man digging into his shoulders with his hands

Managing Chronic Pain

By Alex Lickerman, MD

4/17/11

I have a small cohort of patients who suffer chronic pain so intense and unremitting it prevents them from living normally. They often don’t work, shop, go to restaurants or movies, leave their homes or even their beds except to visit doctors, or have meaningful relationships outside their immediate family, who often struggle to live with and care for them.

One patient in particular has pain that’s so severe she’s become wheelchair bound, chronically depressed, and regularly experiences times when she contemplates suicide on a daily basis. Most primary care physicians, I’ve observed, are woefully under-trained in chronic pain management, often more concerned about painkiller addiction and drug-seeking behavior than quelling excruciating pain they don’t feel themselves. But even physicians who find themselves comfortable treating chronic pain aggressively with all the tools we currently have available sometimes find those tools inadequate. Most people outside the medical profession don’t routinely encounter people whose lives have been ravaged by chronic pain so don’t realize they even exist, much less grasp how awful their lives typically are. But such people do indeed live among us.

CAREGIVER’S ATTITUDES

I remember the first time I met my patient. She described in clear yet unemotional detail not just the quality and severity of her pain but its impact on her life. I found myself moved by all the losses she’d suffered at the hands of it: days to weeks of time absent from work, periods she desperately wanted to but couldn’t play with her children in her neighborhood playground, and the strain on her marriage that eventually shattered it. I told her I would do everything in my power to help her and that I would not abandon her. Strangely, her response to my saying that, in contrast to the way she’d described the ruin of her life from pain, was to choke up with tears (which she tried, heartrendingly, to hide). She thanked me for my commitment in hoarse tones.

Only several years later did I come to understand her reaction. Other providers before me, when they too had tried to help her and failed—not for lack of trying and through no fault of their own—had appeared to her to lose all interest in her, gradually coming to return her phone calls sluggishly or not at all, to resist filling prescriptions for her, and even to become irritated when she would report her pain had increased (as it sometimes did for no discernible reason). They had all seemed to care when they’d first met her, she told me, but all failed to stick it out with her in the long run. She knew medicine’s ability to help her was limited, but what she wanted more than anything besides pain relief, she told me at that first visit, was someone who would simply stick by her even if that was the full extent of what they could do.

Ironically, this proved itself even more difficult for her previous providers than finding effective ways to treat her pain. Though I never said so, I understood why. They hadn’t abandoned her out of indifference or lack of caring but, I believed, from frustration—not with her or her pain but rather their own impotence. Perhaps as a result of a psychological coping mechanism, as a group, doctors tend to ignore what they can’t fix.

I, too, have felt inclined to ignore patients I can’t help. And, after a time, I began to feel it with her too after proving no more adept at controlling her pain than the doctors who’d tried before me. But she’d warned me well. By calling attention to what her previous doctors had done, she forced me to reflect on their behavior and on my tendency to mimic it. By making me acutely aware of the temptation to turn my back on her, she predisposed me to resolve not to.

And stick with her I have, for the last ten years. And not abandoning her, I’ve come to realize, is the best treatment for her pain that I’ve had to offer. Not that it’s been adequate, by any means. But it has been helpful. At least, that’s what she says.

WHAT CAN BE DONE

Pain is a fascinating subject when one isn’t experiencing it oneself. It may feel to us like a single unified experience but in fact is generated in our brains in a series of sequential steps. Counterintuitively, the physical sensation of pain registers in a different part of the brain than does its aversive quality. We know this because of patients who’ve had damage to the latter portion, the insula, develop a syndrome called pain asymbolia wherein they feel the raw sensation of pain but not its aversiveness. That is, they feel pain but don’t much care. If that seems hard to understand, it’s because to those of us with an intact brain who are incapable of experiencing them as separate things, it is.

But it raises an interesting possibility: might not there be methods we can employ that exploit this hidden duality? Rather than attack chronic pain at the trigger point (i.e., an injured tissue or even the misfiring of the peripheral nervous system itself), perhaps we could attack it where it actually lives, in the brain itself. If we can’t do much to alleviate the source of chronic pain, can we in some way reduce its aversiveness?

The answer, at least to a limited degree, seems to be yes. A number of studies have explored ways to do this. A recent article in U.S. News reported the results of a small study in which “healthy medical students attended four 20-minute sessions to train them in ‘mindfulness meditation,’ based on techniques such as focusing on breathing and banishing of distracting thoughts. Before and after the training, participants underwent brain scans with a pad heated to a painful 120 degrees attached to the back of their leg. They reported a 40 percent decrease in pain intensity and a 57 percent reduction in pain unpleasantness following their training. Morphine and similar drugs typically reduce pain by about 25 percent.” If validated by other, larger studies, this represents an astounding result. When considered in combination with the results of another study in which viewing a loved-one’s picture had pain-attenuating effects, we might hypothesize that the degree of aversiveness of pain is at least partly determined by how much attention we give it. If so distraction—though by no means a cure for chronic debilitating pain—may be an effective treatment.

The problem with pain, of course, is that it’s designed not to be ignored. Normally, acute pain indicates something is wrong in our bodies that needs our attention. But in many chronic pain syndromes this isn’t the case. Rather, the pain itself becomes the disease, often centered in an “overactive” nervous system response rather than chronically injured tissue (though the latter is certainly common as well). Distracting oneself from such chronic pain requires consistent effort that’s difficult to sustain. But the study above gives me hope that though we don’t yet have the technology to relieve all chronic pain sufferers of their experience of pain, they themselves may be able to surmount their pain’s aversiveness in a way that enables them to reclaim at least parts of their lives. It’s not a good solution, I readily admit. But it’s better than nothing.

Though how we subjectively experience pain is undoubtedly influenced by many other variables, just the notion that we have more influence over our experience of pain than previously thought is encouraging. Though I’ve suggested to my patient, based on the study above and others, that she begin a program of meditation, she hasn’t yet. “How could it hurt?” I ask her. “What else do you have to try?” She acknowledges my logic and promises to start. In the meantime, I continue to do what I’ve done: stand by her and care.

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