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The Contradictions of Pain Therapy

Saturday, December 1, 2012

Several years ago I asked a leader in the Maryland pain community what percentage of Marylanders had enough chronic pain to deserve medical therapy. He replied matter-of-factly, “One hundred percent.” I thought he was joking, but he quickly explained to me that everyone has chronic pain at some point, meaning pain lasting for more than three months. Because medical therapy is available, such pain is needless, he argued; therefore all Marylanders were candidates for chronic pain therapy.

Although extreme, his position exemplifies the new and aggressive stance toward chronic pain in the country at large. The medical profession now estimates that 116 million Americans suffer from chronic pain and merit some kind of treatment — more than a third of the entire population. This number doesn’t even include sufferers of acute pain, or children. Already eight million Americans use drugs to manage this pain, representing a tenfold increase in the last fifteen years. Pain that a generation ago would have been overlooked as a natural part of everyday life now has the attention of physicians, leading to an enormous increase in both narcotic and nonnarcotic prescriptions, with narcotics now representing the most widely prescribed class of medications in the U.S. Indeed, $600 billion is spent annually on the chronic pain problem.

All surgical patients hate pain, but even as late as the 1970s, anesthesiologists typically ignored mild to moderate postoperative pain.

As an anesthesiologist, I have observed a corresponding change in popular attitudes toward acute pain. All surgical patients hate pain, yet even as late as the 1970s, anesthesiologists typically ignored mild to moderate postoperative pain, not out of cruelty but because they were unconscious of the complaint. Had the public pressured anesthesiologists to change their ways, they might have done so. But the public did not. Some anesthesiologists saw postoperative pain as a useful respiratory stimulant to counteract the depressant effects of their anesthetic. Others worried (wrongly) that aggressively treating pain in the recovery room might lead to drug addiction. But most of the indifference toward pain was convention, among both doctors and patients, and the weight of a reigning convention is like the weight of the atmosphere — it is so universal that no one feels it. Today, such indifference would be considered poor practice if not malpractice.

Pediatric anesthesia exhibits the clearest trend. As late as the mid-1980s, anesthesiologists rarely anesthetized infants for surgery, in part because they worried about the effect of potent anesthetics on sick babies, but mostly because they assumed infants didn’t feel pain, a concept that grew out of 1940s research that showed newborns failed to pull their limbs away when pricked with a pin. Anesthesiologists simply paralyzed infants with muscle relaxants to keep them from moving while the surgeon cut. During my training in the mid-1980s, some of my professors would jam breathing tubes into awake and struggling infants, then, during surgery, administer a little nitrous oxide, a weak anesthetic. They were almost humane for their times. Today, this practice seems barbaric. Although the infant’s pain experience remains a mystery, since infants can’t talk, the empathic sensibilities of both anesthesiologists and laypeople have been so aroused that letting a surgeon operate on an awake infant today would be inconceivable.

Obstetrical anesthesia reveals the same trend. As late as the 1970s, many anesthesiologists and patients saw epidurals for pain relief during labor as a luxury. Although the labor epidural technique was established in 1942, and the equipment for continuous labor epidurals came into being in 1949, even as late as 1961 prominent anesthesiologists assumed the old, substandard method of pain relief during labor, including narcotics and nitrous oxide, would suffice for most women, and that only ten to twenty percent of laboring women would need epidurals. Today, American women expect epidurals. Sixty to 70 percent of American women get them; the rate approaches 90 percent in some hospitals. Most anesthesiologists share in the new attitude. Indeed, I have often placed epidural catheters in women before their contractions have even started, in preparation for dosing the catheters at a later time, simply because the women wanted to be “ready” for the onslaught, which seemed reasonable to me.

Our culture’s heightened sensitivity toward acute pain is so profound as to confound medical practice. In the past, emergency room patients presenting with abdominal pain had to first be evaluated before being treated with narcotics, out of concern that narcotics would mask the pain symptom needed to make the diagnosis — for example, in appendicitis. Today, patients in pain often demand narcotics immediately, and regulations compel emergency room staff to prescribe them, sometimes interfering with the surgeon’s exam.

Our culture’s sensitivity toward acute pain is so profound as to confound medical practice.

Occasionally the heightened awareness of acute pain crosses over into the ridiculous. I once had a patient whom I had to stick several times to secure an iv — an uncommon event but not an extraordinary one. After surgery the patient asked me if there was a “support group” for people with a history of difficult iv sticks that she might join. I told her I didn’t know of any. Upon discharge, she kept calling me, asking me for the name of a support group. In the end I referred her to mental health services.

Although the management of both acute and chronic pain has changed significantly over the past few decades, the public focus has largely been on chronic pain. Treating acute surgical pain with narcotics, for example, does not lead to addiction. Nor does it strain state and federal budgets. Chronic pain is the problem, and on several fronts.

First, the mass treatment of chronic pain is expensive. Yet not treating chronic pain incurs its own expense. The $600 billion figure quoted above includes the medical costs of pain therapy but also the economic costs related to disability days, such as lost wages and productivity. The lost productivity is significant. An estimated 42 million American adults report that pain disrupts their sleep at least a few nights a week. In one study, thirteen percent of workers lost productive time in a two-week period due to pain.

Second, some doctors hesitate to treat chronic pain because they fear inciting drug addiction or other medical problems, resulting in the loss of their medical licenses. Both public opinion and government encourage doctors to treat chronic pain; at the same time, government zealously scrutinizes physician prescription habits, and stands ready to prosecute doctors who are outliers, even those doctors who prescribe in good faith. In Suffolk County, New York, for example, a grand jury recently blamed doctors for the epidemic of prescription-drug addiction over the past decade. Some physicians have abandoned their pain practices for this reason.

Third, many chronic pain patients feel a stigma attached to their therapy. They fear some quarters of society view them as a bunch of drug fiends. They particularly resent being grouped with patients who take psychoactive drugs for everyday unhappiness. Masking unhappiness with psychoactive drugs risks leaving a person mired in bad life circumstances that need to be changed; in such cases, unhappiness needs to be felt. But what possible value can there be in pain? Why should pain be felt, ask chronic pain sufferers? The ensuing wall of silence infuriates these patients, and not only against their public critics, but also against doctors and government bureaucrats who seem resistant to doling out medical therapy.

At the same time, government authorities do have a legitimate interest in how chronic pain is being treated. Drug diversion, in which opiates prescribed for a chronic pain patient end up in the hands of someone else, often for nonmedical use, has steadily increased over the past twenty years. In addition, deaths resulting from accidental overdose of opiates have tripled among chronic pain patients since 1999.

The mass treatment of chronic pain is beset by doubts, recriminations, and resentment, but the word that best captures the treatment climate is confusion. Neither doctors nor patients nor government officials know where they stand. On the pain issue, each distrusts the other; indeed, each almost dislikes the other. To resolve this confusion, the first order of business must be to explain its origins, beginning with a recognition that trends in acute and chronic pain are of a piece. Indeed, although not a public policy concern in its own right, the acute pain experience sheds considerable light on the chronic pain problem.

Measuring pain

Whenever i roll a patient into the recovery room after surgery, the receiving nurse asks the patient, “Do you have any pain?” If the patient answers in the affirmative, the nurse follows up by asking the patient to estimate his or her pain, on a scale of one to ten, with ten being “the worst pain of your life.” The nurse does this to establish the patient’s pain score. If the number is high, I will invariably prescribe a pain medication, typically a narcotic.

The pain score has become an essential feature of pain management, both in acute and chronic pain, so much so that it has been called the Fifth Vital Sign (after blood pressure, pulse, respirations, and temperature). The Joint Commission on Accreditation of Healthcare Organizations (jcaho) now requires doctors and nurses to ask patients to estimate their pain, whether in the form of a number, a verbal description, or a visual diagram (for example, on a scale ranging from a happy face, meaning no pain, to a frowning face, meaning a lot of pain). The estimate serves as a measure of patient discomfort to help guide therapy.

At first glance, the pain score seems no different from any other medical measurement, such as blood sugar or hemoglobin. But it is different. Although often expressed as an objective number, the pain score is completely subjective. It captures how a patient feels, irrespective of whether that feeling is justified. Indeed, most of the pain assessment scales used in medicine today evolved from rating scales used in the 1950s in social science, public opinion polls, and marketing research. Unlike other measurements in medicine, the provenance of the pain score is decidedly nonscientific.

Why does a complaint of pain, unlike of breathlessness or muscle weakness, cause logic to suddenly leave the room?

When a patient declares a high pain score in the recovery room, many doctors and nurses react so strongly that it’s as if they had unlearned to think. It is an amazing spectacle. A patient emerges from anesthesia, he or she expresses a myriad of different feelings, and recovery room staff carefully scrutinize these feelings when making clinical decisions — for example, when weighing complaints of breathlessness against oxygen measurements that show normal lung status, or when weighing complaints of muscle weakness against nerve stimulators that show normal muscle strength. But when the patient complains of pain, all discernment suddenly disappears.

I am as guilty as the next physician. A postoperative patient appears comfortable, his vital signs are stable, his facial expression suggests boredom — but when the nurse asks him to estimate his pain, he says it’s a “ten.” The nurse calls me to evaluate the patient. “Are you sure your pain is the worst you’ve ever experienced?” I ask, somewhat doubtful. With calm countenance he replies that it is. And in his mind, at that moment, in these circumstances, it does seem to him like the worst pain he’s ever experienced, even though it’s probably not. Invariably I treat him with a narcotic. If the patient says his pain is the worst pain of his life, then it’s the worst pain of his life — and I am compelled to treat it.

Sometimes a postoperative patient complains of pain that’s a “ten” — before nodding off to sleep. The nurse hesitates to treat, since the complaint doesn’t make sense. At such moments my faculty for discernment kicks in, and I hold off on therapy. But other doctors will prescribe a small dose of narcotic in such situations, just to cover themselves, in case the patient later complains that his or her pain wasn’t attended to.

Why does a complaint of pain, unlike a complaint of breathlessness or muscle weakness, cause logic to suddenly leave the room? Because when a patient complains of pain, it is no longer the patient speaking, it is his or her pain speaking, and when pain speaks today, it speaks authoritatively. Doctors and nurses today have great respect for pain — perhaps somewhat too much. They fear getting into trouble if they respond too slowly to the complaint. Both jcaho and federal law command doctors to treat pain aggressively. The courts now recognize pain, standing alone and without any other physical injury, as a legitimate basis for a lawsuit. State medical boards increasingly reprimand doctors who neglect people’s pain. More than once I’ve cut my fingers rushing to crack open a glass ampule of morphine in the effort to spare a patient an extra 30 seconds of pain.

Pain has attained ideological status in American culture, making it similar to breast cancer and hiv — other medical problems with political overtones. Activists speak of a “right to pain relief.” Doctors who hesitate to treat pain sit next to bankers and oil company executives in the culture’s pantheon of evildoers. Doctors have the same responsibility to treat pain as they do breast cancer or aids, but unlike the latter two, they have no authority to diagnose the problem, or to say whether or not the problem even exists in a particular patient. It’s an untenable position.

To bridge the gap between themselves and their patients, doctors have spent more than two decades in search of a measure that will let them objectively measure a patient’s subjective experience of pain, thereby returning authority to them to sit alongside their responsibility. In the chronic pain field this dream measure is commonly referred to as the Holy Grail. It has never been found. That doctors dream of finding it is telling. Until then, and so long as pain remains a subjective experience, doctors will continue to view some chronic pain complaints with a tincture of distrust.

The “science” of pain

All anesthesiologists learn the concept of mac (Minimum Alveolar Concentration), which is the fundamental concept in anesthesia science. mac is the concentration of anesthetic gas needed to keep 50 percent of patients motionless while being cut on. However, mac has no direct correlation with pain. At multiple levels of mac anesthesiologists cannot really say for sure what a patient feels; all they can say is whether or not a patient moves in response to a noxious stimulus. Indeed, one of the concept’s founders joked that mac had been around long before he had discovered it, writing, “Every time I give anesthesia and the patient moves, the surgeon says, ‘Hey, mac!’”

One would expect anesthesiology to have a rigorous scientific explanation for pain, but it doesn’t. Its most fundamental concept is crude. Indeed, today’s scientific explanations for pain hardly differ qualitatively from observations about pain made by scientists several centuries ago. Writing of a division between body and mind, Descartes concluded that pain is a “hard-wired,” sensory experience: A noxious stimulus sends signals from the periphery to the brain, where pain is experienced; there is no mental, or psychological, contribution to the pain experience, he argued. This “hard-wired” approach to pain remains a basic concept in pain science to this day, in the sense that a noxious stimulus is presumed to send a signal through specialized nerve fibers to the spinal cord and on to the brain.

The major difference between Descartes and today’s physicians is that today’s physicians officially recognize the role of thoughts and emotions in modulating the pain experience. I say “officially” because some 19th-century doctors also recognized psychology’s influence on pain, but their theories lost influence towards the end of the 1800s, and did not regain strength (and eventual ascendancy) until the mid-1960s.

This short detour away from psychology sowed the seeds of even more distrust between doctors and patients. While doctors sometimes distrust their patients because pain has become a completely subjective experience, patients sometimes distrust their doctors because they vaguely recall a period spanning well into the 1960s when the subjective aspect of pain was ignored altogether, causing countless patients to suffer.

Anesthesiology doesn’t have a rigorous scientific explanation for pain. Its most fundamental concept is crude.

To some degree, 19th-century doctors who ushered in this short-lived era were victims of a setup. Unlike other psychological experiences, pain typically has a connection with the body; therefore, unlike unhappiness or anxiety, it seemed reasonable for the medical profession to absorb the pain problem. Indeed, the 19th-century tripartite division between acute pain, nonmalignant chronic pain, and pain resulting from terminal illness remains the general schema for organizing pain today. But the physical and the psychological in pain are inextricably intertwined; moreover, some recognized pain syndromes are associated with no obvious tissue pathology. For example, pain associated with dysfunctional sympathetic nervous system activity is real pain, as opposed to hysteria. Nevertheless, it lacks an obvious lesion. Thus, some pain experiences — those associated with visible lesions — conformed to the new physical, mechanistic approach to disease better than others, and there was no definite line dividing one from the other.

Organized medicine had to draw a line somewhere, to separate what doctors wanted to acknowledge as “true” pain, but it could nowhere divide completely “true” pain from completely “false” pain, since the physical basis for pain was smeared over a continuum stretching from the visible to the invisible while pain’s psychological basis penetrated at odd points. The entire pain spectrum was (and remains) like a shade between white and black, and no matter where the line might be drawn it was impossible to get pure white. Still, organized medicine drew that line, consistent with the scientific approach of the day, and did it as well as it could.

In drawing this line, organized medicine made two grave errors. First, to reject more emphatically the pain it did not accept as legitimate, and to give more weight to the pain it did accept, organized medicine put one general seal of infallibility on all that it approved. The notion that pain comes from a visible lesion and nothing more was taught in the nation’s medical schools. By this, organized medicine harmed all that it accepted, for having accepted the white, the less white, and the gray — that is, the more or less pure teaching — and having stamped it with a seal of infallibility, it deprived itself of the right to explore, innovate, and elucidate on “true” pain, hobbling medical research for many decades.

Second, as a growing body of evidence showed that “true” pain could exist without a visible lesion, and that psychology affected pain, the line that doctors drew fell under siege. Having acknowledged the necessity of a visible lesion in pain, doctors had to justify everything, shut their eyes, hide, fall into contradictions, and, alas, often say what was not true when confronted with countervailing evidence. By the 1920s, the division between “organic” pain (pain associated with a tissue lesion) and “functional” pain (pain that is “all in the head,” and taken less seriously) had become canonical. Chronic pain sufferers without obvious lesions were considered deluded, or, worse, malingerers and potential drug abusers. The medical profession ignored them to preserve the integrity of their line.

When that line collapsed in the 1960s, the previous attitude, in retrospect, seemed scandalous. The situation was not unlike what arose after the civil rights movement, when all that had been taken for granted for over a century was seen with new eyes. Doctors felt guilty. Chronic pain patients were angry, and henceforth sensitive to any whiff of doctors dismissing their troubles. The distrust that chronic pain patients feel towards the medical profession continues to this day.

The pain trap

Several years ago, I happened to be in the same room as an anesthesiologist was speaking on the phone with a dea official. The anesthesiologist had called the agency to ask an innocent question about his license renewal. All of a sudden, the anesthesiologist froze and even seemed to cower, then stood up with a jerk and darted off. He had entered a trap: The official on the other end of the line had demanded that he read some numbers off his license, even though he (the anesthesiologist) had been the one to initiate contact. If he couldn’t produce his license, which, according to the official, should always be on his person or within view at work, there would be “trouble,” the official warned; they might even come for him. The anesthesiologist ran to his office and retrieved the necessary document (it was in his briefcase), then returned and spoke the numbers with a quiver, thereby saving himself.

In the chronic pain world doctors and patients sometimes suspect each other, but so also do doctors and government officials, as the two groups have different goals and often work at cross purposes. Doctors want to treat pain (although, as noted above, what pain is can be hard to say), while some government officials want to clamp down on the illicit use of pain drugs (although other government officials work to implement the activist agenda on pain treatment). The result is often confusion and suspicion, if not acute dislike. Many doctors consider government officials fools, bureaucrats, and petty tyrants who issue orders without once considering their viability in practice, while some officials look at doctors who aggressively prescribe opiates for chronic pain as if there were something of the underground about them, something illegal, that called for tighter surveillance.

Doctors had been suspicious of pain when unaccompanied by a lesion, and even more grudging about treating it.

This mutual distrust arose, in part, from the anomalous method by which doctors gained control over opiates. Unlike most 20th-century prescription medications, which were created in tandem with the medical profession and to fight a particular disease, opiates had been around long before American physicians took over their sanctioned distribution; moreover, control was awarded not because of the biological problem of disease but because of the social problem of addiction. Laudanum, a mixture of opium and sherry, was created in 1680. Morphine was invented in Germany in the 1820s, and introduced in the U.S. a decade later. In 1898, heroin was introduced as a cough remedy. Throughout much of the 19th century, opiates were sold over the counter in the form of liquids, pills, and headache powders, leading to a serious addiction problem. By 1900, one in every 200 Americans was addicted to opium or cocaine.

In response, the 1914 Harrison Act severely restricted opiate distribution in the U.S., while allowing doctors to dispense the drug in the course of their professional practice — but not to addicts, since addiction in those days was considered to be a social malady and not a disease. Indeed, several doctors who prescribed opiates to addicts were thrown in jail. An expansion of federal police powers followed in 1970, with the passage of the Controlled Substances Act.

Although the government’s purpose in awarding doctors control over opiate distribution was to manage a social problem and not to fight disease, it was in sync with how doctors of the period viewed pain. As noted above, doctors had been suspicious of pain unaccompanied by a lesion, and even more grudging about treating such pain. Sexism also crept into the doctors’ calculations, as a majority of addicts were women self-treating for pain associated with women’s “problems,” which, like pain without a visible lesion, were taken less seriously. When government awarded doctors control over opiates to restrict their use, doctors, for their own reasons, eagerly complied.

The alliance broke up in the 1960s when pain became a subjective experience. Public opinion demanded that doctors aggressively treat chronic pain, while some activist government officials agreed. But those government officials in agencies charged with controlling the addiction problem, such as the dea, remained true to their purpose. As a result, doctors found themselves caught up in a dangerous, potentially career-threatening trap: On the one hand, they had to aggressively treat pain (which the patient, and not the doctor, now defined), or risk their licenses; on the other hand, they had to be careful about dispensing opiates to treat that pain, or risk their licenses.

Indeed, the line that doctors treating chronic pain must walk is a truly narrow one, since “addictive behavior” (which is not the same as addiction) can be an unavoidable trade-off when treating chronic pain. In some cases the treating physician must ask himself or herself, “What is a reasonable degree of addictive behavior in this patient, allowing the patient enough pain relief to function, but not so much that the addiction itself leads to problems?” A narrow gulf can exist between adequate pain relief and addictive behavior.

These nuances are often lost at the level of government, creating tension between doctors and officials. An example of this tension surfaced in 2011, when the fda wrote preliminary guidelines for doctors prescribing opiates for chronic pain that focused mostly on the risks of abuse and illegal drug trafficking. The American Pain Society complained, noting that the agency had ignored the salutary benefits of opiate use in chronic pain, as if chronic pain medicine had few redeeming qualities and barely sat on the right side of the law.

The average chronic pain doctor can pretend to be in sync with government officials all he wants, he can make it appear that he shares their ideas fully, but even if he learns to speak to their language, he knows they will never trust him completely. If his patients sell their pain drugs illegally, he risks guilt by association. If rumors reach government officials that he is outside the norm in his opiate prescription patterns, even for legitimate reasons, federal agents can (and likely will) crash his office and scrutinize his files. Some government regulations command him to treat pain, while other regulations tell him to watch out. The doctor feels cribbed, cabined, and confined; he feels as if he were in a vicious circle where the quest for a plain and simple answer about how to practice is hopeless. The regulations reproach him, they put awkward questions to him, they try to hurt him, they ask him riddles and leave him without an answer.

The typical pain doctor today treats his patients with the police sitting in the back of his mind. At the same time, he also observes that nothing bad has happened to him yet, in which case perhaps the regulations don’t matter a straw, and he should just take care of his patients as he thinks appropriate. The doctor concludes he is safe — “for the time being” and “up to a point” — until the moment he’s no longer safe, and his “time” has come.

Pain and culture

As an anesthesiologist, I can separate a patient’s rational consciousness from his individuality through intravenous drugs or regional blocks. During a regional block, for example, the patient can calmly hold a conversation with me while his anesthetized body part is being operated on. In other words, the patient’s individuality — that side of him that desires and lives for happiness — can be separated from his rational consciousness, which is not particularly inclined toward anything. When the block wears off, the two parts — rational consciousness and individuality — are suddenly thrust back together again, and the patient grows miserable with pain. The patient is miserable in part because of the physical experience of pain, but also because his mind, which had been at peace during the anesthetic, is suddenly plunged into a kind of civil war. When individuality and rational consciousness are forced back together, the patient’s individuality bids him to live and find happiness, while the patient’s rational consciousness tells him it is impossible to live and find happiness because he can’t escape his pain. The patient “feels” the partition in his mind that runs along the line of my anesthetic. He feels cut in half, so to speak; the contradiction is horrible, and rends his mind like torture.

Opiates do not rid a person of pain so much as they cause a person to become indifferent to his pain.

We experience a more general version of this tension in everyday life. Every person is composed of two elements: one, individuality, which desires happiness; the other, rational consciousness, which knows that lasting happiness is impossible. People desire happiness, they desire life, but life is filled with impediments to happiness, while whatever happiness people do attain all ends in one and the same thing — in sickness, death, and annihilation. A man asks: How am I to live? What am I to do? But there is no reply; it is the fundamental contradiction of life. Still, it is necessary to live. A man’s individuality bids him to live happily, his reason tells him it is impossible to live happily, and the man is painfully conscious that he has been parted in twain.

Since the dawn of civilization two methods have existed for managing this contradiction. I, as an anesthesiologist, rely on one of them whenever that contradiction manifests itself in pain. The two methods are clouding a person’s rational consciousness or clouding a person’s individuality.

Chemicals such as alcohol, laudanum, and opium cloud a person’s rational consciousness. I use more refined chemicals in the operating room to manage the specific problem of surgical pain, but the principle is the same: I cloud a person’s rational consciousness, sometimes to the point of unconsciousness, so that a person ceases to be aware of his futile search for happiness. Opiates, for example, don’t rid a person of pain so much as they cause the person to become indifferent to his pain. The person is vaguely aware of his pain, but no longer cares about it, as if the pain belonged to someone else. Aloof toward his pain, the person ceases to feel the tension between what he desires in life and the limits of life.

On the other side of the equation, religion clouds a person’s individuality (which is not the same thing as clouding reality or a person’s identity). Religion’s goal is not to deny the existence of the individual, but to stop a person from recognizing the existence of his individuality as life and happiness. The emphasis on individuality and personal happiness fuels the fundamental contradiction of life, says religion; therefore, put less emphasis on individuality and personal happiness. Occasionally, instead of stifling individuality, religion actually redefines individuality, such that a person finds happiness and self-expression in pain (for example, the Christian Flagellants or the Hindu Fakirs). Again, the purpose is to distract a person from his quest for conventional personal happiness.

An emphasis on individuality tends to find its way into all areas of life, including the area of pain management.

This is a secular age, an age that emphasizes individuality, self-expression, and personal happiness. After centuries of writers preaching the greatest happiness for the greatest number, the importance of desire, and the uniqueness of the inner voice, most Westerners today believe in personal happiness and individual fulfillment as life’s purpose. They have for some time — and there is no turning back. Some ideas go in and out of fashion, but other ideas take the form of irreversible trends and signify a permanent departure from the past. Over the last three centuries the West has trended towards more equality. During this same period the West has also trended towards more individuality.

An emphasis on individuality finds its way into all areas of life, including the area of pain management. It intensifies the fundamental contradiction of life, ever so slightly, but enough to produce a sea change in people’s attitudes and expectations regarding pain. People no longer accept chronic pain as their lot in life. Constantly reminded that personal happiness is not only desirable but also essential, they resent their pain and the fundamental contradiction of life that exacerbates it. They demand relief.

A parallel change has occurred in people’s attitudes toward death. True, the fear of death is timeless and universal, yet it comes with subtle gradations that are amenable to change. There is the average human view of death, which varies little, as everyone fears death to one degree or another. There is the personal element that infuses individuals differently, giving them a more poignant interest, and bringing them closer to ourselves, while also making broad generalizations more difficult. Then there is the cultural attitude toward death, which is subject to the rumors of periods. Like the cultural attitude toward pain, the cultural attitude toward death has also changed.

Historian Philippe Aris, in The Hour of Death, calls the new unease toward death manifested in Western culture “Death Denied.” According to Aris, contemporary Western culture tries to banish death from awareness. People avoid talking about death. They ship people off to hospitals and hospices to die out of sight. Adults clamor to join the youth culture, which pushes old age and death out of mind. Today, it would be considered impolite, if not morbid, to share one’s thoughts about death during casual conversation. According to Aris, past centuries saw death as a normal part of life; today, death is more concealed than ever because the subject secretly terrifies people.

Both pain and death bring to the fore the fundamental contradiction of life. In a culture where individuality constitutes the operational basis of all thought and action, that contradiction is felt more intensely, and pain and death are feared more. Pour the confusion that surrounds contemporary pain management over this red-hot contradiction, and the result is the chaos now gripping the pain industry.

More than 50 percent of drug diversion in chronic pain is someone getting the drug from a friend or relative.

The field of chronic pain is at the beginning and not in the middle. It’s not that more therapies have yet to be discovered, but that the force of a profound and irreversible cultural change is being felt for the first time — a growing popular resentment toward chronic pain. That force will only grow, and regulatory agencies must adapt, starting with a stronger division within drug enforcement agencies between those officials who fight the “drug war” and those who regulate the same drugs when applied to chronic pain.

Currently, many officials involved in the drug war look upon the chronic pain field as a sideshow in the larger struggle against illegal drug use. True, drug diversion is a serious problem. Yet drug diversion patterns in chronic pain are not the same as in the larger drug war. More than 50 percent of drug diversion in chronic pain is the result of someone getting the drug for free from a friend or relative. Less than five percent involves someone buying the drug from a drug dealer or a stranger. Deaths resulting from drug overdose are also a serious problem. Indeed, both the absolute number of deaths and the recent rate of increase in the number of deaths are higher for prescription opiates than for illicit cocaine and heroin. Yet deaths resulting from prescription drug overdose usually originate in a different spirit of human motivation — not the urge to play or get “high,” but the desire to control pain.

An altogether different, and culturally significant, trend is emerging in the mass use of narcotics. That trend cries out for institutional recognition and a new bureaucratic division. Too often, for example, legitimate medical findings in chronic pain become grist for the larger crackdown on all opiate use, both legal and illegal. For example, recent epidemiological evidence suggests that long-term opiate use actually may be counterproductive. Not only does it increase the risk of hormonal dysfunction, immune system suppression, and heart disease, but in many cases results in less pain control and worse function. In 2011, these findings inspired Washington State to implement more restrictive regulations regarding opiate prescription. Yet almost immediately, and not without some justification, critics of the new policy feared that it would give government authorities a chance to crack down harder on drug use, as part of the drug war, thereby risking return to the days when chronic pain was grudgingly treated.

Such fears need to be factored out of the equation when setting chronic pain policy, starting with an institutional separation between chronic pain (and even drug diversion within chronic pain) and the drug war. It is possible that the pendulum swing toward greater use of narcotics in chronic pain will move back toward neutral. Pain doctors increasingly recognize the importance of cognitive/behavioral therapy in managing pain. Pain patients often have better outcomes when learning coping behaviors and changing maladaptive ones. Indeed, many pain drug studies show that opiates can be effective, but that a placebo is usually almost as effective. Yet in order for this pendulum swing to occur, policy decisions surrounding chronic pain must be separated from those involving the war on drugs. Without separation, even some doctors will resist the swing toward neutral.

The outpouring of legitimate demand for pain medications over the past two decades is an outpouring of discontent, one that expresses a deep change within Western culture. Confusion overlies that discontent, and exacerbates it, rooted in rival understandings of what pain is and how it should be treated. Each group of actors in the chronic pain field — patients, doctors, and government officials — simultaneously paralyzes the other two with its power. To the degree that policymakers can take command of this issue, their goal should be to sort out the confusion, especially the distrust between doctors and government. But the underlying contradiction fueling the growth of the pain industry will remain in force.

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