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There are days that all of us regret. Some are related to a misunderstanding of some kind, others are related to a conflict we cannot resolve, yet others are due to chronic illness and how it affects our spirits. Chronic pain and fatigue makes cowards of every man, woman, and child. A life with chronic pain, for whatever reason, is difficult. There are two different types of chronic pain. One is somatic: some part of a person's body hurts all the time. The second is emotional: Post Traumatic Stress Disorder is one of the most common forms. Both types of pain can be devastating.

One of the most confounding realities in the medical industry is the lack of necessary tools to assess chronic pain. Humans are visual creatures. Physicians are a subpopulation of the human race and they possess all of the flaws that a visual creature has when dealing with non-visual situations. In medical school, we were taught that the best way to diagnose disease was to take a thorough history of an illness and its progression over time. It is the spoken word that helps most in finding where someone hurts, how they hurt, and possibly what is causing their pain, not physical visualization. Patients present with all kinds of symptoms, but pain is probably the leading symptom that drives people to seek medical attention. Pain is not something anyone can visualize in another person, regardless of whether it is a condition that maybe fleeting, episodic, or constant. There are no meters to measure pain. People have different pain thresholds. And each physician has vastly different emotional and cognitive constructions about pain, especially how to assess and treat it.

Chronic episodic unrelenting pain, either somatic or emotional, is probably the most difficult symptom to diagnose and treat. Many patients who experience chronic pain become frustrated with the medical system. Most of the time they are told that their blood test results and scans are all negative for any chemical or anatomical derangement. Physicians are usually dismissive of their pain when they do not find a concrete anatomical disturbance that could be related to the narrative of their painful episode or emotional demons. Part of the problem is that people in pain tend to look normal - whatever that is. Those who suffer from chronic pain usually develop coping skills to allow them to function in the world while being in agony.  A patient may have a splitting headache at the time of their physician's evaluation and be able to calmly carry on a conversation about their cephalgia at the same time. Or, their arm may be sending intense pain signals to their brain but they are still able to put on make-up or dress up while seeking the attention of a doctor purely out of respect for the medical system as a whole. The better a patient looks during an examination, the less likely a physician is to take their complaints seriously.

A woman came into the office last week from a small rural town on the extreme eastern border of Kentucky. She had a number of ailments, one of which was chronic pain. She was under the care of a number of physicians in various specialties, chiropractors, massage therapists, acupuncturists, nurse practitioners and physical therapists, all of whom had vastly different opinions about source of her severe occipital neuralgia and chronic pain. She was on fifteen or more drugs, all of which made her more ill, not less. She was very clear about her onset of her headaches and the fluctuations of her menstrual cycle. When her ovaries were removed, her headaches went away for months. She thought she was cured. But when the headaches returned, no one measured her estradiol levels. Her physicians believed the trigger was from something else. However, her blood results showed she was making an abundance of estradiol without her ovaries. Her adrenals and body fat were producing a large amount of estrogen. She had the levels of a woman who was in her follicular phase of her menstrual cycle. She did not have postmenopausal estradiol levels. Her results were much higher. It made me ask the question, "Are you sure they took your ovaries out?" She said, "Damn sure."

When I showed her the levels, she was as amazed as I was. We decided to take a course of treatment that would not only block her estrogen receptors but also diminish the adrenals ability to make estradiol and estrone. I am not sure it will be successful, but we have a good chance that the medications can reverse her pain by reducing the untoward effects of her endogenous production of estradiol. Despite the fact that she did not look ill, she was.

Chronic emotional pain is much more devastating for our patients. No position in life is comfortable. Talk therapy is seldom helpful. Something goes hay wire in the thought process itself. The human brain's operating system goes rogue and can no longer stop the limbic system from firing off sadness or misery. Everything is dark, gray, and compassionless. Numb is followed by tears, which is followed by more tears and more emotional pain. It never seems to end. Every day is just another day to breathe in the breath of unhappiness. Medications do not reverse the pain or suffering. Patients think about death as a possible way out but cannot make any plans because they almost live in a vegetative state. Physicians are uncomfortable around these patients and these patients are uncomfortable around their physicians.

So, what is the point? The point is you cannot judge a patient by the way they look, just like the cover does not define the book. Chronic pain is real and affects millions of people worldwide. The next time someone says they are in pain, think about what it is like to be in pain. If you have never been in pain, you may not know.

But for us who have been in pain, we know. And we know is not how you look that matters. It's how you feel. Everyone deserves a chance to be pain free. Everyone.

Doc  

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