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Half of a Buddhist Saying: “Pain is Inevitable”

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden Lundgren
December 18, 2019

In the early 1990s, another nurse and myself represented our agency at a meeting convened by another federal office interested in the quality of healthcare. There were north of a dozen people around the table, clinical and academic, representing both public and private sectors. The subject of the meeting was the undertreatment of pain. There were no disagreements. Everyone in that room believed that the use of opiates should be increased.

I myself had spent too many years witnessing physicians who were terrified of causing addiction prescribing paltry doses of Demerol (the opiate of choice at the time—thought to be less addictive than morphine) to patients who only briefly needed relief from post-surgical pain and those dying of cancer. For the former, the chance of addiction was extremely low. For the latter, addiction would be the least of their worries. When I transferred to a Coronary Care Unit, the switch was flipped. Standard procedure on admission was to administer IV morphine until chest pain ceased. The dreaded morphine was effective, and I never saw a case of addiction.

Now we find ourselves in a world where powerful synthetic opioids have been all too freely prescribed and have all too often resulted in addiction and death. Widespread opiate use is not a new thing. In Mesopotamia, poppies were cultivated for opium production in 3400 BCE. The ancient Greeks, Persians and Egyptians used opium for pain relief and as a sedative. Trade along the Silk Road in the 6th or 7th centuries CE brought opium into Asia.  By the 19th century, with full awareness of the dangers of addiction, Great Britain basically forced opium on the Chinese. At about the same time, America suffered its first full-out opiate epidemic.  Scientists had isolated morphine, the active narcotic in opium, early in the century. That drug, which by then could be administered by hypodermic injection, was widely used to ease the suffering of soldiers in the Civil War, resulting in nearly a half million addicted veterans. Late in the century, Bayer promoted heroin as a cough suppressant especially for children. By 1895, 1 in 200 Americans was addicted. The Harrison Narcotic Act of 1914 was the first federal attempt to regulate opiates. Many others followed…and here we are.

The typical statutory/regulatory response to addiction by prescription has been punitive, and less than nuanced. Moreover, it fails to recognize that the real problem is pain, not narcotics. Take away the narcotics, and the pain is still there. Then too, pain is not a single entity. The stubbed toe in the middle of the night is not a sprained ankle, nor a headache, nor a fracture, nor childbirth, nor a herniated disc. People differ widely in their responses to pain. Professional athletes accept aching bodies as a badge of honor. Women often discount the pain of labor and delivery at the baby’s first cry. The pain of a healing wound is easier to bear knowing that it will be temporary. I had one exceptionally devout patient who welcomed the pain of cancer as a redemptive experience. Then too, there are factors that exacerbate pain for everyone: fear, anxiety, fatigue, even the time of day. Pain is almost universally experienced as worse at night.

The first lesson of pain is this. Pay attention. Pain is a signal that something is amiss and is often a roadmap to both diagnosis and therapy. But outside of that use, it is usually an experience to be avoided or managed. The issue is how to help both patients and practitioners treat pain better and avoid the potential harms of that treatment. Regulation now is largely directed at limiting physicians’ ability to prescribe (e.g., limiting the numbers of pills).  One outcome of this one-size-fits-all approach is that patients who need long-term opioid treatment do not get it while patients do not receive prescriptions anyway. What is clear is that physicians today are no better at managing pain than the doctors I worked with and their unjustified love of Demerol. The prescription-based opioid epidemic is evidence for this. We see more evidence in the fact that the number one reason people go to complementary and alternative medicine (CAM) practitioners is for pain relief.

Regulatory intervention can improve physicians’ ability to manage pain. State Boards of Medicine can require successful completion of rigorous pain treatment education programs (including non-pharmaceutical means of pain management) both for licensure and re-licensure. Physicians should also be made aware of evidence-based CAM pain therapies. Access to these therapies can be increased by requiring insurers to pay for them. When insurance pays for a physician’s office visit and pharmaceuticals but not for CAM, patients are forced into situations where the most likely intervention will be drugs.

There is room here for public education too. We all have to learn the first lesson of pain. We would like to just take a pill and be done with it. But pain is telling us to slow down, to investigate, to take a time-out, to pay attention. The second half of the Buddhist saying? “Suffering Is optional.”

Author: Burden S Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care.  After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA.  She has served as a consultant to a number of non-profit groups.  Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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