Understanding Chronic Pain

Summing Up

[From Chapter 18 of Understanding Chronic Pain]

I have attended many patients with chronic pain, most of whom have been sick for many months and often many years. They have defied conventional, and often unconventional, treatments. What is their recovery rate? It's over 50 percent, a lot better than it was just a few years ago. Even at best, however, recovery is incomplete. Ongoing drug therapy is necessary, just as it is necessary in diabetes and hypertension. Nonetheless, amelioration of pain sufficient for a life of relative comfort can be achieved.

Why do patients get better? It is the drugs. Without question, it is the drugs. If they are so good, why don't more people recover? The reasons are three. They are the comorbidities of opiate dependency, the devastation imposed by childhood abuse, and—perhaps most importantly—our societal and medical attitudes toward the disease, chronic pain. In painfulness, as in no other illness, the effort to recover is balanced unfavorably by the effort to achieve other satisfactions.

This is the conundrum of opiate therapy. Compassionate in usage, it nevertheless destroys those brain mechanisms which could sponsor recovery. With opiate therapy, the brain's analgesic systems wither and atrophy. Opiates deprive the patient not only of the psychologic resources for recovery, but also the physiologic resources.

We do a poor job of treating painfulness and the comorbidity of opiate dependency because we often employ blame as a treatment strategy. "If you will just stop taking those pills, your headache will get better." We blame the patient, and that is not a very useful modality in the treatment of substance abuse. We used to blame the alcoholic for his disease. It was only when we discarded the idea that alcoholism was due to characterologic weakness that we achieved any hope of meaningful recovery.

The role of childhood abuse in the creation of the painful state must once again be addressed. The incidence of that experience in those who suffer chronic pain is staggeringly high. The occurrence of painfulness as a product of abuse, particularly sexual abuse, could almost certainly be diminished by early recognition, intervention, and care, but the event is usually entered into denial, there to kindle into chronic pain. I am inexpert in the modes of counseling and psychiatric care of the sexually abused, but I will offer a judgment. Treatments are directed to removing the patient from guilt and shame. This is a laudable and worthy aspiration, just as it is in the treatment of substance abuse. Nonetheless, I often see women who have completed their counseling, come to grips with their experience, and addressed their perpetrator with purpose, finality, and a sense of worth. Guilt is removed, but the pain goes on.

We will not cure the painfulness of substance dependency or childhood abuse without restructuring our treatment protocols. Nor will we cure more than 50 percent of patients with chronic pain without restructuring our societal attitudes toward their disease.

An astonishing fact. At least a third of my patients with chronic pain have had to retain an attorney to seek redress for grievances and even to obtain, under Workers' Compensation, proper medical care. They bring suits against insurance companies, employers, and not infrequently, physicians. They require legal aid in obtaining disability and Social Security benefits. What would be the treatment outcomes in congestive heart failure or diabetes if a third of those patients were in litigation because of their disease?

You can read the rest in Dr. Cochran's book, Understanding Chronic Pain

Last Updated: 248 days ago

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