A neighbor of mine is in constant chronic pain, and he keeps working past the age of 70. His doctor is responsible and does not shower him with pain killers.
Keep telling us that we are a nation of wusses, and we may become one, on the basis that we need to 'suffer' in order to grow. The Pill Industry in America is a booming and lucrative business, but many of us are trying our best to stay away from the side-effects of some of these 'magical pills', as they were known in the 50s.
Emotional suffering does not always solve the underlying issues, and it is a great way to take to the bottle and have to deal with two issues.
'My heart has always been weak' from a matronly woman sitting on a bench to a young male jogger. 'You remind me of my husband, the healthy one, he was always fit as a fiddle. Me, it is my heart', as she smiles.
2
The greatest specialist to whom my PCP referred me after years of undiagnosed suffering is a Physiatrist. Within minutes he knew exactly what was causing me tremendous pain, and how to give me months of relief. I refer EVERYONE I know with intractable pain to a physiatrist. It's a specialty that needs and deserves MUCH more visibility.
15
@Esther
With chronic mid- & upper back pain, I have visited & tried 3-4 physiatrists. Tried medical marijuana (didn't like feeling stoned in the 70s & 80s; don't like it now; it doesn't help). A good martini relaxes me for the evening. Distraction helps, sometimes. Guess I'll go back to Dr Sarno's book & video.
4
@Esther I applaud your success. My physiatrist and I became frequent visitors as she methodically evaluated my hip and lateral back pain. After some time, injections, painful EMGs and some potent topical creams which made me bleed easily, we (I) gave up. I still go up and down stairs slowly but even those most likely to help with finding a cause sometimes fail. My pain is worsening and while I once climbed ladders and even ran for exercise, those days are long gone. The arrival at the conclusion that nothing more can be done (and no tumor or metasasis is causing it) was hard to accept, but that's where I am now. Still in pain, but always smiling since this isn't going to rob me of living what time I have left. I just miss out on a lot of things that others seem to be enjoying and cannot understand why I don't just go do them.
5
One of the most illuminating things I've learned about this subject is this equation: Suffering = Pain X Resistance. Whether physiologic, psychological or spiritual, resistance to negative sensations undoubtedly leads to their amplification, through the release of stress hormones; meditation and mindfulness have been shown to be remarkably effective at reducing suffering, by dampening the feedback loop which amplifies pain. The mind body connection is truly more than psychological; it impacts physiology as well.
12
@Jeanne
Suffering = Pain X Resistance
That is so wrong I don't know what to say.
6
@Jeanne
You seem to sincerely believe this.
Come back after bone surgery and tell us how your meditation is working for you.
1
Haider Warraich's reminiscence about back pain and how a supportive environment helped him, describes another expression about pain, in addition to the one he mentioned. That is "sharing the pain". Not only humans can feel empathy at the sight of somebody in pain, but that somebody's pain might be alleviated - literally decreased by sharing - by the empathy of his fellows.
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@abjad It can also be forced on another. Against their will and better judgment. This is very very common.
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Studies show most back pain in young adults will improve with time.
Excellent article. In order to address our current opioid crisis we need to look at the complexities of treating pain. Not all who are addicted got to that point because of pain therapy. However, many seem to think pain can only be relieved with a pill. New approaches to patients with back pain or headache, 2 of the leading causes of chronic pain, would reduce prescription and consumption of opioids. Addressing chronic pain needs to use multiple modalities to be effective. The article brings this to light by discussing the mental health issues that are tightly wrapped into chronic pain conditions.
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Contemporary meditation practices such as Insight meditation and the more popularly known mindfulness would also make the distinction between pain as an emotion versus a sensation. This does not make pain any less real for those experiencing it, but this idea opens up ways to treat pain that were previously untried. I hope the skeptics reading this will keep thier minds open to this idea because what western medicine currently offers does not work for everyone.
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Amongst other things, poppy flower pod tea, alcohol and cannabis have all been used for thousands of years for pain control, as has willow bark for inflammation, pain and fever.
Most of our modern medicines have a base in the Natural World: They have to in order to fit the body's receptors or to knock out the pain causing problems.
I have been a chronic pain sufferer for decades, and have been on Morphine for about 9 years now. My doc cannot prescribe higher dosage, so he told me to "Use more pot" as I live in Washington State, it is Legal here, medically and recreationally.
Since I could not smoke so much, being an older ex-welder, I started to eat the cannabis concentrate with high CBD numbers as well as the THC and other terpines.
I found my general pain levels going from a 6 overall on the 1-10 scale, dropping down to a 4 overall, and I have found that it is due to the decreased full body inflammation. I talked with my doc and my psych counselor, and they were glad to see that I had found a form of relief that was Working, aside from the morphine.
Eating the concentrate also gives me less of a 'high' from the THC, it is still there, but lower level, and that is a good thing as well. The morphine never made me feel 'dopey' but then I have extreme arthritis from a rebuilt broken neck, so I do know a few things about chronic pain.
It CAN be a mindset, but there are clearly physical components, those without the empathy should not do chronic pain treatment at all!
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As a 73-year old male, I'd like to share that getting older comes with acquiring more pain—in one's joints, one's muscles, one's everything. I've found that the best medicine is commiserating with other 70+ friends. It helps keep things in perspective. Of course, one continues to feel pain, but it's more bearable. NSAIDs help too. I recommend against opioids because they can be addictive (and they can cause constipation).
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Cancer pain is acute pain that is chronic. It's time line is chronic but the pain itself is due to evolving acute pain.
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The opinions expressed in this piece are ill-founded and dangerous. The idea that pain is not a physical sensation is a nonsensical assertion. Anyone who’s ever stubbed their toe or put a hand in a fire knows this. I have a very high pain tolerance - I’d never taken a pain killer in my life even through root canals and multiple stitched wounds. Then out if the blue I experienced a severe herniated disc that impinged my L4 nerve and began to suffer unrelenting pain, 10 on a scale of 10 for months. Try telling me that was emotional. I could not have made it through that without opiates. The author suggests ibuprofen is as effective - that’s laughably naive. I took jars of it and it didn’t even touch that pain. The notion that academics or lawmakers, with poor information at best based on this piece, can legislate whether those suffering the worst imaginable pain can be denied access to drugs that alleviate that pain is simply inhumane. What’s virtually non-existent in our current system is the proper guidance on tapering off opiates and the use of anti-anxiety medications to help facilitate that withdrawal. Too often patients are left to their own devices and inadvertently become addicted. Sadly our health care system has become a “patient mill” in which patients are rushed out and not followed-up with. There are consequences caused by that. Don’t blame the drug that gives comfort to tens of millions of people with excruciating pain that is physical and very real.
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@Tom
..and it is a small subset of physicians that run script mills. Nevertheless they graduated medical school and endured a long residency in order to find financial satisfaction pandering to drug addicts.
Just another white collar criminal, a pusher in a lab coat. Other physicians rarely intervene and often overlook this form of malevolent medicine. After all they are all colleagues, unless it infringes on their own practice.
Physicians should resist finger-pointing and pontificating about the pain of strangers until they have cleared their profession of the criminal doctors, some of whom are well aware of those script-doctors in their own community.Fat chance.
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@Tom I'm curious if as you claim that pain is a purely physical/structural phenomenon, then how do you explain phantom limb pain -- the chronic sensation of pain in a body part that no longer exists?
Also, how does one explain acute pain with no injury? That time when a guy gets a nailgun fired into his boot and is in acute pain until the boot is taken off and can see the nail went between his toes?
Or acute pain where someone gets severely injured but it doesn't start hurting until they see the injury?
Or perhaps a study that was conducted by Dr. John Sarno and has been duplicated by others showing doctors detailed MRI images of spines in varying degrees of degeneration and yet none of them could distinguish better than random guessing which patients had debilitating back pain and which were pain-free?
Maybe the idea is not that pain is "all in your head" but that since the brain is the place where pain is interpreted into sensations that it can sometimes get things wrong due to neuroplasticity and learn to produce faulty sensations -- real pain -- long after the original injury has healed or in places where there was no structural injury to begin with.
In those cases, how much benefit is there in suppressing the pain with drugs if it doesn't address the reason why the chronic pain is present?
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They’re not just opinions. the author has linked to studies showing that there is no scientific evidence that opioids help with chronic pain. Your personal anecdote is not enough to change that.
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With all due respect, I must say that I am disinclined to consider a cardiologist, however bright and well-meaning, an expert in chronic pain. I'm afraid that this op-ed reads rather like the latest in the long, long series of entries in the "literature of moral panic" inspired by our current obsession with the dangers of opioids.
As any honest, real expert will attest, opioids, when of known purity and dose and safely administered, are really quite safe drugs. When pain sufferers are driven, by lack of access to the foregoing, to rely upon black market products of dubious composition, very bad results become much more likely. That's where we are in America, today.
I suggest that Dr. Warraich consider minimizing the reality of his own pain, not that of others.
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@Douglas
Be it cardiologist or pain management specialist, reality is that if some one suffers from 'chronic' pain they are usually seen by many different physicians and I agree with Dr. Warraich's opinion that pain has been giving an unjust coverage by pharma companies to push their terrible money driven agenda. Opiates are never a good option for 'chronic' pain, in fact its quite the opposite. Dr. Warriach cited scientific evidence on how opiates change the physiology of the human body. There are so many ways it affects the chemical composition of the brain adversely as well which manifests as opiate addiction, depression and anxiety among others.
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@Douglas. I truly thank you for speaking out as you have about this subject. This Warrich opinion article is damaging to the reality of varied chronic pain conditions and treatments, that affect all kinds of people.
It is not a matter of 'high' when you have chronic pain, it is a matter of simple relief. To be yourself, and enjoy your loved ones.
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Douglas states " I am disinclined to consider a cardiologist, however bright and well-meaning, an expert in chronic pain."
Exactly.
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Pain is a sensation totally embeded in and interacting with emotion. Like every other sensation. Our mind/brain is intimately connected to our body.
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Certainly empathy could help. But I think a more effective approach can be for the patient to practice the principles of mindfulness to their pain. By allowing and accepting the pain, pain's severity can be lessened. When we accept and allow our pain, and struggle less, we can give it space and loosen it's grip. This applies to emotional as well as physical pain. The author alluded to this but seemed to miss this important point.
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@Robert You can only 'accept' the pain of a Broken Neck and Major arthritis only so much. I have practiced mindfullness all my time since being hit by the car, some 50 years now, growing up after that with 'Buck up, everyone hurts', and 'what are you crying about, I will GIVE you something to cry about', and tons of other times I have been told even by doctors that it was all in my head (One I returned to within months of him saying that he thought I was just a big long-haired bearded hippy freak and refused to treat me...I came back with the neck surgery report, and he was forced (in front of the assembly of nurses and aides he was going to chew ME out in front of) to swallow his own words).
There is a lot to pain, and I am finally getting moderate relief after 50 years of deep suffering, and all that is doing is allowing me to be able to move around better, sleep, eat and not be so grumpy. One cannot do much with failed neck rebuild, arthritis and the internal scarring.
Learning to 'just accept' pain put me in the position of being in the hospital with intense nausea, vomiting and 'discomfort' abdominally. Not 'pain' which would have gave them a big clue, but the CAT scan showed a massive gallstone blocking the entire bile duct and backing up both liver and Pancreas, which the doctors explained is a normal '10' on most people's pain scale, and how was I rating it and against what.
Once they got That figured out, Real Pain level, they were able to take good care of me.
It's unfortunate that in medicine it takes us 30 years to recognize the mistake we've made - and who knows how much longer to do something about it.
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Pain is a sensation. Psychological suffering is consciously or unconsciously chosen reaction to pain.
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So, the big question is..... if there is observed pathology, is pain still in the head? Some folks tolerate pain. Many succumb to it. One can learn to live with the pain but it is still there, due to pathology. Doe this mean there are mental health issues. Some counselling suggests pain is blocked emotions. Hmm, time to shake out the emotions.
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Perhaps academia can figure out how to make pain less experiential and more academic.
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Clearly pain is no 5th vital sign. It can't be measured by an outside observer unlike the traditional signs: blood pressure, respiratory rate, temperature, and pulse, and the new one, oxygen saturation. Yet it is an important contributor to our well-being. It serves its role as a signal to our brain that something is not right, and we had better do something about it right now! The brain does not directly interpret the signal; that falls to consciousness, and that is where things go wrong, because our consciousness is also influenced by all the things Dr. Warraich mentioned, including emotions. Until individuals are better able to control their response to real signals, the response to pain will not necessarily be useful.
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I've had a lot of surgery & some chemo & have said for 50 years that supposed pain killers -esp. opiods- do nothing to alleviate the pain & I get a lot more relief from n-saids.
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