The subject matter of this volume is chronic pain, as distinguished from acute pain and pain associated with terminal illness. Pain is, of course, distinguishable in a number of important ways from suffering. It is virtually axiomatic that pain can exist in the absence of suffering and that the opposite is equally true. There have been efforts, ultimately misguided, to characterize pain as physical and suffering as mental. Such characterizations have given rise to what David Morris refers to as the "myth of two pains.''7 Unfortunately, the myth has also engendered the tendency among health professionals to label physical pain, i.e. that which can be directly and objectively related to an identifiable lesion, as "real," and all other reported pain, consequently, as "in one's head'' and unreal. As we shall see, the regulatory climate, particularly in the USA, has encouraged medicine's search for an identifiable physiologic cause that would legitimize the pain reported by the patient and justify a physician in the prescribing of controlled substances for pain relief. This approach can have horrendous consequences for the victims of chronic pain syndromes, which, as has been pointed out, "are almost by definition conditions in which the degree of pathology does not seem to explain the severity of the perceived pain or the limitations in bodily functioning the pain produces.''8 When physicians intentionally withhold or reduce readily available palliative measures from their patients with chronic pain, there is added to the baseline level of suffering an incremental level of iatrogenic suffering which may be exacerbated even further to the extent that the physician calls into question the patient's veracity or suggests that the patient is derelict in some unacknowledged yet presumed duty to bear affliction.
Eric Cassell, who has written extensively on the physician's responsibility to relieve suffering, observes that, "While pain and suffering are not synonymous, physical pain remains a major cause of human suffering and is the primary image formed by people when they think about suffering.''9 Moderate to severe, persistent, nonmalignant pain can produce significant suffering, and at some point in the chronicity of the condition efforts to make precise semantic distinctions between pain and suffering, and the extent to which one is physical and the other is mental, become not merely absurd, but unintelligible. Cassell cuts to the shallow core of the effort to impart some meaningful distinction between physical and mental pain or suffering when he states, "bodies do not suffer, persons suffer.'' Implicit in this observation is the incontrovertible fact that people, and hence patients, are not merely bodies. To the extent that I use the terms pain and suffering interchangeably in this chapter, as to some extent I do when I address the physician's responsibility to relieve suffering, I will be referring specifically to the suffering that is produced by severe and persistent pain.
Another term has entered, and to some degree further complicated, the nomenclature: intractable pain. During the last 15 years, a number of state legislatures in the United States passed "Intractable Pain Treatment Acts.'' In such legislation, the term "intractable," which is most commonly defined as uncontrollable, is applied to chronic nonmalignant pain that arises from an underlying condition that is resistant to diagnosis or cure. The purpose of these statutes was ostensibly to legitimize the use of opioid analgesics in the care of such patients. However, the actual experience after their enactment may provide a glaring example of the law of unintended consequences. Many of these statutes strongly suggest that opioids will only be considered appropriate for the management of chronic pain after the clinician has painstakingly documented that all other approaches to pain management have failed. Few clinicians can be expected to demonstrate the expertise, patience, and determination such an approach would require.10
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