New Treatments for Cancer Pain. Part 3.
We don’t really understand the patients. You know, they don’t choose to be in pain. It rips apart every fabric of their life. By the time they seek medical attention – and it’s the most common reason a patient walks into your office, it’s the most common reason a patient walks into a drugstore and asks the question – but by the time they’ve seek professional advice they’ve already tried everything in their medicine cabinet, and in many cases everything in their neighbors and relatives medicine cabinets. They’ve tried everything they’ve ever seen advertised on television and increasingly they have tried everything some 19-year-old kid in the general nutrition store has told them is good for pain.
But more importantly, they’ve assigned a meaning to the pain. They’ve assigned a meaning to the pain. Now this meaning is a belief – and you have to understand that, because when you tell them what the pain means that doesn’t change the belief. You can’t change a belief by telling them once. So all their actions, all of what they do, all of their beliefs, all their behaviors are based upon the meaning they have assigned to the pain. This is what you see in your chronic non-malignant pain patients. All of their beliefs and these are beliefs. You can teach them that their beliefs are wrong but it’s just a little bit easier than teaching a teenager that wearing corduroys is cool when nobody else is wearing corduroys. It just isn’t that easy to change a belief. And this is what’s going on inside their mind. You know, terrible things are being done therefore worse are threatened. The outside forces are in control, the will is helpless. They cannot will this away. They can’t function. There’s all kinds of things that they can do. Since no one has been able to give them any time limit on when this is going to end – or they have no perception that it’s getting better – the only logical conclusion is, it’s going to go on forever. “Until I die.” And it will probably get worse and worse each day.
And the pain is meaningless, but more importantly, they focus all of their energies on things that make the pain less or they talk about the pain, or they avoid all behaviors that might exacerbate the pain. So they focus everything on themselves. And chronic pain patients are not likable. Even people who love them do not like them anymore. They really don’t. They are just not likable. And you thought you were being bad people because you can’t stand these patients. Nobody can stand them. They really can’t and it’s because the pain is their entire world. Now I know there is a percentage of patients for whom the pain has a lot of secondary gains and all that. I don’t have time to talk about all that psychosocial stuff. I’m just talking about those patients for whom we can do effective drug therapy.
And we don’t understand the elderly. You were probably taught that the elderly are less sensitive to pain. Now what that experiment was, was they used thermal probes and they had a group of patients, old and young and whatever, had their hand on a plate and have a thermal probe and very slowly they lower the thermal probe down. The patients are told, “Take your hand out when you can’t stand it anymore” and the elderly patients took their hand out much later than young people. You know what young people is? That’s people your age. I’m young. Inside I’m 34. But those probes were like at about 150 degrees. If you change the temperature of the probe to 400 degrees the age-related differences disappear. If the temperature of the insult becomes really dangerous there’s really no difference between the point at which a 90-year-old pulls his or her hand out and a 16-year-old pulls his or her hand out.
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