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Pain Specialist Urges a New Dialogue

October 15, 2012 -- The problem with how we address pain doesn't just lie with the medical community, and the problem is not solely that prescription painkillers are overprescribed, said Dr. Alex Cahana, a pain specialist with the University of Washington who spoke at a recent pain management conference in Portland.
October 15, 2012

October 15, 2012 -- The problem with how we address pain doesn't just lie with the medical community, and the problem is not solely that prescription painkillers are overprescribed, said Dr. Alex Cahana, a pain specialist with the University of Washington who spoke at a recent pain management conference in Portland.

“For me the whole opioid crisis is not about opioids, it's about an impoverished dialogue,” Cahana said. “We don't talk to each other.” That results in clinical harm – 50 opioid overdoses per day – as well as the social harm of recreational dabbling in opioid medications, and perpetuates a larger cultural harm.

“We really think we can't go through life without medicines. We can't do sports without doping. We can't deal with pain without using painkillers,” Cahana said. “There are scientific studies that the use of these types of medications handicap our bodies to actually use the endorphin systems. The endorphin system is responsible for all of our appetites and bonding, and maternal-infant bonding.

That problem is symptomatic of bigger issues in the culture: not just the desire for quick fixes that may hinder people long term. Another problem is the way we talk about pain as a culture, since there are actually different types of pain, but they tend to be treated the same way. “It's unfortunate that in English we use the same word for pain as a byproduct of a disease as for pain as a disease,” Cahana said, drawing a distinction between the type of pain that arises from an easily identifiable underlying cause, such as a broken arm or an inflamed appendix, which is what most people think of when they refer to physical pain.

In reality, he said, it's in a different category from chronic pain, which he defined as pain that arises when there is nothing to do – no medical process to address the underlying issue, but unfortunately both types of pain are treated the same way.

“The medical community is trained to manage diseases. We're not trained to help people manage their lives. The medical community is medicalizing existential suffering,” Cahana said. “We think of pain as something that we feel. When you think of pain as something that you feel, then my job is to fix it.”

Cahana urges patients and providers to think about pain as a verb rather than a noun – as something that all people do: “I am paining. You do it well or you do it poorly.” One reason alternative therapies can be so powerful, he said, is that they try to address the mind-body connection rather than simply the body. Good pain management should focus on trying to help the patient lead as normal a life as possible and decrease the patient's reliance on the health care system.

“Many times we use the word pain, but I think we mean suffering,” Cahana said. “Suffering is the negative behavior. I like to think of suffering as an unfulfilled promise.” Americans are promised that they'll always be young, healthy, sexy and rich – and when that isn't fulfilled, they suffer.

Patients don't go into doctor's offices saying they're having a hard time coping with the loss of a job or the departure of a spouse, though, Cahana said. “They don't come say that to me. They come and say their back hurts. This is not to say that there's no room for injections, no room for pills. It cannot supplant a meaningful dialogue. It means a professional that's poised to listen and poised to create a life plan.” Part of that necessitates a patient who is willing to listen and make major life changes to improve their overall health, he added.

“I think we will find out that there are two things: not all pain relief is good. We accept also that not all pain is bad,” Cahana said. “If we can pain as a verb better, we will get one step closer to sustainable happiness.”

Comments

Submitted by Kris Alman on Thu, 10/18/2012 - 10:10 Permalink

Bravo for talking about alternative therapies! The American culture is broken and society is sick. No controlled (or illegal) substance can mask that pain. Touch and talk can help. But that takes time. And time is money. Physicians have become the proverbial hamsters on the wheel. Treat to the test is reflexive in an era where doctors hands touch a keyboard more than the patient. Physicians must pledge to uphold the modern version of the Hippocratic Oath. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html HIPPOCRATIC OATH: MODERN VERSION I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. —Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.
Submitted by Kris Alman on Thu, 10/18/2012 - 10:12 Permalink

HIPPOCRATIC OATH: MODERN VERSION I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. —Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.
Submitted by Steve McCrea on Thu, 10/18/2012 - 10:37 Permalink

These comments are especially true regarding the treatment of mental/emotional problems. We are being taught that any kind of emotional suffering, be it anxiety, depression, aggressive feelings, or weird thoughts, is a de facto "disorder" and needs treatment. The upcoming DSM-5 (the huge volume that lists out the "diseases" of the mind and their symproms for purposes of insurance reimbursement and diagnosis) goes even further down this road. For instance, they want to re-define bereavement to give you only two weeks to recover substantially from a loss and regain some semblance of normal functioning. Apparently, if you're still deeply upset, have a hard time getting out of bed, have a hard time sleeping or eating properly, are crying a lot, or have thoughts of suicide even two weeks after the loss of a husband, wife, child, parent, or other loved one, you will be classified as having "Major Depressive Disorder" and most likely be referred for antidepressant treatment. Hey, guess what? Losing someone you love is SAD!!! Crying and feeling hopeless and depressed is pretty darned normal, and two weeks for most people is not even sufficient time to process the fact that the loss is even REAL, let alone to recover from it! We're being taught that we should always be happy, never be upset or down for more than a brief period, and that doctors have a pill to make it all better any time something hurts. It's nonsense and it is dangerous. Thanks for this excellent article. I hope more doctors start thinking like this author. ---- Steve