The Pain Chronicles

by Melanie Thernstrom

  Many of Dr. McIver’s patients testified at the trial as to his success in rehabilitating them, such as a farmer and cattle rancher who, under Dr. McIver’s care, was able to return to work by taking 1,600 mg of OxyContin a day. After Dr. McIver’s arrest, the farmer’s family doctor reduced his prescription to one-sixth of that—240 mg. He told Tina Rosenberg that he now gets three hours of sleep a night and can no longer stand for more than half an hour. He sold his cattle and stopped working, resuming his previous identity as a full-time chronic pain patient.

  Dr. McIver also successfully treated a woman suffering from complex regional pain syndrome (CRPS, also known as reflex sympathetic dystrophy syndrome—an unusual, terrible disease of the autonomic nervous system) who had recently been addicted to crack cocaine. Under Dr. McIver’s care, she did not become addicted to opioids, and her pain improved. But the prosecution presented the very attempt to treat such a person as an example of Dr. McIver’s recklessness.

  Along with a twenty-year sentence for drug distribution, Dr. McIver also received a concurrent thirty-year sentence for dispensing drugs that resulted in one patient’s death. Yet the patient who died had suffered from advanced congestive heart failure, and there was no conclusive evidence that the stable dose of OxyContin he had been taking for many months had contributed to his death of respiratory failure. (Pain specialists say that a dose previously well tolerated would be extremely unlikely to cause respiratory failure.) Moreover, it is pain, not pain medicine, that adversely affects the heart.

  Not all of the DEA’s investigations and arrests of pain doctors are bogus: in some of the cases the doctors seem clearly to have been acting as dealers and writing prescriptions to patients they never saw. But in recent years there have been hundreds of investigations and dozens of arrests, and many of the cases seem to echo Dr. McIver’s. Appeals of his case have been denied.

  THE INVISIBLE HIERARCHY OF FEELING

  Although affluent, educated patients are often able to find physicians willing to treat their pain for them, the most vulnerable members of society are not. “Pain is a good measure of our humanism,” Dr. Daniel Carr says. “To value someone’s suffering, you have to validate them as a person. We shouldn’t be surprised that the least-valued members of society get the least pain relief. The deck is increasingly stacked against treating pain if anything about the patient’s profile suggests their treatment course may be problematic. Poor people are more likely to sell their drugs. A lot of physicians feel, Why bother?”

  Sex, race, and class adversely influence pain treatment. Many of Dr. Carr’s patients would have—and have had—trouble finding another doctor to prescribe pain medication for them, because they have some social strike against them. Many are minorities, women, recipients of public assistance, workers’ compensation cases, patients suffering from mental illness, patients with histories of substance abuse, or patients who fit several of these categories.

  It has often been observed that male and female patients with complaints of pain are treated differently. Men are more likely to be given opioid medications, surgery, and complete exams, while women are given psychotropic medications for depression and anxiety. (One survey found that women with an identical complaint and diagnosis were 82 percent more likely than men to be given an antidepressant and 37 percent more likely to receive medication for anxiety.) Women tend to be either less aggressive in demanding pain treatment or aggressive in ways that are dismissed as mere hysteria. Dr. William Breitbart conducted a study of women with HIV that found that they are twice as likely to be undertreated for pain as men are. Dr. Breitbart found that women’s fear of being perceived as demanding when asking for pain medication, as well as their heightened sensitivity to disapproval, made them hesitant to report pain to their physicians. He decided to design a course for female AIDS patients on how to better communicate their needs to their doctors, and (“I swear this is true,” he says) some doctors he met when lecturing on this topic responded with concern that the course would “teach a bunch of addicts how to score.”

  Many studies have found that blacks are more likely than whites to be undertreated for pain and denied opiate analgesics. Studies led by Dr. Richard Payne, then the director of the Pain and Palliative Care Service at Sloan-Kettering, showed that minorities are up to three times more likely than others to receive inadequate pain relief—and to have their requests for medication interpreted as “drug-seeking behavior.” A 2005 study at twelve academic medical centers in a primary care setting found that although blacks had significantly higher pain scores, whites were much more likely to have been prescribed opioid analgesics (despite the fact that there were no significant socioeconomic differences between the two populations, such as disability status, unemployment, income, or use of illicit substances). Racial differences became even more pronounced in the groups’ comparative likelihood of receiving stronger and long-acting opioids. The study concluded that racism—“systematic mistrust, bias, or stereotyping phenomena” and “cultural communication barriers or mistrust”—may cause physicians to discount blacks’ pain reports. Other studies have found that physicians perceived blacks as less compliant and have documented unequal treatment of minorities in hospital settings. Pharmacies in minority neighborhoods exacerbate the problem by failing to stock adequate stores of opioids.

  Historically, the unequal treatment of pain has been justified through theories of pain sensitivity, by which certain groups suffered pain less than others. This invisible hierarchy of pain sensitivity was believed to extend from wild beasts to fair maidens and was organized by such attributes as gender, race, social status, education, age, personality, obesity, and even hair and eye color. Countesses and criminals, saints and soldiers, slaves and “savages,” responded to pain according to their fixed, true nature. Some of these theories still hold sway in the practice of pain today.

  The second-century Greek physician Galen, whose theories shaped medicine up until the end of the Renaissance, linked personality to physical traits such as pain sensitivity or vulnerability to disease. He found that of the four “humors” (temperaments), pudgy, contented, phlegmatic types enjoyed a greater pain tolerance than did thin, irascible, choleric ones. In keeping with the Victorian love of classification schemas, nineteenth-century theories of pain sensitivity grew ever more elaborate. Such theories remained prevalent through the mid-twentieth century and are still not entirely extinct.

  A colorful 1938 international bestseller about the history of anesthesia, Triumph Over Pain, by the German author René Fülöp-Miller, reflects many of the prejudices of the day, asserting that pain sensitivity is “a subjective matter, depending on personal characteristics, the outcome of heredity, environment, racial and social circumstances, varying with sex, occupation, age, climate, and individual temperament.” The countryman is “less sensitive than the townsmen, and the mental workers more sensitive than the manual workers.” The old are less sensitive than the young because “British and French investigators have proved that sensibility to pain diminishes with advancing years.” The European is “at least twice as sensitive as the savage,” and some European “races” are more sensitive than others.

  Popular theories of pain sensitivity cannily valued the suffering of the elite while dismissing that of others as not only unimportant but nonexistent. “In our process of being civilized we have won, I suspect, intensified capacity to suffer,” lamented Dr. Silas Weir Mitchell, a pioneer of neurology who documented the lingering effects of nerve injuries among Civil War soldiers. “The savage does not feel pain as we do,” he concluded, echoing the belief of pain theorists through the ages: they do not—cannot—suffer as we do.

  While fortitude manifested by soldiers and other manly men was a virtue, there was no bravery or endurance to speak of on the part of those who supposedly lacked the capacity to acutely feel pain. Poverty was a great anesthetizer, as was the criminal’s lack of morals. Cesare Lombroso, an Italian criminologist, argued that in their insens
ibility to pain, “criminals closely resemble not the insane but savages. All travelers know that among the Negroes and savages of America, sensitivity to pain is so limited that the former laugh as they mutilate their hands to escape work, while the latter sing their tribe’s praises while being burned alive.”

  Slaves’ animal natures dulled them to pain, as did the supposed thickness of their colored skin (although the addition of white blood made mulattos more sensitive). “Negresses,” an editor of a British medical journal stated matter-of-factly in 1826, “will bear cutting with nearly, if not quite, as much impunity as dogs and rabbits,” while an 1856 article in the Southern Medical and Surgical Journal assured slave owners that “the Negro . . . has a greater insensibility to pain” and “suffers deeply, but not enduringly, from affliction.” Lack of civilization was also believed to immunize “savages” from pain. “Savages . . . endure with comparative indifference inflictions which to most persons of the higher races would be terrible,” wrote the British surgeon and pathologist Sir James Paget.

  Theories of pain sensitivity set social expectations with regard to surgery, torture, and corporal punishment and were even employed to justify testing excruciating surgeries and medical experiments on criminals and slaves. The celebrated “father of gynecology,” Dr. J. Marion Sims, one of the most renowned doctors of his time (whose statue can be found in Central Park today), honed his techniques on slave women. One of his greatest accomplishments was inventing a surgical repair for fistulas—tears in the vaginal wall caused by difficult labor. The tears allowed urine from the bladder to leak into the vagina, leading to incontinence and other problems, making such women outcasts. Sims obtained several Alabama slaves who had developed fistulas and kept them in a small hospital where he practiced, without anesthesia, procedures on them over the course of four years. It was not until June 1849, during the thirtieth operation on Anarcha, one of the slave women, that he succeeded in the repair. Moreover, during the last two of those years, anesthesia was already available!

  The insensateness of “savages” was generally viewed much more favorably than that of slaves. Although Native American cultures placed a high value on pain endurance (many Native American puberty rites, for example, involved physical mutilation), whites attributed such endurance not to cultural conditioning but to innate character. Although this myth helped justify torture and slaughter, it also won a certain admiration for Indians. While Indians were sometimes seen as brutish, they were also viewed as innocents. According to the theory of the noble savage, indigenous peoples were untroubled by pain because, like animals, they had tasted less of the fruit that exiled Christians from the natural world. Lacking knowledge of good and evil (lacking even self-consciousness to properly clothe their bodies), they had evaded Adam’s curse and legacy: suffering pain.

  White children were subject to similar debate. One strand of Victorian thought was that since children were not yet fully civilized, they lacked developed capacities for suffering. Another strand of thought viewed children as delicate creatures, more like women than like animals, who required special protection from pain. The increasing prevalence of the latter belief contributed to the decline of corporal punishment and child labor during the century. Since the development of the intellect was thought to yield greater pain sensitivity, there was even concern that education itself might create excessively sensitive children and should be curtailed, especially in the case of young girls.

  Of all sensitive civilized Victorian creatures, however, the most sensitive of all was thought to be the fair-haired, fair-skinned upper-class lady. From ancient times it was believed that the same strong physique that made men hunters and warriors also shielded them from the pain of wounds—a protection not shared by the weaker sex. Belief in the exquisiteness of female pain sensitivity reached its zenith during the nineteenth century. As spiritual creatures, women were expected to suffer from their earthly embodiment; indeed, suffering was considered positive evidence of their spirituality.

  “With her exalted spiritualism” a woman “is more forcibly under the control of matter; her sensations are more vivid and acute, her sympathies more irresistible,” wrote the British surgeon John Gideon Millingen in 1848. The masculine and feminine ideals in regard to pain were not just different, but opposite from each other: men were admired for stoicism and bravery, while women were to cultivate hyperalgesia (abnormally heightened pain sensitivity). In an era whose seminal work was Darwin’s On the Origin of Species by Means of Natural Selection, Victorian society nonetheless favored women who seemed particularly unsuited for corporeal life, especially in regard to reproduction.

  Medical texts treated menstruation in well-bred women as something that required bed rest. Childbirth was thought to be “exceedingly painful . . . especially in the upper walks of life.” City-dwelling women were deemed more sensitive than countryfolk, fair hair trumped dark hair, and of course fair skin outranked all other pigmentation. Even Sir James Young Simpson—the doctor who discovered chloroform and was the first obstetrician to use anesthesia during labor—was convinced that “women in a savage state . . . enjoy a kind of natural anesthesia during labor”!

  Pain sensitivity was considered so reliable a reflection of social status that it was regarded as a proof of rank—an idea starkly expressed in the Hans Christian Andersen fairy tale “The Princess and the Pea,” variations of which are found in classical India, East Asia, and other cultures. Indeed, the tale appears in enough forms that a standard classification system of mythology and folklore labels these stories the “Princess and the Pea” type. In an Italian version of the tale, “The Most Sensitive Woman,” three exceptionally delicate ladies compete for the hand of the prince. One suffers from sleeping on a wrinkled sheet, another is pained when her comb pulls a hair from her head, and the third—the most sensitive of all—is injured by the fall of a jasmine petal onto her slender foot.

  In the 1835 Andersen version of “The Princess and the Pea,” the queen places a pea under twenty mattresses and twenty eiderdown quilts to test whether the bedraggled young woman who shows up at the castle one stormy night is a real princess. The result: in the morning the princess declares herself grievously bruised, thus proving herself fit (albeit not in the Darwinian sense!) to be the prince’s mate.

  The previously incontrovertible fact of female pain sensitivity came to be debated at the close of the century, when some theorists suggested that women could actually bear more pain than men, a point they defended from an evolutionary perspective. “Women, upon whom nature imposes the painful and arduous task of childbearing, can, in general, bear pain better than men,” asserted Triumph Over Pain.

  PAIN THRESHOLD AND PAIN TOLERANCE

  Confusion about pain sensitivity continues, and many of its myths still exert a pernicious influence on patient care by justifying discriminatory treatment. Is there actually an invisible hierarchy of feeling? Or does the curse of ‘etsev and ‘itstsabown afflict all mortals equally?

  Pain sensitivity is measured in three ways. The first measure is on a cellular level, where the nociceptive threshold marks the point at which a thermal (burning or freezing), mechanical (pinching or pulling), or chemical (poisonous or acidic) stimulus is sufficient to trigger the peripheral nerves (nociceptors) designed to sense cell damage. Because it is hardwired by evolution, the nociceptive threshold is common to all members of a species and can be altered only by disease processes, such as leprosy and diabetes, that eat away the peripheral nerves, causing local areas of numbness (called peripheral neuropathies).

  A second measure of pain sensitivity is called simply the pain threshold. The pain threshold is a function of consciousness; it is the point at which the brain processes information from the nociceptors and perceives a stimulus as painful—for example, the sensation of pressure turns to the sensation of crushing pain or the sensation of warmth turns to the sensation of burning. Although it is not as uniform across a species as the nociceptive threshold, the pain thresho
ld is also fairly similar from individual to individual.

  The third measure of pain sensitivity—pain tolerance—accounts for the variability of what we can endure. Pain tolerance is commonly measured in experiments, for example, as the point at which a subject declares a painful stimulus unbearable and asks for it to be discontinued. Pain tolerance depends not only on the temperament of the individual but also on the circumstances of the pain. Not surprisingly, participants in pain studies have no particular motivation to suffer for the sake of an experiment, so their tolerance tends to be low; by contrast, the study’s conductors are very motivated to sacrifice in the service of their own work and therefore tend to discover that their own pain thresholds are high.

  Yet the very participants who are quick to find a mild heat stimulus unbearable in a laboratory would respond quite differently if they had a compelling reason (or, indeed, any reason) to endure it—say, if they were rescuing their cat from a fire, or fire walking in a Hindu rite or a Western team-building exercise. Even in an experimental context, pain toleration varies with circumstances; subjects asked to hold their hands in icy water will endure it twice as long if they are not alone.

  Is pain tolerance affected by gender, race, age, ethnicity, weight, or educational level? Are whites more sensitive than blacks, women than men, the slender than the stout, the fair-haired than the dark-haired, the young than the old, the educated than the ignorant? Clearly, different cultures respond differently to pain. A well-known study of housewives in the late 1960s found that in the United States, what were then known as “Yankees” (white Protestants of British descent) had the highest pain tolerance, followed by first-generation Irish, Jews, and, lastly, among those studied, Italians. (Interestingly, another paper found pain tolerance markedly increased for Jewish subjects with the presence of a non-Jewish, as compared with a Jewish, investigator.)