When night falls and the world slumbers
You call me with your bitter whispers.
My dreams fill my soul with their dreaded demons,
And you save me from them with your metal fangs
When work trudges on and I grow weary,
You offer no aid, only overwhelming dysfunction.
My calling occupies my mind with lives to save
But you tear me apart before my ego allows me the satisfaction.
Your gentle embrace often becomes a clutch of agony,
That torments me from deep in my very bones.
No cry for help convinces you to release me from my anguish,
As you hold tight, I feel your unwanted love for me.
Daylight reveals your unrelenting obsession,
You neither care nor notice that I wish you away.
My attempts to chase you hence,
Only increase your unrelenting devotion.
Your dance with me is a savage tango,
While the music may sound mellow,
Waltzing with you is quite excruciating,
I am a prisoner of your melody.
Copyright secured by Digiprove © 2018 Linda Girgis, MD, FAAFP
Well said, Dr. I. I practice about 80% with pain patients, the rest with injured, stroked, arthritic, and paralyzed, and they have their own, different pain. The med just complicate things. Though trained in addiction medicine, I’m amazed how intelligent, well, read, and devastated these patients are, yet they always seem to become a hostage to the chemicals. What little life is left, the pills will take from them.
See a few CRPS patients in one week, and you’re done. The cognitive dissonance, the hopelessness, the despair and loss of control, the way so many other doctors make them feel….”Everything is internally replaced, you should be having only a little if any pain…..tell me, how’s your marriage going” and the CRPS patient is ready to scream. Just the air blowing over the sking activates allondynia and altered nociceptive fibers, no different than a thalamic stroke.
So not only in pain, these poor souls feel crazy, because they’re told they must be, since there’s no anatomical reason for your pain, and if so, it doesn’t follow any nerve or spinal root pattern we recognize. Then come the well meaning docs that will cut nerves, add drugs on drugs, send them to a doc for their depression, and still the average latency from onset to diagnosis is months long at best, usually longer, around 7 months, and the irony there is its nearly too late to reverse it fully. Even the Civil War victims who originally had “Causalgia” were mercifiully relieved of their morphine addiction by having the painful leg amputated. Only to learn that the CRPS pain persists, only now its in the foot that isn’t there, and its worse pain since now one really feels crazy, who knew about deafferentation syndromes back then?
Well, we don’t cut limbs off any more, but we still mutlilate, medicate, and miss the chance to give these people back their lives. There are ways to penetrate what has become a fortress of a person, layers on layers of defense mechanisms, walls behind walls, to let anyone in. They’ve had to, no one could understand what they’re going through, and everything doctors try helps a little at first, then it ends up hurting more.
And like you, Dr. I, most of these folks became chronic pain patients from otherwise functionally productive lives, in a matter of seconds.
As pain physicians, we are obligated to try and understand the limbic response to pain, the drop in dopamine and serotonin that fogs the brain, the longterm loss of restorative sleep, the curse of fatigue so unpredictable it makes no sense to even make plans, since it might be a “bad” day which means staying home and numbing onself with pill du jour. Pain doesn’t cause depression, it IS depression, the same derangement of neurotransmitters in enogenous depression is inseparable from that found in chronic pain. Years ago, no surprise that primary care discovered that, given antidepressants, (usually tricyclics back then) the patient felt better. Therefore it was depression with somatic overlay, right? Nope. It was because you afforded a minor correction in the neurobiology of chronic pain, by giving them a drug that increases serotonin and dopamine, can sometimes help with fatigue, and often, helps with restful sleep. But like everything else, it only works for awhile.
The concept of “Double Crush” etiologies for pain from the 80’s is now not only “Triple Crush”, but we are at the “Quadruple Crush” stage and growing. Chronic pain patients have not only the anatomy that caused the pain (Single Crush), but usually the perpetuating feature that won’t let the pain get better (the C-6 radiculopathy that kept the fingers painful after CTS surgery) and we face the (triple crush) of the self propelling depression and lassitude that brings on the psychiatrist or at least cognitive therapist, who help you with the inevitable (fourth crush) addiction to scheduled medications that well meaning docs have each added to the solution to the patient’s pain. So we have an addiction to treat as well.
By now, usually disabled, divorced, unemployed, depressed, foreclosed, repossessed, and addicted, this is how my patients arrive. And we wonder why PMR has the 2nd highest physician burnout rate among the specialties……..