Notes from the Office: Chronic Pain

A lot of patients I see deal with physical pain as well as mental anguish. 50% of patients with physical pain have co-morbid depression. Where physical pain ends and mental pain begins is a gray murky mess.  When doctors become frustrated with the lack of success in managing a patient’s pain, they often refer their patients to me. This is often on the  grounds their refractory pain must be ‘psychosomatic’. This makes patients even more depressed; not only is their pain no better, now it is being dismissed as ‘not real’. “Psychosomatic” is an emotionally charged word I do not use. It implies there is no ‘reality’ to their pain and it is somehow ‘all in their head’ – whatever the hell that means.

I educate my patients with pain conditions there is NO correlation between a person’s perceived level of pain and their physical findings.  Taking 100 people at random would reveal perhaps 10 of them will report having arthritis in their knees and it is painful. In the X-rays of the 90 ‘OK’ people, I would find a few cases of arthritis.  “But I don’t have any pain!” they would say. In the arthritic patients, several of them would have X-rays showing no overt abnormalities.  “But it hurts!”

An error patients make – and many doctors (who should know better) – is chronic pain just acute pain that has merely continued. The physiology and neurochemical components of chronic pain are quite different than those found in acute pain. The treatments of acute and chronic pain are very different. For example, ‘pain killers’ with opiate components (such as Vicodin or Oxycodone.) usually do nothing for chronic pain. In fact, these medications often make chronic pain condition worse.

As a shrink, my job is to manage the depression, anxiety, and insomnia these patients are likely to have. As a doctor, I always try to comfort. I listen to their sorrows and validate their suffering. Assuring them they are not nuts or ‘making it up’ is helpful. When I can, I prescribe Rx that helps mood disorders and chronic pain disorders too.  I try to get pain patients around Rage and ‘Victim’ mind sets.

At times all I can do is help people manage their pain, to make pain manageable, because the real ‘medicine’ lies in learning to free ourselves from the futile passion for a pain-free life.