Shades of Pain

Many people think of pain as one sensation, one thing. But as I've learned on the pain service, pain comes in many forms and colors; each distresses a patient in a different way and each requires a separate treatment modality. For most of us, we think of pain as nociceptive pain, the type of pain we experience if we cut ourselves or burn ourselves or touch something acidic. It is the pain we expect someone to have after surgery. And indeed, a majority of our patients are post-operative, and this kind of pain responds well to opiates. But other types of pain include neuropathic pain, the type of discomfort long-standing diabetics feel in the absence of injury. Phantom limb pain occurs when a patient has an amputation but still feels his hand and fingers. I saw a patient with this that was extraordinarily difficult to control. Headaches have many characters but most of them are not related to the pain we feel if we slam a car door on our fingers. Whether a common tension headache, a low pressure headache worse when standing, an electrocuting trigeminal neuralgia, or debilitating migraine, pain takes on many different masks.

The worst pain I saw on this service was cancer pain. Unremitting, relentless, and unabating, cancer is really an awful perpetrator. These are the patients where we pull out all the stops. When metastatic disease invades muscle, nerves, adjacent organs, the spine, we have to tackle the discomfort with everything we have. The most extensive pain regimens I've seen involve patients with end-stage widely invasive cancer; they are on multiple fentanyl patches, suck on fentanyl lollipops, use hydromorphone PCAs with settings that would immediately overdose anyone else. We even use medications that double as street drugs like ketamine. What makes this difficult for me is that cancer pain does not get better. While pain improves after a surgery or a cut or a burn and even occasionally with nerve damage, cancer pain is dogged and challenges our ability to palliate until the end of life.