Down With Pain

97 million Americans with chronic pain and I got a 57 year old screamer in a wheelchair. Back pain, leg pain, pain in places she was not sure of. No, psychiatrists are not supposed to give out morphine.  Yes, I know I have a prescription pad.  But I keep it close to my heart, locked in my file cabinet, or in my purse, because I actually enjoy practicing medicine and do not enjoy the vision of my license certificate on wings on its way out the window. Even if I could have done it fearlessly, I would not have increased her pain medicine.  The more you give, the more they hurt, the more they need.  This is written in a lot of places but you only have to look at the patients who have been created into addicts, and there are plenty of them.

Alternative recommended approach nobody will listen to: A Bryn Mawr college student, apparently not loaded down with clinical cynicism or even clinical experience, came up with this one.

The way it is said is brilliant.  We all act as if we had a pool of attention, and the more of it we place on something that is not pain, the less pain we feel. Experiments cited go from virtual reality to guided imagery to music.

I wish I did not have as much experience with this as I have.  Acute pancreatitis, Ocular Herpes simplex (at least the resultant blindness got me out of the Army) and too many others. When I was in the Army, I managed to remember a religious chant my grandmother of blessed memory had taught me.  It diminished my eye pain mightily.  The most cynical of atheists may argue that I was working so hard remembering and chanting correctly that I took my mind off the pain.  Me, I think there is something or other out there in the universe that we understand poorly and describe and explain rottenly, but that still exists.  I don’t much care if I did something Jungian or religious or weird, but it worked just fine.  I love things that work.

Although the research reported here, and pretty much anything I can find deals with low to moderate intensity pain, is some kind of bias. Most people I know who do research choose their topics in ways to get good results and “tenure,” the academic word for job security.The one or two people I know, including me, who tried to go out there and influence the advancement of science independent of the politics involved end up outside the system, like me, trying to be creative, and to support their idealism.

The writer of the article above cites the differential effectiveness of this kind of intervention on people. This, of course, is a lot of the whole damned problem with science. Patients are “normed.”  It is not necessary good reasoning, but cheap reasoning, making life easier for a practitioner or academic, but certainly not for the patient.

I have a vivid memory of the last time I did a lumbar puncture.  Not supposed to be painful, really, but it often is and well, that is a clinical reality. I gave this young woman a step by step description of a walk on the old cobblestone streets of the Ile St. Louis in Paris, the only part of the city with no subway; an ancient and wonderful part of the city, and an island in the Seine.  She had been screaming when she started, but she asked “Already” when it was over.  I had to ask a few questions to know that Ile St. Louis and not something else would do this. And I guess people who do research have neither the time nor the interest.  This data is not the sort of thing that is quantitative or measurable or gets you published in a journal.

Me, I had a terrible knee sprain recently. Quite painful, resulting in a doctor offering lots of drugs I did not take. I did not want to turn over on the side of that knee, not put weight on my left foot, even in bed. On the opposite, side, I think I struck the pose of Paul Gauguin’s 15 year old Tahitian model, who happened to be sleeping on the sun on the good side for me (the right) when he painted her.  Not hard to finish the imagery; warmth, tropical breezes, beach, maybe a couple of flowers.  Knocks me out every time.

Okay, so there is maybe something going on in my prefrontal cortex, some kind of pain modulation pathway.  Hard to track in the human (may have been demonstrated in lab animals) but I only care about that when I am contemplating the wonders of the brain. Granted I do that more than normal folks, but I don’t care about the brain when I am trying to get rid of pain. Mine or someone else’s.

No research, no documentation, just fact. We seem to be getting farther and not closer to a medicine that works.

I did try to tell my 57 year old screamer in a wheelchair that she might profit from some none drug ways to reduce pain.  She told me she had tried everything and it was not strong enough or good enough for her.

I looked at my watch; luckily I was wearing the one with the nice picture of a sagittal section of a human brain.  I could almost see where a pathway might be.

No.  She is probably still screaming.  Another day at the clinic, and my watch said there were only a few hours to go. And that day I thought what I told her, and I told myself, too. “Never give up; never surrender.”