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WHAT and Pains?


When a patient comes to a health care provider with intense chronic pain, and the health care provider sends the same patient away still in intense chronic pain, I don't believe the health care provider has done anything to reduce the patient's risk of addiction.

Found via this article, which was found in turn via FWD/Forward

This makes me want to bake cookies for my own doctor.

I swear, I have met the author of “Fakes and Pains” several times throughout my diagnostic journey of endometrial glee. And each time, I have wanted to scream. Or wish said doctor a massive urgent BM in the absence of TP. Or, you know, make it so he can actually feel when I am in pain. Because I think, maybe especially when it comes to female sexual health, there’s a pernicious loop that goes like this:

Dr: We can’t treat your pain until we diagnose the cause.

Roe is gone. The chaos is just beginning.

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Dr (later): We can’t diagnose the cause; therefore we cannot treat your pain.

— OR —

Dr (later): We can’t diagnose the cause; therefore you are not actually in pain.

The author’s argument is that when prescribing potentially habit-forming medication, the risk of addiction is too great:

Trust me: If there is anything worse than an undiagnosed pain patient, it’s an addicted, undiagnosed pain patient.

I’m not discounting the risk of addiction, but here’s the thing. Well, two things, the first backed up by data (admittedly, data reproduced in a non-peer-reviewed source), the second only by first- and second-hand experience (more commonly called anecdata). First, an individual’s statistical likelihood of becoming addicted is dependent on a variety of factors; there’s not really a set constant for addiction risk that applies to all people. Additionally, when a patient comes to a health care provider with intense chronic pain, and the health care provider sends the same patient away still in intense chronic pain, I don’t believe the health care provider has done anything to reduce the patient’s risk of addiction.

For some of us, various addictive substances (even totally legal addictive substances) are easier to obtain than effective pain management. But it’s not any kind of physical or emotional “high” we seek; it’s pain reduction, plain and simple.

It’s okay, though, not to treat because “that kind of diagnosis will invariably be challenged.” In many cases, it is. However, even leaving aside the issue that a lot of us are taught to accept a doctor’s medical opinion as unshakable authority, there are some more mundane barriers to consider. Repeat specialist visits are expensive (in the U.S., even for those privileged enough not to be uninsured or underinsured) and wait times for new patients are often long. The financial burden and lost time invariably add up.

I’m self-admittedly very privileged when it comes to reproductive health care: I’ve almost always had adequate health insurance and a support system outside of a single doctor. My diagnosis still cost 14 years, thousands of out-pf-pocket dollars, and dozens of times of being called a liar. I cannot imagine what it must be like for someone who has to choose between health care and making rent or buying food. When doctor after doctor after doctor tells you, “you’re not actually in pain,” at some point, it becomes sort of perversely tempting to believe them.

Of course, this is assuming it isn’t just all in your head. According to our charming doctor:

The truth is psychological or social need is a common source of undiagnosed pain.

You know what’s also a common source of undiagnosed pain? Phyiscal or neurological issues that are poorly understood and often overlooked or misdiagnosed. These include but aren’t limited to: endometriosis, in which patients typically show symptoms for 10 years before receiving a diagnosis; fibromyalgia, another condition that’s difficult to diagnose and that overwhelmingly affects women; and vaginismus, a condition that’s often dismissed, belittled, or lauded as how sex “should” be.

But we must be doing it for the money:

And there’s always the money angle, which — no surprise — is very common.

Because let me tell you, paying for doctors’ visits, long drives for consults, birth control methods without generics, ultrasounds, MRIs, acupuncturists, massage therapists, herbalists, surgeries, and a pain management arsenal worthy of great envy has made me oh so independently wealthy. Oh, wait. In reality, my income comes from my 50-hour work weeks, which (somewhat) effective pain management allows me to continue doing.

Nope. Still lying — and doctors know.

But even if we can’t prove it, we can usually “tell”, and quite easily.

Except, you know, for the roughly 80% of my previous providers who’ve been totally head-up-the-ass wrong. While I definitely need to allow for the limitations of my anecdata, I have trouble believing that the stats for doctors who possess a magical internal polygraph is completely at odds with that. Which means that some health care providers are refusing to treat people with physically treatable pain — because providers can “tell” those people are lying. I will admit that I haven’t been to med school, but I wasn’t aware that they offered courses in ESP. 

ESP must be a prerequisite for the course on curing pain with positive thinking:

“Accentuate the negative” may be sound legal counsel, but it’s the worst possible medical advice anyone could ever give. It’s a pain for the doctor, and often ultimately, an even bigger pain for the patient.

And I think this gets to the heart of this doctor’s complaint. Even when it’s done in conjunction with a provider who’s knowledgeable about pain management and who takes seriously patient priorities, effectively managing chronic pain can be a long, involved, frustrating, trial-and-error process. It requires a certain amount of time having one-on-one contact with a patient, perhaps even listening to the patient’s history, symptoms, and other concerns. No doubt for some doctors, the inconvenience this causes and humanity it requires is tantamount to pain.

Certainly, I do think it’s preferable, when feasible, to treat the underlying condition that causes chronic pain. But that’s not always possible or practical. For times when it isn’t, health care practitioners who work with patients to provide compassionate, effective pain management are helping give something that is huge and real and concrete for those individuals. Sleeping through nights. Standing upright. Maintaining and advancing an education and/or a career.

But that can’t really happen when one assumes that said patients are habitually drug-seeking, attention-seeking, and lying. If you run into a doctor who does so, please remind them of this. And wish them explosive poo, special from me.