There are certain concepts that need emphasis to answer this
question. The first of these is that pain and suffering are not
synonymous. Although pain has been described as an unpleasant sensory
and emotional experience arising from actual or potential damage
to tissue, only when the consequences of pain—usually prolonged—begin
to interfere negatively with the physical and emotional experience
of life is suffering said to occur. In this way, pain may be likened
to stress. A little pain is not necessarily a terrible thing. It
may serve to focus attention on a stimulus and foster an appropriate
reaction to it, but too much pain may prove overwhelming, exhausting,
and demoralizing. It may lead to depression, which may intensify
the experience. And depression is not benign. With little warning,
it may lead to suicide. Saying that “there is nothing more
that can be done” may take away the only hope that keeps
the patient going.
Continuing the analogy to stress, pain is difficult to study.
It is not easily monitored or objectively assessed, nor are its
effects predictable from one individual to another. Indeed, pain
thresholds may vary, not only between people, but also within the
individual person over time according to mood, previous experience,
and expectations. This complexity, fortunately, provides multiple
levels or points at which pain management may prove successful.
Appropriate interventions may be pharmacologic, invasive (i.e.,
surgery or nerve block), behavioral, or a combination of all three.
What, then, is the difference between pain and suffering? To
answer this question, it must be understood that pain may affect
a person’s life in different ways according to their general
state of well-being. Someone who is tired, hungry, anxious, or depressed
reacts to an unpleasant sensation differently from someone who is
well rested, in excellent shape, and in high spirits. When pain persists
and overwhelms a person’s coping mechanisms, it is likely
to be seen as insurmountable and may take on a life of its own.
Eventually, the tail wags the dog, as the saying goes. With this loss
of control and autonomy and a growing feeling of helplessness, the
person begins to experience a downward spiraling of emotional and
physical well-being, in which severe deconditioning threatens normal
functioning at home, work, and play. The consequence is a state
of suffering of which only a portion is physical pain. This is why
pain management clinicians do not advocate simply prescribing the
strongest medication possible when the patient states, “if
you just give me something to kill the pain, I will go back to work
and everything will be OK.” If only it were so simple!
The wise practitioner tries to convince the patient that going back
to work first—in graded increments—may offer a
useful distraction from the pain and explains why a concurrent and
multifaceted approach to pain management is needed. Although no
single physician is capable of all aspects of care, in a multidisciplinary
setting, there needs to be one clinician in overall charge of each
patient’s regimen to avoid processing patients “by
The Downward Spiral That Turns Pain into Suffering
To illustrate how a fairly minor event may lead to catastrophic
results if early warning signs of chronic pain are not recognized
and responded to appropriately, one may use the common scenario
of a 50-year-old citizen sitting in a stationary car, hit from behind.
There is no apparent injury at the time. Over the next few days,
the patient experiences tightening up of muscles and low back pain,
described as “spasms.” These get worse over time.
The patient is reassured by the family’s practitioner that
it is only a muscular problem. Although the patient is willing to
accept this for a while, a friend suggests initiating a lawsuit
just in case something is more seriously wrong. This philosophy
is reinforced by an attorney who states that he has seen many patients
settle a case too early only to find out later that they have a
lifelong disability for which they have no financial coverage.
The driver now sues and becomes hypervigilant about symptoms,
becoming anxious every time pain is felt. The family physician reasserts
that there is no neurologic dysfunction and states that x-ray studies
fail to show any skeletal injury. The patient disagrees. The pain
is prolonged and is seemingly becoming intensified. He or she seeks
a second opinion and, not satisfied with it, seeks a third, fourth,
and so on until somebody is found who echoes his or her concerns
and who is willing to order a magnetic resonance imaging (MRI) scan.
MRI then reveals degenerative changes not apparent on x-ray films,
but probably consistent with age, such as “bulging discs” that
do not clearly impinge a nerve root or the spinal cord but nonetheless
are read correctly as just “touching” a nerve
root. The consulting surgeon, wanting to help the patient, offers
to operate and see if he or she can remove the tissue that “might” be
touching a nerve and setting off the pain. The patient agrees, giving
consent, but doesn’t hear the qualification “might.”
As often happens, the surgery does not ameliorate the pain, and
within a few months, a new pain begins. Subsequent MRI reveals evidence
of scarring about the nerve root, one of the possible complications
of invasive surgery. As the scar contracts, it pulls and irritates
the nerve root, causing radicular pain in the dermatomal distribution
of the corresponding peripheral nerve. The patient becomes frustrated,
despondent, and depressed. The family physician then prescribes
antidepressants for pain, but they seem to negatively affect the
patient’s ability to think clearly at work. The patient
now no longer trusts the family physician’s judgment (or
prescriptions) and begins to take multiple over-the-counter drugs
or uses “alternative” therapy that may be expensive
and of dubious value. The pain persists.
Eventually, the family physician is forced to prescribe a mild
narcotic for ongoing and worsening pain. This is taken over the
next few months, with escalating dose requirements because the patient
has developed tolerance to the drug, leading to stronger medications,
a pattern to which the clinician responds with concern, stating
that he or she is not going to prescribe these medicines any more “because
you are becoming addicted to them.” They argue, and the
patient is forced to seek care elsewhere. By now, having missed
work so often and failing as well in personal relationships, the
patient is fired at work and unhappy at home. The patient becomes
more depressed and cannot sleep well, escalating the pain.
Having been physically inactive now for several months, the patient
is physically deconditioned and the ensuing poor posture and ill-functioning
musculature (some muscles are chronically contracted to minimize
painful movements; others are weak and flaccid from disuse) induces
myofascial (soft-tissue) pain, worsening the situation. The patient
is no longer able to go out with friends or to visit family because
of neck and back pain that prohibit driving. Sitting or standing
in any one place for too long brings on the pain. The family withdraws,
unable to console the patient and feeling inadequate. The patient
ends up at a multidisciplinary pain management clinic, diagnosed with
failed back surgery syndrome complicated by depression and severe
deconditioning. A fairly long and expensive treatment program is
now required to help the patient pick up the pieces. The pain has
become a state of suffering.
Without analyzing this scenario step-by-step, it is clear that
a fairly innocuous event initiated a domino effect, resulting in
biologic, psychological, and social disruption of the patient’s
life. This is why a biopsychosocial approach to pain management
is necessary. Early recognition of this downward spiral might have
helped the patient if a brief period of pain management–oriented counseling
or relaxation-based cognitive therapy was initiated to help the
patient look at the pain from a different perspective. Furthermore,
the likelihood of successful pain management might have been increased
by incorporating physical therapy early to prevent a deconditioning
process. Short-term use of nonsteroid antiinflammatory drugs (NSAIDs),
tricyclic antidepressants, or muscle relaxants might have decreased
pain and improved sleep, minimizing the potential for depression.
Close communication between the clinician and patient is needed
to develop mutual trust. Limits need to be specified with regard
to medication refill requests and self-adjustments of dose to avoid
misunderstandings that might lead to suspicion of addictive behavior.
Prescribing medications without adequate thought and discussion
and then abruptly stopping them simply generates patient frustration,
bewilderment, and resentment. Setting limits early and paying firm
attention to them fosters the patient’s respect and trust.
With the rules established at the outset, perhaps in the form of
a signed agreement, the chance for misunderstanding is minimized.
Such an agreement amounts to informed consent.