A World of Hurts

Why your doctor is afraid to ease your pain

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Sometimes pain is more frightening than death. Recent initiatives in New York and Oregon to approve physician-assisted suicide are reminders that many people would rather end their lives than continue to suffer the agony of terminal illness. A study published in the Journal of the American Medical Association (Nov. 22, 1995) reported that more than half of the conscious, hospitalized terminally ill patients followed by the study died in moderate to severe pain, often made worse by 'aggressive' medical techniques. Meanwhile, doctors are often reluctant to prescribe painkilling drugs in the dosages that would relieve their patients' suffering.

Why aren't doctors more aggressive in alleviating pain? First of all, they're afraid of making their patients drug addicts--and many patients, even terminally ill ones, are afraid of addiction, too. They are blurring the distinction between a pain sufferer's undoubted dependence on drugs and actual addiction. Seddon Savage, M.D., director of the outpatient pain clinic at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, admits that opioids (painkillers not derived from opium but having opiate effects) 'have been underutilized over the years.' But, she adds, doctors can determine if a person is predisposed to addiction by examining the individual's history, and even where there is a risk of addiction, there may be some room to maneuver.

Won't increased drug dosages damage a patient's judgment? Again, research suggests that the answer isn't necessarily yes. In a Helsinki University study reported in Health (Nov./Dec. 1995), the reflexes and judgment--in a simulated driving test--of cancer patients who were on regular doses of morphine turned out to be only slightly inferior to those of a control group that was not given drugs. The difference wasn't big enough to impair the medicated patients' driving ability, according to the researchers.

Drugs can, however, endanger doctors, especially when they get caught in the crossfire of the war on drugs. In Hippocrates (March 1995), Ingfei Chen recounts one doctor's ordeal with the Drug Enforcement Administration (DEA). The doctor's medical license was suspended after he prescribed up to 100 pills of a strong opioid for a patient suffering from severe, chronic bone pain--a dosage that Chen views as entirely in line with the doctor's responsibility to provide the best care possible.

The DEA contends that 'script doctors'--physicians who knowlingly prescribe drugs for uses other than medical ones--play a major role in so-called drug diversion, the movement of prescription drugs onto the illicit market, which, according to the agency, accounts for about 40 percent of all drug abuse and illegal drug traffic in the United States. But, according to an estimate made by the late Robert Angarola, former director of the U.S. Cancer Pain Relief Committee, diversion is really responsible for closer to 5 percent of the trade, and 'script doctors' account for only a portion of that figure. He believes that unnecessary government regulations and 'a few overzealous enforcers have scared doctors and victimized pain patients.'

There may be deeper reasons, too, for modern medicine's failure to confront pain. According to the 20th-century idea of disease, writes Michael Long in Notre Dame magazine (Winter 1995-96), pain is a mere symptom, secondary to the disease. Thus it's seldom the focus of treatment, even though several recent studies show that pain can impede healing. The medical credo is 'cure the disease and the pain will go away'--rather than the idea that pain itself is a disease and relieving it is a worthy end.

Interestingly, a really comprehensive medical understanding of pain and its complexities reveals that drugs alone are insufficient to relieve many varieties of it. The medical model of pain, which reflects what is often called the mind-body split, is a mechanistic and ultimately inadequate way of looking at pain, writes David Morris in The Wilson Quarterly (Autumn 1994). It doesn't account for chronic pain in the absence of a physical cause, the placebo effect, psychogenic pain, phantom limb pain, or the effectiveness of certain mind-body therapies--such as biofeedback and meditation--in bringing relief from pain. Morris believes that we are in the midst of a 'revolution in thinking about pain. that goes beyond the biomedical focus on nerve and neurotransmitters to consider the ways in which biology, mind, and culture interact' to produce physical suffering. Not only are older ways of thinking of pain unhelpful, he adds, but 'drugs alone cannot control the wide range of pain syndromes, and an individual's overreliance on drugs may simply exacerbate the problem.'

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