CMDA's The Point

The Purpose in Pain

January 28, 2021
01272021POINTBLOG

by Amy Givler, MD

When my husband and I worked at a mission hospital in Kenya for six weeks in 2013, we ate dinner every evening with another volunteer doctor, an orthopedic surgeon. We often discussed the use of opioids, or rather, the seldom-use of opioids in Kenya. After a U.S. surgery, he said his patients would receive opioids round the clock in the hospital, and they’d go home with a prescription for 30 to 60 pills. Yet here, patients’ pain was managed with non-opioid pain medications, and nobody was prescribed opioids after discharge.

One young man who had just left the recovery room after a complicated tibia/fibula fracture repair grabbed our friend’s arm as he was making rounds. “Daktari,” he said, his face contorted, “My leg—it really hurts.”

Our friend gave him his full attention. “Yes,” he said, nodding gently, “fractures hurt. But now it can heal.”

The patient’s face—and his whole body—immediately relaxed and he smiled. “Thank you, thank you.” The difference was dramatic.

Pain is part of the body’s warning system that something needs attention. This young man needed his doctor to know that pain was happening, maybe something was wrong. But once he knew his pain was a normal part of fracture surgery, his relief was complete. He trusted he was on the path to healing. He could endure the pain.

The United States accounts for 5 percent of the world’s population but consumes 80 percent of the world’s opioids. Peri-operative use of opioids is markedly higher in the U.S. compared to other countries.

This young Kenyan’s pain probably completely resolved with the healing of his bones. But all pain does not eventually resolve, alas. Many people live with chronic pain, such as low back pain, arthritis and headaches. What purpose could that pain possibly have?

In the U.S., there tends to be an expectation of zero pain. Life shouldn’t hurt. Yet not only do our bodies or our brains generate pain because of known or unknown factors, our emotions can be painful also. Depression hurts. Anxiety is very unpleasant. Fear is distressing. And it’s a vicious cycle. Anxiety and depression make body pain intensify. And having physical pain often leads to even more emotional distress. And on and on it goes.

Having long-standing pain is nothing new. Humans have been dealing with this since they were, well, human. Nor is it new to desire to alleviate pain. Many medications decrease pain. And any medication that relieves pain with minimal, or at least acceptable, side effects, is one that I am all for. The trouble is, opioids don’t fit that description. Not only do they have a slew of side effects, they also lower the pain threshold. That is, they may dampen the pain for a few hours, but when the pain returns it is worse than it would have been without the opioid.

I don’t want to get lost in the weeds of treating chronic pain, mostly because I have written about it before. Instead, I want to take two giant steps back and look at the entire landscape of psychotropic drugs, excluding those for psychoses.

Psychotropic (acting on the mind) drugs have a long and infamous history in the U.S., beginning with the 19th century’s tonics and nostrums and patent medicines, which were all heavily advertised as “cure-alls.” Many of them basically consisted of alcohol, but they were potentially laced with cocaine, opium, morphine, sulfuric acid and arsenic.

The early 20th century history saw many pharmaceutical companies reaping huge profits in sales of cocaine, heroin and barbiturates. But as the century proceeded, their production became more weighted toward medications that treated physical illnesses, since research into treatments for physical illnesses was leading to more effective medications.

The glaring exception was Purdue Pharma, run by three Sackler brothers who seemed to be primarily profit-driven advertising moguls first, and psychiatrists only a distant second. Their story has been well described in many recent books, but most completely in Gerald Posner’s monumental new book, Pharma.

Before he ran Purdue, Arthur Sackler’s advertising company successfully promoted the sales of Librium and Valium. After his death, his brothers at Purdue Pharma notoriously pushed OxyContin, a long-acting formulation of oxycodone, thus fueling the opioid epidemic. Arthur Sackler developed heavy-handed and multi-pronged techniques of advertising previously unknown in the world of medicine. As Barry Meier put it, Sackler “helped pioneer some of the most controversial and troubling practices in medicine: the showering of favors on doctors, the lavish spending on consultants and experts ready to back a drugmaker’s claims, the funding of supposedly independent commercial interest groups, the creation of publications to serve as industry mouthpieces, and the outright exploitation of scientific research for marketing purposes.”

Yet none of the Sackler brothers’ efforts would have borne fruit if the soil of American anxiety and depression was not such fertile ground. In the 1950s, newspapers and magazines ran stories about stress from worrying about the Cold War, and Americans considered themselves to feel justifiably anxious. Psychotropic drugs dampened the anxiety, and they have been wildly popular ever since.

In 1963, Betty Friedan wrote about American women’s response to their inner angst in The Feminine Mystique, “You wake up in the morning and feel as if there’s no point in going on another day like this, so you take a tranquilizer because it makes you not care so much that it’s pointless.”

One of the problems with benzodiazepines (such as Librium, Valium and Xanax) and opioids is that they are physically addictive, causing withdrawal symptoms if you stop them, and tending to need higher doses over time to get the same effect. Another problem is that they dull your mind, making it harder to think things through.

Americans also tend to consider that a pill should be prescribed—for whatever symptom they are experiencing—whenever they go to their doctor. I have felt that pressure from patients during my 30 years of being a family physician.

So often what an anxious patient needs from me is to listen carefully to their concerns, to help them see some of the root causes of their anxiety and to walk alongside them as they garner resources to move forward. Yet, that takes time. It’s much quicker to give a pill that is likely to decrease anxiety to the extent they stop caring about the difficult situation they are in.

Why is this a problem? Because life is often sad. Emotional pain is a common part of life. Anxiety is inevitable. Difficulties are the universal human experience. How can we face them if our brains can’t focus and seek solutions?

In talking about this with my friend, fellow physician Ejiro Onos, she had wise words to say: “So often we are asked to medicate non-illnesses, as if we could anaesthetize life. Many of my patients consider all pain—emotional and physical—to be bad. I may think they need counseling, which would be a slow process, but they want the microwave experience. The trouble with giving them a benzodiazepine is that the brain fog they cause might keep them from doing the hard work of finding out the root of the problem.”

Not all psychotropic drugs cause brain fog. In fact, most anti-depressants seem to help clear the brain of fog, and allow for more logical thought, even as they lift the mood. That was certainly the case for me the two different times in my life I’ve been depressed and took anti-depressants. Also, there are some people whose anxiety has tipped over into causing irrational thoughts. And, of course, others are out of touch with reality, such as people with schizophrenia. Medication is often of great benefit for these folks.

When individual states started approving marijuana for “medical reasons,” I groaned. A total of 36 states and four territories have now jumped on that bandwagon. Not only is the medical research showing benefit extremely sparse (and in most cases non-existent, despite what the list of “treatable conditions” on your state’s website says), but marijuana causes a fuzzy brain. As I’ve written before, it also impairs memory and judgment skills, and leads to increased anxiety and depression.

Taking drugs that cloud the brain, just like drinking enough alcohol to get drunk, decreases a person’s ability to think clearly. Without our brains on our side, helping us properly assess our situation, how can we move forward?

Henri Nouwen wrote eloquently about facing our pain as the path to spiritual growth in Life of the Beloved:

“Our first, most spontaneous response to pain and suffering is to avoid it, to keep it at arm’s length; to ignore, circumvent or deny it. Suffering—be it physical, mental or emotional—is almost always experienced as an unwelcome intrusion into our lives, something that should not be there…Still, my own pain in life has taught me that the first step to healing is not a step away from the pain, but a step toward it.”

As many of the great Christian thinkers have discovered before him, Nouwen found that, “My own experience with anguish has been that facing it and living it through, is the way to healing…The deep truth is that our human suffering need not be an obstacle to the joy and peace we so desire, but can become, instead, the means to it.”

Jesus knows we desire joy and peace. After all, He made us. And He had a lot to say about how to achieve those desires. He knew that following Him, and choosing to want what He wants, would be our path to joy.

“If you keep my commandments, you will abide in my love, just as I have kept my Father’s commandments and abide in his love. These things I have spoken to you, that my joy may be in you, and that your joy may be full” (John 15:10-11, ESV).

Our culture seeks to eliminate all pain because it sees no useful purpose in it. Yet pain, whether physical or emotional, may be the very thing that is warning us we are on the wrong path and we need to move in a new direction. As my friend Grace Fox wrote, reflecting on Joseph’s time in a prison cell in Genesis 37-50, “Life would be easier if we could develop character through self-improvement courses. We’d rather forget the cell and forego the trials, but God knows how to best prepare us for the purposes we cannot see.”

The pain of touching a hot stove teaches me to avoid hot stoves. The pain of hurting a friend teaches me to stop saying offensive things. It’s harder to figure out the cause of long-term pain. But God knows. We can trust Him, just as, after fracture surgery, the young Kenyan trusted that his pain had purpose.

About Amy Givler, MD

Amy Givler is a family physician in Monroe, Louisiana. She and her husband Don met in 1980 at a CMDA student event her first year of medical school, and they have both been active members of CMDA ever since. Amy graduated from Wellesley College and Georgetown University School of Medicine, and she then completed her family medicine residency at the same indigent-care hospital where she now works part time. She also works at an urgent-care clinic and is the medical director for a Shots for Tots clinic. Amy loves to write and has written many articles and one book, Hope in the Face of Cancer: A Survival Guide for the Journey You Did Not Choose. She and Don have a heart for missions, and hope to do more short-term trips now that their three children have launched from the nest.

3 Comments

  1. william T griffin on January 31, 2021 at 7:49 pm

    This article is both counter-cultural and right on target. 2 Cor 1:3-5 refers to the “God of all comfort.” If we make comfort our god, we will miss out on the comfort that comes only from the one true God. Thank you, Dr. Givler!

  2. Carolyn Klaus on February 1, 2021 at 1:54 pm

    Thanks, Amy. A much needed perspective. Keep writing and talking!

  3. Ronald Hamner, MD on February 2, 2021 at 10:34 am

    Thank you for this astute article. When we look to the authorities or government to assuage our problems, some form of narcotic or symbolic narcotic can be expected to hide the problem. Pain can discipline or can notify us to prepare for a transition in life. Thanks be to God that he loves us so much that he will use this tool for our ultimate good!

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