Chapter 40: Pain is a Four-Letter Word
And what’s it good for?
I’ve been a pretty sturdy guy all my life with more than my share of stamina, especially at work; a blessing that, ironically, might stem from my earliest days as a newborn infant in Tajikistan at the height of the Second World War when, according to my parents, I was stricken with several life-threatening diseases but managed somehow to survive them all. Malaria, TB, typhus; my theory is that I was “inoculated” by all these and somehow immunized against other ailments as well, resulting in the hardiness I’ve long enjoyed.
But over the years I’ve had to deal with squash injuries to both knees that involved arthroscopies, and the pains resulting from a fair amount of dental work; and for some reason, the common painkillers – Aspirin, Tylenol, Advil, even Percocet (i.e., OxyContin) – just don’t seem to work for me. So I’ve sucked up what pain there was and carried on. In other words, pain to this point has been a minor issue for me. But now, because I’ve not only reached that point where the end of life is naturally on one’s mind but also because in the nature of my work as president of CARP and founder of ZoomerMedia, I’ve come to consider death and pain, including the subject of assisted suicide where, central to the discussion, is the prospect of intractable suffering. We all know someone or know of someone who has died painfully and slowly. So, in the event that I end up with something agonizing, my apprehension is that my apparent resistance to minor painkillers dooms me to a suffering demise. Or is there some other drug or treatment that can help me? In broader terms, does anyone really have to die in pain anymore, or is the fact that some people still do simply the result of poor communication and palliative care mismanagement?
What is the use of the pain, anyway? “Pain” is defined by the Oxford English Dictionary as “physical suffering or discomfort caused by illness or injury.” More interesting is the etymology of the word itself. “Pain” comes from the Latin poena and the Greek poine, meaning “punishment” or “penalty.” Punishment for what? Well, one answer is Sin! Several religions hold that we’re born in sin (hence the pain of childbirth for both mother and infant) and are condemned to subsequent suffering to either “cleanse” us of our crimes and/or to purify us so we can pass into Paradise.
Another answer is the evolutionary theory of pain; that pain is a necessary and lifesaving Early Warning System that lets us know that something bad and dangerous – like cutting or burning or breaking – is going on. Fine, that makes sense, but here’s my question: why does the warning have to be delivered as pain? Why not as a tickle or a bell, a “teehee” or “ding” instead of an “ouch”? Richard Dawkins, anthropologist and author of the notorious bestseller, The God Delusion, asks this question in a slightly different way: why does pain have to be so painful? Why not just enough to do the job? Dawkins’ answer is that the most fit creature is the one whose levels of pain are precisely graded to the degree of threat. Thus, a minor danger like toe-stubbing gets you minor pain, while a great danger like a heart attack begets great pain. To which my retort is to wonder if Dawkins has ever had a paper cut? (Very minor danger, very deep pain.) Also, if pain exists to help us avoid some threats, why do we have so much more of it as we get older when the greatest threat of all, death, is something we can’t avoid at all?
At any rate, of the three basic kinds of pain – chronic minor pain (the kind I visit my chiropractor about), chronic serious pain (which affects an astonishing 20 per cent of Canadians) and the “breakthrough” pain of terminal illnesses like cancer and diabetes (the kind that’s on my mind) – the good news is that the last may be the most controllable of all. According to Dr. Gary Rodin, head of the department of psychosocial oncology and palliative care at Princess Margaret Hospital in Toronto, “In almost any circumstance, we can now make people comfortable. There’s a common fear that pain will be uncontrollable in these situations, but that is not the usual case. We’ve just done a study, which is ready for publication, interviewing end-of-life caregivers. In 80 per cent of cases, they reported very good symptom control. In the remaining 20, there were some problems with pain control on the one hand and what we call ‘transcendent’ symptoms on the other; fear of death and dying. But we can do better than that with this minority as well.”
There are two reasons for the 20 per cent “problem” group. One, end-of-life treatment has historically been more focused on the disease and not on the symptoms, particularly as technology improved. The result has been a generation of physicians who have lacked training in palliative care and been far more concerned with the extension of life than with “side-effect” symptoms, most critically pain and its management. The recent emergence of palliative care as a specialty is a direct reaction to this historic built-in myopia in the medical establishment. The second lingering prejudice confronting effective palliative pain control has been concern about addiction. Some of the opioid-based drugs used in pain control, like morphine and OxyContin, are known to be addictive in certain circumstances. But this concern about addiction has always struck me as totally absurd in the context of terminal patients. Who cares if they become addicted? I would far rather spend my final days as a pain-free so-called addict than as a suffering so-called “clean.” Rodin agrees. “The fear of addiction is misplaced in palliative care. It’s far more of an issue with chronic pain. But people with more advanced cancer, say, should not be concerned about addiction; it’s not a result in the cases and, even if it were, it would be acceptable.” It’s the addiction bogeyman that has probably prevented heroin from being legalized for pain treatment in most countries, despite the fact that heroin (which was originally marketed as an analgesic along with Aspirin by Bayer in the early 1900s), is generally acknowledged to work more quickly than morphine in lower doses and with fewer side effects. But because heroin is arguably more addictive than morphine, to date it is only legal for palliative use in Great Britain.
Another common misconception about palliative pain control is that in many cases the only way to manage pain is by what is known as “terminal sedation”: sedating patients into unconsciousness, effectively putting them to sleep. Again, according to Rodin, not true. “In the majority of cases, doses can be titrated to control the pain at various stages and still reduce side effects. [Terminal] sedation is used only in a very small minority of the very extreme cases.”
So the chances for a relatively pain-free end to life and a conscious one to boot seem a lot more reassuring than I’d feared, even for an apparent pain-medication resistor like me. After all, dental freezing does work for me; and a lot of the products used for pain relief in palliative care, both opioids like morphine and pain-blocks like spinal epidurals (best known for women in childbirth but now used increasingly for other procedures and situations) have a similar freezing effect.
Amazingly but predictably, there are still those who actually maintain that eliminating all pain for dying patients is an unwarranted intervention into the “natural” course of life; and that suffering cleanses the soul before one is to stand before God – this despite the fact that even the Catholic Church, in the person of Pope Pious XII in 1957, endorsed the use of “sufficient medication to control pain, even if there was a risk of unconsciousness or hastening death.” Pope Pius did add, mind you, that such measures could not be used to “prevent the carrying out of other religious and moral duties.” But what higher moral or religious duty can there be, I ask, than to relieve a fellow human being of suffering?
Those who embrace pain as a laudable end in itself, be they certain Opus Dei adherents or Shiite Muslims intent on self-purification or sexual sadists and masochists intent on sensory gratification, are free to march to their own drummers and refuse relief and release. But for the rest of us, the very real advances around suffering and the end of life constitute good news. I’m not trying to sugarcoat the pitfalls of growing old; there are plenty of other sources of age-related stress and anguish that remain resistant to “treatment” – chief among these being the potential psychological pain that can accompany everything from personal emotional issues all the way through to money; the getting and keeping of which creates much anxiety throughout our lives but seems particularly acute at this time when so many of us worry about outliving the funds we have.
To date, no one has come up with a fool-proof way to deflect this brand of late-life psychic and economic suffering. But we have at least reached the point where our bodily pain can be kept to a minimum. “Necessary suffering” when it comes to terminal physical pain is an idea that has lasted far beyond its due date. It is obsolete and has no place in a humane culture. Effective counter-measures exist, and none of us, if we want them, should be denied them. Think of it as a new right – and no small victory.
Moses’ Zoomer Philosophy — which launched in ZOOMER Magazine in October 2009 — is a series of monthly essays on age and aging, and the secrets and the science to living better, longer, healthier and happier lives. The first volume of his collection is now available in e-book format on the Kobo Books website. Click here for more information.