Editor’s Note: This is the second of a two part series on the stigma of chronic pain. This installment features the stigma of being a pain physician. The first installment, written by Terri Lewis, PhD look at the stigma from the patient point of view. We invite your comments.
Stigmatization is alive and well in the world of chronic pain. In fact, the motto of the Pain Action Alliance to Implement a National Strategy (PAINS) is to “de-stigmatize the stigmatized. The reasons for stigmatizing the person with chronic pain are way too simple. They have a problem which defies all treatments and reasonable “objective” explanations. In so-doing, they are a thorn in the side of medical theory. Rather than accept that the square peg the patient presents does not fit into the round hole of our theory and re-working our theories, we blame the patient for their problem and abandon them. If you have a problem you can’t handle, what better way than to be rid of it than to ignore it or sweep it under the rug.
Unfortunately, the problem is still there, festering.
Those who suffer from pain are fully aware of what I just said. That is not what I was asked to write about, though. I was asked to write about the stigmatized pain management specialist, something that is becoming an out-sourced, dying breed. In thinking about this, I am reminded of an old joke I heard in college:
Q: How many pre-meds does it take to screw in a lightbulb?
A: Two. One to screw it in and the other to kick the chair out from under the first pre-med’s feet.
For our discussion, I would replace pre-med with “people” and the answer with 19; that being one becoming a pain management doctor and the other 18 various entities in our society which are more than willing to take him or her down.
Very early in my physical medicine and rehabilitation training, in 1986, I was confronted with a patient with chronic back pain. He’d been surgically mutilated 5x, and the surgeon responsible for the 5th “wanted my expertise.” In reality he just wanted to get rid of the medical “hot potato,” one way too hot for him to want to hold. When I first met the patient, the surgeon welcomed me with open arms and thanked me for my service to humanity and all sorts of other things. The patient was in absolute misery. What the surgeon neglected to tell me was that when they placed the pedicle screw, they put it right through the nerve root. I found this out later from someone who preferred to remain anonymous. It was not the patient that was “screwed up.” In 1986 it was definitely not cool to prescribe opiates. My mentors told me not to do it. However, Kathy Foley and Russell Portenoy were just starting to challenge that paradigm, first for end of life care, then for chronic pain. I read their article published in 1985. I had nothing else to offer this man. His spine was a mess. His nerve was destroyed. So I defied the sages and started him on opiates.
Two things happened. First, the patient got better functionally. Second, the surgeon and his entourage returned to chastise me for addicting him to pain medication. I recall informing them that they had turned the patient’s care over to me. Obviously they had not done such a great job, so I thought other directions were in order.
Nothing in life is ever that simple. I saw this man as someone who’s life was in jeopardy and cost/benefit assessment demanded extraordinary steps. So I did something which I believed to be extraordinary. Short term success is not always maintained in the long term. As Dr. Portenoy has said, there is a sub-set of patients who can do well with long-term opiates management and there are others who can’t. Vigilance by all is necessary in making this determination, and not a little bit of courage.
Unfortunately, this scenario plays itself out every day in the world of pain management in so many different ways and for several reasons, and not just related to opiate management. While many are thrilled someone would be willing to care for these medical pariah’s, they or others in our culture are more than willing to criticize or, much worse, punish the doc when he or she fails to follow societal expectations or the pre-conceived notions of those who choose to criticize.
Why does this happen? For four basic reasons:
- There is no universal understanding of chronic pain.
- There is no universal solution to the problem ; in fact, there is no solution
- There is no universal definition of what chronic pain management actually is.
- A Physician is judged how well his judgment follows the evidence base. What happens if there is no reliable evidence base? What happens if a problem is so complex that that it defies study? Who defines what the reliable evidence base actually is.
I explore these issues in detail in my book: Needless Suffering; How Society Fails Those with Chronic Pain (University Press of New England, 2016).
I would like to close with an illustrative vignette. A few months ago, I had a conversation about the opiate abuse epidemic with a local sherriff. The big problem in our state is heroin. I am scratching my head trying to remember the last time I prescribed heroin, and I just can’t seem to remember ever doing it. Still, he blamed all those bad pain docs and the pain patients. He told me that it is too bad they couldn’t just suck it up and deal with like they did in the old days. He seemed oblivious to the fact that patients have been using opioids, cannabinoids, alcohol, and other things for millennium, totally un-regulated until the past 150 years, often under their own supervision because they were unable to receive care. John F. Kennedy used Demerol and Valium to control his pain while president. The attitude of this sheriff, which was based on his pre-conceived notions, is rampant in our society. Unfortunately, many with this attitude occupy a position in which they can control the behavior of others. Somewhat fortuitously, the next day a police officer arrived in my office suffering from severe pain due to a herniated disc. He was unable to receive any medication to allay his suffering. He told me: “I will never again question anyone’s pain.” In retrospect, I wish I had given him the name of the sheriff and suggested he have a conversation with him.
The true morbidity and mortality from chronic pain, whether treated or not, are not known, but staggering and dwarf that due to prescription drug abuse. Public policy must be balanced and respect the problems created by both. However, stigmatizing those who suffer and those who minister to them is counter-productive and must be stopped. It is exciting that the National Pain Strategy (NPS) addresses many of these issues. I pray for its success.