My father was a small-town doctor. He had a reproduction of this painting on his office wall. Note the poor family, with the child’s bed made of two dissimilar chairs. Note the distraught mother and the worried father, clearly unable to pay a large fee, or perhaps any fee at all. But note the doctor sitting up all night with his small patient. Whom people choose as their role model tells a lot about them. This painting tells a lot about my father.
Later, when I was a medical student, an instructor asked what was the primary duty of a physician. A classmate replied, “To cure disease.” The instructor prompted, “Anyone else?” I said, “To relieve pain.” Later I learned this principle:
To cure sometimes, to relieve often, to comfort always.
– Ambroise Paré, 16th century surgeon
Currently there is agitation about the increasing incidence of deaths from overdoses of drugs prescribed for pain. This gives a whole new meaning to the term “painkiller.” The media are unclear as to whether the patients took more of the drugs than was prescribed, but this seems likely. Government regulators are instituting new restrictions on prescribing opiates and other anti-pain drugs. But as a result, heroin use is increasing – some to satisfy addiction, and some simply to relieve pain.
In discussing cardiac pacemakers or hip replacements for the elderly, President Obama declared, “Maybe you’re better off not having the surgery but taking painkillers.” Now the government wants to withhold the painkillers as well. Have a nice day.
On the other hand, all physicians are required by the California Medical Board to take a course in pain management and end-of-life care. I thought this was a good idea − all doctors should be aware of modern techniques of managing pain. But the Board issued a statement by the deputy chief of enforcement – who is, as expected, a non-physician.
The statement warned that we could lose our medical license if we over-prescribed pain medication, or if we did not detect “drug-seeking” patients who can be “cunning.” There was not one word about under-treating pain, which was the subject of the course we had to take. There was not one word about whether a “drug-seeking” patient might be seeking drugs to relieve real pain. The article could have been written by a drug-enforcement agent, rather than by an official of a medical board.
What the Board is really saying is: “You must spend hundreds of dollars studying pain management, but don’t actually manage pain, or we’ll punish you. The object of the course is to enrich those who give it, not to have you put the lessons into practice.”
If there is a more striking example of hypocrisy and double messages, I have yet to find it. For a more humane view, listen to the American Association of Physicians and Surgeons:
It must be noted that rather than indicating addiction, aberrant drug-related behaviors often signal the presence of under-treated pain.
Recall the torrent of condemnation that descended on Rush Limbaugh, after he announced he was addicted to prescription painkillers and was entering a drug-treatment facility. Reportedly he underwent back surgery in an attempt to relieve herniated discs, but the surgery was unsuccessful. Indeed, failed back surgery often leaves the patient in more pain than before. That’s why, despite years of recurrent back pain, I chose not to have surgery.
But doesn’t excessive use of pain medication show a character flaw? Maybe, maybe not. First of all, what is excessive? The amount of pain medication required depends on several factors. Severe pain requires more medication. Larger people need more medication. Those who have become accustomed to medication need more. Those who are sensitive to pain need more.
After 25 years of treating patients with cancer, I concluded that the proper dose of pain medication was the dose that relieved pain as much as possible, with as few side effects as possible. The dose varies with the individual and the situation. It can’t be dictated arbitrarily. There is no cookbook for medical care – not even if the ObamaCare Independent Payment Advisory Board writes the cookbook.
When I had severe back pain, I tried to take opiate-containing medication. Some people get a “high” from opiates and have difficulty stopping them. But I became nauseated, so I stopped the opiates and got by with Tylenol. I preferred more pain to the side effects of opiates. Still, I had enough insight to recognize that this wasn’t due to my strength of character − it was due to my body chemistry.
Not everyone has insight. Those who never had chronic pain often don’t realize how debilitating it is. Those who don’t get a “high” from opiates often don’t realize how hard it can be to stop them. Those who are lucky often don’t realize they are lucky, and instead attribute their good fortune to their own good qualities. They can’t imagine themselves in chronic pain, so they have no empathy for those who are less fortunate. Lack of empathy is a defect in any human being, but it is dangerous in someone involved in health care.
Illegal drugs ruin many lives. But the war on illegal drugs has nothing to do with preventing patients with medical illnesses from getting needed pain medication. Doctors who sell prescriptions to people who walk in off the street belong in prison jump suits, not white coats. But they have nothing in common with ethical doctors who try to relieve their patients’ pain.
Daytime TV is filled with interview shows, where people bare their emotional problems. They tell things to millions of strangers that I wouldn’t tell my best friend. Having emotional problems is now not only acceptable but almost desirable – it gets you on TV. What’s more, there are many ads for antidepressants and sleep aids. We learn that emotional problems should be treated with pills.
Evening TV is filled with “how to look young” reports, detailing the latest methods for erasing wrinkles and removing “cellulite.” Most people on TV – from reporters to actors playing coroners – are handsome, beautiful, and young. We learn to honor emotional problems, but to fear physical problems, especially those associated with aging or disability.
Many people aren’t religious. They no longer believe there is anything after this life, or that life has any purpose other than to enjoy ourselves. Of course people like that are terrified of old age, disability, or chronic pain – they don’t even want to think about such unpleasant topics.
Why did many people fail to protest when Terri Schiavo was being dehydrated and starved to death over 13 days? It wasn’t cruelty – they would have screamed if a dog were treated that way. No, it was fear – fear of disability, fear of not being physically attractive, fear of not being young and vigorous, and fear of not being in control. Fear is a powerful emotion, but a poor guide for social or legal policy.
Other than non-prescription medications like Tylenol and aspirin, there are no ads for pain-relievers on TV. Instead, there are endless cop shows in which drug dealers are the worst villains, which they are. But the lesson is that emotional pain is okay and should be treated with drugs, while physical pain is distasteful and repulsive – and treating it with drugs is shameful and possibly illegal. Even worse, state medical boards and federal narcotic authorities intimidate doctors from treating chronic pain effectively.
Perhaps bureaucrats feel frustrated by their failure to stem the illegal drug trade. Perhaps bureaucrats feel frightened by violent drug-dealing gangs. Perhaps they take out their frustrations on patients with chronic pain and the doctors who treat it – much safer targets. This is classical bullying − take out your frustrations on the little kids in the schoolyard, but give the biggest boys a wide berth.
Some people feel that if they hold “caring” beliefs and vote the “correct” way, it’s all they need to do to be “good” people – and then they can neglect their families, mistreat their employees, give little to charity, and show contempt for the elderly and the disabled. These people are wrong. What good are “caring” beliefs if they don’t lead to caring actions? Lack of compassion for people in pain is an odd trait for those who call themselves “caring” or “progressive.”
Some people profess compassion for “all the peoples of the Earth,” including criminals and terrorists – but not for those suffering from chronic pain, who apparently are not included among the peoples of the Earth.
During my years in medical oncology, I tried never to forget that the primary duty of a physician is to relieve pain. Not if it’s convenient. Not if it’s politically correct. Not if it won’t cause trouble. Not if some governmental cookbook approves. Not sometimes. Always.
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