A World of Hurts

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.’

We must ask ‘whether personal beliefs and cultural meanings that
we bring to pain are accurate, positive, and helpful–or, as is too
often the case, inaccurate, negative, and damaging,’ Morris writes.
His ideas reflect a cultural shift toward empowering patients to
help heal themselves and offers a more complex alternative than
drugs alone to that saddest and most radical attempt to master
pain–suicide.

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