Managing pain


BUFFALO -- Mr. L. limped into the clinic, a gaunt 30-year-old man with AIDS, wasted away by the disease, stooping, eyes wide as he shakily lowered himself into a chair with his weak legs.

He had an array of complaints: nausea and vomiting, diarrhea, abdominal pain, cough without sputum, insomnia, leg pain, knee pain, and a diffuse, constant pain described as going "all through my body."

He had also lost about 25 percent of his original body weight, and his CD4 count was 8, indicating a profoundly weak immune system. The attending physician explained that given those facts, and a few others, he probably had about six weeks to live.

Apart from the multiple complaints and multiple pains, he may have had multiple motives: this man was a former heroin user who had reportedly exhibited "drug-seeking behavior." This last is a catch-all phrase sprinkled in medical charts meaning anything from complaints of pain that didn't make anatomical sense, leaving a vague impression of falseness, to filling multiple prescriptions for opiates from multiple doctors at various pharmacies.

Also, his previous admission to the hospital was for a tranquilizer overdose. We weren't sure if it was a suicide attempt or not. Given all this, deciding how to manage his pain was quite a problem.

We admitted him to the hospital. At that point, we were suspicious that he might be trying either to end his life or to get drugs for recreational purposes. We gave him fentanyl patches, which are worn on the skin like the patches used to quit smoking. They start to work in about 12 hours, and provide a steady level of pain control. They do not control the periodic bursts of more severe pain, "breakthrough pain," that many patients experience. This is a conservative way to treat severe pain; it does not create much of a high.

Mr. L. wasn't satisfied with this answer, but the issue was settled.

On the hospital floor, it became apparent as the days progressed that there was a good possibility he was in real pain. The team eventually started him on more powerful narcotics. This was a reasonable approach, and a great many physicians would have followed similar lines.

But is there something deeper here? Why were we slow to treat this man's pain aggressively?

Conflicting forces

This case illustrates the conflicting forces operating on physicians when they consider prescribing narcotics: a patient who asks for help on one hand; and on the other the possibility that the patient may be lying in order to get high, the potential for suicide using the drug, a perceived societal expectation that pain medications not be used carelessly and the fear of professional punishment for being loose and easy with narcotics.

These last four forces, the forces pushing against opiate use in the United States, are very powerful from the perspective of a physician.

Though many in health care pay lip service to the need for adequate pain control, there is still a visceral reluctance to prescribe narcotics. Unless one can demonstrate a clear, temporary physiological basis for the complaints of pain, such as a heart attack or a splintered leg bone poking through muscle and skin, physicians tend to feel -- note the word "feel" -- that one generally should not prescribe narcotics.

Why is that? Why, in the case of Mr. L., for example, should a terminally ill man offering vague complaints of pain receive suboptimal pain control?

There is no scientific basis for the decision. The only bases for refusing pain medications are moral and emotional ones.

As James Goodwin pointed out recently in the journal Perspectives in Biology and Medicine, our country was founded by Puritans, and the core of their culture is still with us. To the Puritans, unearned pleasure was suspect, and pain was expected; in fact, pain was seen as somewhat redemptive. Those attitudes prevail in the United States today, usually in an underground or subconscious current of emotion.

As Mr. Goodwin writes, ". . . the primary problem is that medications for pain are pleasurable. Many people given morphine enjoy the experience. This makes pain control a tricky and somewhat dirty business."

Never mind that most people in severe pain will not get high when they receive narcotics; they'll feel blessedly normal. Never mind that the risk of creating an addict by giving narcotics for pain is tiny, something like 1 in 5,000. There's still a risk that someone will feel undeservedly good. We are still Puritans.

American doctors are known around the world for their cavalier approach to pain control. But the doctors, like everyone else in our culture, are subject to our national mindset; we can't blame them. We are all to blame, for not facing our assumptions and hang-ups, and for clinging to our primitive defense mechanism of projection, which leads us to see laziness and undeserved pleasure all around us.

Well, we're still a young country.

Mr. L., by the way, died seven weeks after his admission. Up until his last week, as he was hyperventilating on 100 percent oxygen and unable to move from his bed, people were still writing about his "drug-seeking behavior."

Mike Merrill is a fourth-year medical student at State University of New York at Buffalo.

Pub Date: 4/11/97

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