Home Journal Issues Journal Index Blog Search Contact Us Help

Volume 2, Issue 4
Winter 2006:

The Pain of Pain

Matthew Masewic

Cell 2 Soul. 2006 Winter; 2(4):a4

Whenever a patient appears on my schedule for evaluation of "back pain," I feel disdain. Rarely do I have good options for treating this ailment; often there is no cure. But ironically, I excel at it: I've learned how to talk to patients about pain.

Over the years I have come to understand the manifold dimensions of pain, especially chronic pain. I've spent hours with patients, talking not only about their physical pain, but also about the emotional pain that stems from not being able to work or pick up a child in play; the fear of being regarded as lazy; the loss of personal dignity because they can't do or be what they once were. We discuss the issue of bereavement — learning to let go of their former selves; the inability to engage in activities that once made their lives meaningful and defined them as individuals; the short fuse that comes from being in pain all day, every day; how that affects relationships; the fatigue. I have listened and developed an understanding in all these issues. My patients often express great relief that I do not view them as lazy or sick or broken human beings.

Pain is difficult for each one of us. As a doctor, I am never certain which patient is truly in pain and which one seeks pain medication solely for the euphoric value. I have spent hours mulling it over. I have left the examination room feeling used, manipulated and taken advantage of. Through it all I have come to this conclusion: if we are conservative in our habit of prescribing pain medication (that is, withholding prescriptions), real people in real pain will walk out of the office without relief; if we are liberal with pain medication prescriptions, we contribute to substance abuse. Which of these options feels like less of a problem to you? "What is your poison?"

When I see patterns of addiction — distinctly different from addiction to "not being in pain" — I have learned to confront the patient, despite my personal fear of confrontation in general. I strive to overcome my fear, because I truly believe that confrontation is in the patient's best interest. This leads me to write about John.

John was twenty-one years old, single, and the father of a fifteen-month-old child. He was charismatic and physically attractive, and he loved his son very much. John started to come to me repeatedly with complaints of headache. When I reviewed his chart and medical history, I noticed a pattern. A thorough evaluation, including a CT scan of the head, spinal tap and blood work, showed no abnormalities. The Sunday he called the office to request more pain medication for his headaches, I challenged him. It was nerve-wracking for me, but I felt relieved when he acknowledged my concern and asked, "What do we do next?" When I offered to arrange a hospital admission to orchestrate a more comfortable withdrawal from the narcotics and a psychiatric consultation, he accepted. John and his family were quite happy with the outcome. He subsequently joined Narcotics Anonymous, returned to work, and seemed to be productive. I heard nothing of him for some time.

I remember the next time I heard about John as if it were yesterday. I was cutting through the ER on my way to the office after morning rounds. One of the ER doctors whom I know and respect stopped me with a sad and serious look on his face.

"Hey, Matt," he said, "got a minute?"

"Sure," I said, with some trepidation.

"Your patient John B. came in last night. Auto accident. His CT scan and x-rays were normal, so we sent him home. This morning they brought him back. No heart beat, no respirations. I tried everything I knew. Couldn't get anything going. I can't remember ever seeing such a lack of response in someone so young." His words sounded desperate, but he went on: "John's family is here. Could you talk to them for a few minutes?" He was very distressed. Obviously, the ER staff felt that they had missed something the previous evening and the whole staff seemed down.

I spoke with the family at length. John's little boy played at my feet, unaware. His mother could not stop crying. His stepfather felt it necessary to explain that, although he wasn't John's biologic father, they were very close. His girlfriend looked confused and said little. All of them were waiting for social services. To my dismay, risk management had been summoned. The family only wanted to know what had happened. I had no answers for them and felt quite useless. John was dead and nobody knew how or why. The grief was palpable.

Weeks later the autopsy report came back bearing the cause of death: "Fentanyl Overdose". The ER doctors hadn't missed anything, I thought — but I had. Intellectually, I knew that I had done the right thing in helping John to break his addiction. Yet I couldn't stop thinking that, had I kept on prescribing narcotics for him, John at least would have used them at safer doses under my care.

I think of him often. The multiple dynamics role around in my head and my heart like some great unfinished project that I cannot bring to a conclusion: the pain, the right thing; the meds, the pain; the right thing, the meds. The pain of pain extends beyond the physical pain of the patient — far beyond.

Return To Top