The meaning of pain

It seems like a ridiculous question for which there is an obvious answer.  Why do we treat pain?  In particular, why do we treat cancer pain?  Why even waste the time to write about an idea so basic?  Pain bad.  Comfort good.  Enough said.

Or is it?  Perhaps, there is a deeper goal in controlling pain. Does pain have meaning?

What are the obvious reasons that we treat pain?  First, as the smallest child will attest, pain hurts.  Pain is a miserable experience.

Pain disturbs sleep.  We must sleep, to heal.  Pain, therefore, interferes with our ability to rebuild, recover and mend.

Pain stops us from moving and by limiting ambulation weakens our muscles, causes swelling, increases the risk of blood clots, pneumonia and a host of other complications.  Not only is pain caused by sickness, pain makes us even sicker.

Pain stops us from eating.  Food loses its attraction as we descend into a fog of agony. Without nutrition, we cannot heal.

Pain destroys our ability to share, think, or communicate.  It breaks down precious relationships and interferes with careful planning and decisions.

Pain continues after death.  Agony is remembered by friends and family long after the patient is gone; the ripples of suffering affect the future.


Yes, pain is bad and the list continues.  Nevertheless, in addition to the obvious, pain is bad not just for how it feels or our reaction to that discomfort, but what pain means.


If, on a perfect bright morning with a slight breeze from the west, I am walking down the street, and I trip over a curb or rock or can and fall, breaking my arm, then I will have pain.  I will need an x-ray, perhaps a rod and pin, likely a cast. I will lose time from work.  Yes, I will have lots of pain.

On the other hand;

If, on a perfect bright morning with a slight breeze from the west, I am walking down the street, and I do not fall, but suddenly my arm breaks, then I will have pain.  I will need an x-ray, perhaps a rod and pin, likely a cast. What if the x-ray shows a hole eaten into the bone and the biopsy shows advanced lung cancer, which has metastasized to the bone?  Once, again, I will have lots of pain.

However, you would not propose the pain is the same. The same bone may be broken, the same nerves inflamed, perhaps even the same surgery performed, but the pain is different.  The first, the pain from a fall, is inconvenience, minor disability and physical discomfort. The second, the pain of cancer spread to bone, is much more.

The pain of cancer means the loss of family, friends and loves. That pain means the end of career, dreams, goals and hope. It is infinite pain. Cancer pain means death.


This may be the most important reason to control pain.  When a person has a dangerous disease, pain is a penetrating reminder of the illness.  Stabbing deeply into the soul, it undermines personality.  Cancer pain destroys all futures.

The wonderful miracle is this.  Controlling pain can restore a man or woman’s spirit.  Medicine, which relieves physical discomfort, can balance the mind.  When pain is gone, vital energy, hope and possibility return.  Even without physical healing, even without treating the cancer itself, the spirit can mend, at least for a while.

So, why must we treat pain?  What is the final goal?  To sooth and comfort not only the body, but the human soul.










    • James Salwitz, MD
      Thank you, jcs
  • Dr. Salwitz, I read several publications by the American Pain Society. They discussed current treatment trends, guidelines and many stories of patients going from doctor to doctor and then..finally finding some resolution. One issue was the importance of swiftly resolving acute pain so as not to cause chronic pain. Also, There should be evidence as to what level of pain most persons would experience during specific procedures.
    • James Salwitz, MD
      I would a agree that monitoring the level of pain is critical. On the other hand, it is important to remember that pain, especially in life threatening disease, can be highly subjective. Thanks, jcs
    • Liz
      And untreated pain can cause PTSD... I remember reading a research article that soldiers who were wounded who got adequate pain control in the field, before they even made it to the medical facility, were far less likely to end up with PTSD than those who did not. Made me think of cancer patients and lack of adequate pain control... and on a related note nausea control during chemo. Cancer number 1 (I am on my 5th) was breast cancer. Had a mastectomy and free tram flap reconstruction which is an excruciatingly painful reconstruction (but very nice results give or take a few "side effects" of the surgery, like it much better than the implant on the other side when I got BC again on the other side - both times lumpectomy was not a viable option due to number of tumors). I had a bad reaction to the pain medication the first day and so I was given only tylenol and was in agony, not wanting to move a millimeter. The stupid resident (surgeon was gone at the San Antonio breast cancer conference) told me I was over reacting and in pain due to anticipating pain. Yeah right. I was not swift enough at the time to ask him when was the last time he had had this surgery to know about the pain levels from it). Took 3 days to get given another stronger pain med which then only partly controlled the pain. I was reasonably sure, even prior to reading that article that this level of horrible pain so connected to the BC surgery is what has made me struggle with surgical and bone marrow biopsy pain ever since (and then of course there is scan anxiety...). During chemo for a different cancer (the one that will kill me) we could not get the nausea under control no matter what was tried. I spent 4 months with terrible nausea, lost 32 pounds... Thought that was the end of it until several months ago (2 years post chemo) when I was given a medication that caused nausea. I way, way over reacted to the nausea and fortunately recognized it for what it was - PTSD.
      • James Salwitz, MD
        We can easily be imprinted by terrible experience (see Tatoo to the Brain - I think doctors too often think that once the event is over, the patient will forget. These pains can last for years. jcs
        • Physiological pain..acute..does not go away usually...geez
        • Next time I have a terrible experience..and am imprinted....geez..I will be less emotional..and controlled rape me..hey I do not show my emotions...(sorry Dr> but that is the rationale one receives at the local police dept.)
          • Liz
            Jill - No one is saying to be that way. What he (and I) was saying is that one of the lasting impacts of all of this is psychological/emotional - something many doctors/people who have not experienced this first hand tend to not understand.
        • The physiological pain is not always also can be a constant reminder of the very painful experience, both physically and mentally. Pain response triggers a normal reaction...when someone tells you to be quiet or control ones emotions..a bit callous.
  • Beautiful. As an end-stage cancer patient, I've had my share of pain and it is exactly as you describe. I also have had my share of denials for cure, mostly in a hospital setting - to the point where I now am terrified to go to the hospital. This should be required reading for everybody in healthcare.
    • I meant denial for control, of course. Cure, I know, is already denied me.
    • James Salwitz, MD
      Thanks very much for the feedback. Make sure your doctors know that failure to treat pain is starting to impair your care. Hang in there, jcs
  • gopja
  • Angela Evans,R.N.
    Your blogs are so insightful. Pain is a constant remember that SOMETHING is wrong. Obviously the pain of cancer is far different than the pain of say pneumonia. I think though if a person has never been ill and suddenly is thrust into the pt. position that can be an extremely frightening and unnerving position for them. Again,thank you for being a caring,down to earth physician. We need more doctors in all specialties that think like you.
    • James Salwitz, MD
      Thank you for your kind words. I think we are seeing more doctors, especially in the younger generation, aware and caring about these issues. jcs
      • Hmmmmmm.....
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  • Liz
    Thank you for frequently writing about end of life issues/snippets about end of life . As someone with a cancer that will kill me I think about these things on occasion (especially if I am having a pity party). My family refuses to allow me to discuss any of this with them. My oncologist needs his feet nailed to the floor to have any kind of conversation (and I have already learned the risk of changing oncologists - being fired from a practice and entire medical system having been there done that already with an incompetent one so finding a new oncologist is too high risk). While not the same as actually discussing these things with someone (and the counselors I have tried to talk to about these things have their own issues with death - including the one the oncology practice has - and aren't especially useful for this aspect of having cancer either) it does help me process what having a terminal cancer means as I find this is qualitatively different than how I felt with the other (4) cancers.
    • James Salwitz, MD
      I am glad I can help, but wish you had someone personal to speak with. Have you checked to see if there is a palliative care physician in your area? If you need help finding one, you could contact the AAHPM (American Association for Hospice and Palliative Medicine). jcs
      • I am not a need someone who will openly speak about and receive any info or what ever you want to say..pity are dying...
        • Liz
          Jill - It is pointless to have a ton of pity parties, a few yes as one struggles (especially early on when grappling with the reality), but to wallow in what can not be changed just makes life more miserable. Life goes on. One has to learn to live with what is and can't be changed (doesn't matter what kind of tragedy if the tragedy event can't be undone/changed). Cancer is only part of my life - at times it dominates it, but it is not who I am. It is what I have. Not all of my life is about cancer. Took me a while to get to that point and now that I have I am happier than when I was in the acute stage of struggling. I still have my moments but they don't last as long and are further apart.
      • Liz
        Dr. Salwitz - haven't checked, but I am unemployed (getting unemployment compensation but my state pays the lowest in the nation so am living below the poverty line) and so the $40 copay will be more than I can afford. While there may be foundation help for copays for this, frequently you are limited to the amount of use you can be awarded by the program and I know another program you have to owe $300 before they will help. Rather I need to save it until I really need it - I am not at that point right now. At the moment reading about end of life issues is meeting my needs. I know that won't always be true, and initially was not true, but right now it is enough.
  • I cannot believe what a--h----are family members...
    • Liz
      Jill - family members are human and have their own strengths and weaknesses. While I wish things were different, and I spent some time really angry, I can understand how denial works to protect one from more emotional pain. I nearly couldn't get myself to talk with my dad over his planned assisted suicide because I was still struggling with my brother's death (turned out he was murdered, but for nearly 10 years we thought it was suicide and so my dad's impending suicide death was close to more than I could handle). Yes they have hurt me over this however but I have a choice in how I respond. I could just walk away - but I don't want to do that. I love them and so that would just punish me in the end. Given that and given that I can't make them change I had to figure out how to come to terms with this aspect of our family. I had to figure out how to maintain relationships despite the fact that their behavior over this hurts me and didn't meet my needs. I had to figure out how not to let occasional anger over this (and my pain over this) poison our relationship.
      • There has been major tragedy in your life. I have lost two of my brothers, one a year older than myself, his life was very tragic, and my youngest brother..just wrenches me, asthmatic who did not make it to the ER, and would always be made to feel uncomfortable when he had to go there, and so. Neither were 50 yet. My medical mismanagement. He was not 50 yet either. All of them were 6'4" handsome and bright. Wrenches my heart. The first brother I mentioned was born with vision impairment., eventually his eye was removed, 19 I think, he was hit on his bicycle. He had been a stabbing victim in NY. I have never really had involved relationships with any of my family members..always thinking and education..paths, very different. I had some violent behavior experiences when I was young and felt, and still do ,separated from them because of the experiences. I picked up on things like you did but somehow your resolution seems a little convoluted to me.
        • Liz
          Not convoluted... I love my family and and I realized that in order to maintain connections I needed to accept them for who they are and stop trying to change them. That was just frustrating me. Took a while to get to that point, and I spent time angry like you seem to be, but it was important enough to me that I made a choice to deal with the situation that way. Others may make different choices.

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