What physicians can learn from chronic pain narratives

Listening to patients tell their pain stories can be an important tool in helping them cope

Percolating through the rich fabric of life among one in five Canadians today is a silent epidemic capable of bringing lives to a screeching halt.

Even if patients can miraculously endure the long wait-list times to see a physician, they are often met with a disappointing lack of symptom relief. In the meantime, 6 million Canadians grapple with the wrath of chronic pain tearing their lives apart, with more than half suffering from depression and nearly 35 per cent contemplating suicide.

Contrary to acute pain, chronic pain refers to pain that persists for longer than three months. The complex experiences of chronic pain vary widely between individuals and require a thorough pain assessment that addresses its multi-dimensionality.

Although standardized pain assessment tools may be employed, they are simply not enough.

Perusing the evolution of pain assessment strategies reveals an unmistakable thinning of clinical language to describe pain.

Decades before the advent of modern anesthetics, physicians were encouraged to elicit complex pain accounts from patients.

For example, a patient once asked his physician in1730 whether he was tired of hearing “so tedious a (t)ale” of pain, to which he graciously replied, “your (i) ngenious way of telling it, gives me a greater insight into your (d)istemper, than you imagine.”

Since then however, the test of time inevitably took its toll on physicians’ perceptions toward pain, who came to view patients’ descriptions of suffering as contributing little to the identification of disease processes. They refuted the validity of the rich language with which patients conveyed their enduring aches by invoking the flawed nature of physiological symptoms.

Nowadays, although pain tools such as the McGill Pain Questionnaire provide a language with individual words, they fail to solicit stories set within the lifetime context of the chronic pain patient. Meanwhile, other tools such as the Visual Analog Scale — which delineate a spectrum from “no pain” to “the worst pain imaginable”— renounces the importance, if not the existence, of patient narratives.

With no choice but to bravely adopt a façade of normalcy, chronic pain patients are internally suffering from copious amounts of pain medications.

To make matters worse, medications may exacerbate the pain over time and are associated with adverse effects of clouding the patient’s mind and mood, often leading to self-isolating behaviour.

Not all hope is lost, however. The clever metaphors devised by patients may compensate for the erosion of clinical language to describe pain. For instance, a patient with chronic back pain once exclaimed, “(it) hurt so bad I felt like I had a large grapefruit down about the curve of the back” and a woman who said her persistent headache felt “like a bowl of Screaming Yellow Zonkers popping hard behind my forehead.”

Although important, capturing pain intensity with standardized pain scores should not be the most important aspect in guiding treatment.

Oftentimes, attentive listening to patient stories is the ideal opportunity for physicians to guide the patient in rebuilding their perception of pain through proper education. Initially, patient narratives may expose beliefs that may be harmful, such as beliefs about chronic pain that result in catastrophizing.

Patients at higher risk of disability can be identified by carefully listening to how they speak about their pain predicament, which may reveal counter-therapeutic narratives that prevent healing. From there, physicians can help patients replace harmful narratives with more constructive ones, situated comfortably within a patient’s culture and beliefs.

Thinking back to the young girl I saw during my pain clinic shadowing who was suffering from a tingling coldness in her foot so intense that it crippled her ability to walk, I wonder if the questionnaires booklet did her pain any justice. Did it tell us if her pain trickled up her leg? Did all the 4s she circled reflect her being forced to give up her childhood passion of competitive dancing?

As I mull over these questions, one fact becomes clear: for conditions such as chronic pain for which medicine is not always the remedy, the most important role of physicians is their ability to listen.

Listen to the stories of pain that transcend the dichotomy of being or not being in pain.

Listen to the stories of patients’ heartbreak from never being heard that only magnifies their pain.

Listen to the stories of resilience from patients who continue to creatively frame their experiences that reveal the unspoken meaning attached to their suffering — the long neglected yet indispensable piece of the complex chronic pain puzzle.