Drug History Canada

Musings on the history of drugs in Canada.

Month: January, 2017

Pain and perception

So today in response to an interview I had on CBC and some tweeting that was going around some mysterious person stated “The human body is not meant to be pain free.”  I refuse to engage in troll-y debates, so I figured I’d do what I promised yesterday and begin to dig into some of the stories I have learned since the op ed on pain was released last week.

But first a reflection on language.  You often hear the phrase “meant to be” as in “the human body was not meant to be pain free” or “their love was meant to be.”  It might just be a convenient cliche, but when you talk about something that was “meant to be,” you are implying intention and conscious action by some outside force.  So if someone says “that little boy didn’t mean to hit his friend” or “I meant to take my Christmas tree down yesterday” we are talking about an act of intention.  So to say something was “meant to be” is to say that there is a predetermined outcome, or a predeterminer. In other words, you’re saying God meant this.

The human body was not meant to be pain free is an asinine statement that suggests your god wants you to be in pain.  Now, I’m no religious scholar, but even in religion pain is something to be avoided. Job wasn’t exactly thrilled that he was plagued with injury; Jesus wasn’t singing show tunes hanging from the cross.  The very process of The Crucifixion was in itself an act of pain and degradation, and it is framed in Christianity as the process by which humanity is saved by Jesus taking on the punishment that deeply flawed humans are supposed to have suffered.  He “suffered for us.” It’s a fundamental of Christianity, and so pain avoidance is not a problem.

But perhaps this person is really just saying it is unnatural to be pain free. Fair enough, but pain is not a desired nor a normal state.  Pain is an indicator that there is something wrong.  We have evolved to avoid pain. If we didn’t, we would not have likely evolved, since our ancestors would have kept doing things that caused pain and possibly not procreated, and kept the race going.

Pain is, however, natural.  It is that thing in our brains that says “don’t do that.”  So if one were to say “the human body was not meant not be unable to feel pain” or “it is not natural not to feel pain” I’d be in agreement.  But to suggest that feeling pain is a natural state is just silly .

That aside, usually such statements are made by people who are not in chronic pain, have not faced the debilitating blinding pain of people like my friend Lisa I mention in the op ed, and have a “suck it up” attitude based more on a sense of superiority over weak people, rather than any kind of sophisticated appreciation of the dimensions of pain.

The problem is: our health and the integrity of us as physical beings is more than just about living in fleshy machine that gets our brain through life. It is fundamental to our being.  This is why the field of medical ethics and bioethics is so important. Unlike work on a car, or on your house (both of which have different levels of emotional involvement) work on your body affects fundamentally your sense of self.

I invite such people who shrug off stories of pain to get heart surgery without anaesthetic. Or, less vindictively, I will reproduce some of the stories I’ve received about pain.

Let’s get the less challenging stuff out of the way first. One correspondent thanked me for my “supremely intelligent essay on pain – a problem I share with a great deal of life-destroying intensity.”  Life destroying intensity relates to that sense of self, and the reality that quality of life is filtered through our experience with a body in pain.

Something more heartwrenching came in a few minutes later

Normally I am up @6:00 a.m. But today slept in until 8:30 because of a brutal pain attack which 2 naproxen, 2 tfa, ointment, heat, cold did not alleviate.

My output today will be well below normal but I will find my way to my Chinese doctor for a foot massage.  I will be 80 next Friday but still active… and have endured pain for nearly three decades. My Doctor who doesn’t do pain didn’t prescribe Naproxen until I brought it to her attention five years ago.

As I lay sleepless last nite, some times screaming out (some distance from my wife so I wouldn’t bother) I wondered why can’t I get opioids to ease the pain?

So thank you for your help.

This was a difficult one, a personal story of endurance and the persistence of pain. Screaming out in pain at night, avoiding close contact with his wife so he wouldn’t disturb her, and a gap in medical knowledge.  A doctor who “doesn’t do pain” is a startling concept.  .

The final one will be difficult to anonymize, but I will try.  It is about an individual’s family member. I use the acronym AB for this person.

Fifteen years ago AB was given benzoes and high dose painkillers (Percocet)  for CFS [chronic fatigue syndrome], fibromyalgia and anxiety disorder. AB has lost [his/her job] and is on long term disability.

Recently the B.C. College of Physicians and Surgeons, in a very crude and sledgehammer approach , dictated that no Dr.s shall prescribe OxyContin, something AB was switched to from Percocet. So AB has had to try and go cold turkey. Even finding a Dr. at one of the walk in… clinics is next to impossible. Most have signs stating unequivocally only one problem per patient! Ten minutes at most for any medical advice. How AB will end up is a constant worry for us – and more so for AB.

Pain is pain and cannot be just ignored because of a dictate by the esteemed medical community. The edict by the College ignores thousands of people suffering from real, life changing pain.

There are several elements of this story that reappear elsewhere. Problems with understanding of pain management, access to consistent medical treatment, sweeping directives that leave many people in an untenable position.  I should note that the BC College “edict” is explained by the college as guidelines, although it has some rather punitive fines for doctors who run afoul of the system.

Pain is something we try to avoid. Pain that is persistent is distracting at the least, debilitating at the worst.  You may be able to limp along on a strained ankle, but if there is no way to ease that pain, if you can’t sleep because of it, if your relationships are strained, your work is lost or diminished, your opportunity for advancement curtailed, it is more than an inconvenience.  Pain is a fundamental feature of our life; it is what helps keep us safe, and avoiding it is something we all try to do (even sadomasochists have safe words). But when we can’t avoid it, when the control over the fundamental integrity of our body, the one thing we truly possess is lost, it can strike to the core of our being.

So don’t tell me pain free is an unnatural state.  Having no empathy for people in chronic pain is unnatural.

But before I click “publish” I want to make something clear. My discussion of pain is not intended to justify pain medication.  There are many ways to address pain that do not involve pain medication. However, medication can be part of a pain strategy.  and some types of pain need certain types of medication. Long-term therapy helps, but we should not reject the need for a pharmaceutical intervention due to stigmas of addiction or dependence or at just some kind of ideological rejection of the pharmacomedical industrial complex. Pain management, just like the issues of addiction, is a complex process requiring thoughtful consideration of multiple factors.

 

Fentanyl crisis and historical perspectives

Over the past month or so I’ve been mulling over the current opioid crisis and what it means, and of course what history can tell us about it.  It culminated in an op ed in the Globe and Mail entitled “Why is everyone talking about painkillers, but not about pain?” I felt that this article in its 700 word format was a decent introduction to the complexity of the current opioid crisis, but of course there is so much to say.

Having written op eds before, on cannabis legalization and liquor control, I don’t think I was prepared for the type of attention this article received.  I guess it was the timeliness and the national scope, but also the emergent nature of the crisis. I will in the next few days try to capture some of the response without betraying any confidences. Suffice it to say when dealing with pain and medical treatment, people have a lot of stories to tell, and they need to tell them.  As the recipient of these stories, I’ve been humbled and saddened but also enlightened. Moreover, it has reinforced my resolve that the current painkiller crisis has much deeper roots and needs more concerted efforts to address its origins.