When the view from your living room includes hundreds of lobster trap buoys, out-of-town visitors expect to be served lobster for dinner. It often comes as an unnerving surprise to our guests, though, when they hear the clattering death throes of unfortunate crustaceans entering the steaming pot.
Inevitably, this terminal event shifts the conversation to the concept of who or what can feel pain. Marilyn and I try to reassure the squeamish that scientific research (probably funded by the state of Maine) has shown lobsters to lack the neurologic equipment to feel pain.
Pain has also become a hot topic in medicine, and “pain management” has joined the pantheon of medical buzzwords for the new millennium. The mantra at our hospitals seems to have become, “No pain shall go unmeasured or unmedicated.” It has even crept out of the hospital. I have heard parents asking their toddlers, for whom counting is a recitation of 10 words they don't understand, to rate their pain on a scale from 1 to 10. This exercise in quantification is only slightly more futile than pointing to an array of pictograms with smiley and grumpy faces.
Sometimes, this well-intentioned passion to measure and eliminate pain can go awry and actually interrupt the timely discovery of the correct diagnosis. It may even interfere with a patient's ability to access other forms of comfort, such as the soft words and gentle touch of a parent.
Now, don't get me wrong. I am not advocating that we return to the bad old days when pain was seriously undertreated because we physicians harbored an irrational fear of creating drug addicts. Most of us, myself included, still have a lot to learn about the pharmacologic management of pain, particularly in patients with terminal illnesses.
I think, however, that we should all look more closely at nonpharmacologic solutions and try harder to understand why some patients appear to experience more pain than others. There must be genetic and biochemical components to these differences in pain tolerance, but in the last few decades it has become obvious to me that uncertainty and depression are two critical factors in making pain less tolerable. Fortunately, these are things that I as a physician can influence with a combination of clinical skills and medications that are not usually considered analgesics.
A few years ago, for example, a urologist had to rescue me from my own inattention. At one point, he explained to me that, over the next 8 hours, I would be experiencing what could be very painful bladder spasms. He described their cause and assured me that they would be temporary. He encouraged me to ask for pain medication, but he also mentioned that it might temporarily slow my recovery.
Comforted by his confident and detailed explanation of what I was going to experience, I elected not to take any medication. He was correct about everything, including the severity of the pain, but because of its spasmodic nature and because I knew what to expect, it was tolerable. In effect, my skilled physician had used his own version of the Lamaze technique to help him manage my pain.
Ever since that experience I have tried whenever practical to tell a patient as much about his or her pain as I can: what is causing it, how long it will last, and what we can do to ameliorate it. Over the last few years, my efforts to dispel uncertainty seem to have made a positive difference for many of my patients. Ferreting out and treating the depression component have been more difficult tasks than educating and reassuring, particularly when the pain appears acutely and the patient is a child I don't know very well. However, by at least considering the role of depression in my patients' diminished pain tolerance, I can often get us started on the path toward the correct long-term solution.
Fortunately, for Marilyn and me, by the time the lobsters are ready to eat, the discussion has usually drifted away from pain management. Then it's time for a short course in crustacean anatomy and how to find the succulent meat hidden inside those crimson shells.