There is one aspect of treating chronic pain that physicians almost never discuss with patients. It’s too upsetting to the patient, and frankly it sounds like an insult.

It’s simply this: despite all their protestations to the contrary, few patients with chronic pain act as if they really want to get better. Indeed, most physicians I know avoid treating people with chronic pain. It seems like a lost cause from day one.

Of course, the sort of patients I’m talking about insist the exact opposite is true: they can’t find the right doctor who will make them better. It feels like there’s no one who will take them seriously. Doctors promise great results, but their treatments fail, and then the doctors dump the patient or accuse them of not having “real” pain. Or the pain is “all in your head.”

Why discuss this at all, since it’s so upsetting? Simply this: if you’re someone with pain not due to cancer that’s lasted more than a few months, you might be able to use the information I present here to get better.

There are four possible reasons why a person with ongoing pain hasn’t gotten better. The first is no one’s found the true “cause” of the pain. (This is what most pain patients believe.) Second, the right diagnosis has been found, but the patient hasn’t received the correct treatment. Third, the right diagnosis has been made and the correct treatment supplied, but all the available treatment can’t relieve the person’s pain. Their problem is simply too severe. Finally, the person in pain is behaving in a manner incompatible with getting better.

In many of the patients I see, all four of these reasons are true to some degree, but the last is often the most important.

Let’s talk about “Arnie,” a fictional patient of the sort I’m talking about. Arnie comes to my office five years after injuring his low back. He’s had three surgeries and over a dozen injections into the back. None of eight physicians who have treated him could help. He’s taking large amounts of “narcotics” like Norco and OxyContin, and the dose keeps creeping up. His back pain gets worse every year. Now it’s spread to his neck and whole back. He hasn’t worked for four years and is broke. He can’t sleep. He is incredibly irritable and depressed because he hates himself for not being able to function and he hates his life. His marriage is rocky, and his family avoids him. He insists all he wants to do is get better and get back to where he was before he was injured.

Arnie limps into my office leaning on a cane. His face is contorted in pain, and he shifts position frequently. He’s suspicious and has a chip on his shoulder. The gist of his history is that all of the doctors who’ve treated him so far are incompetent and uncaring. Arnie erupts in anger when I ask about emotional or psychological issues. He insists, “I have real pain!” He tells me no one could possibly understand how he feels unless they have pain as bad as his.

Arnie has had a tough life from childhood, although he’s also had periods that worked well. Arnie insists everything was perfect before his injury. Arnie has zero insight into his emotions. He blames whatever’s gone wrong on other people who don’t care. He treats every adversity as an obstacle that must be defeated. He knows just two ways to cope with any problem: fight with all his might or to give up in defeat. He constantly reminds me he’s not a quitter.

Arnie is clueless how angry he is. When someone points out excessively irritable behavior, he denies it or blames it on others. (If you’re not careful, he’ll do this at the top of his voice.)

There are variations on this theme:

  • “Annette,” another fictitious patient, has had fibromyalgia since her 20’s. She’s gone from one dysfunctional, abusive relationship to another. She has no idea how to find people who won’t take advantage of her and actually seeks out people who “need” her. She has severe adverse reactions to every treatment provided.
  • “Joey” is the helpless, passive version of Arnie. Though inside he’s just as angry, on the surface he’s much more reasonable. He is overwhelmed, depressed to the point of paralysis. His family keeps reminding him how much everyone always takes advantage of him. He’s too tired or upset to really engage in treatment and just goes through the motions.
  • “Margo” has trouble keeping a job for more than a few months. She’s a professional victim who’s sued every employer she’s worked for. Most treatments make her pain worse.
  • “Howard” is an addict who discovered how easy it is to fake a workers compensation injury and then be paid to sit at home and use drugs.
  • “Connie” worked for a small, family-owned firm for twenty years. She loved her job and worked countless hours off the clock, without pay, just out of devotion. Two years ago, her employer sold their business to a large corporation, who hired a new manager. This “boss from hell” came in to clean house and has set her sights on Connie. Connie was rear-ended three months after her previous employer left the firm. Now her whole body hurts, and she’s been disabled for a year.

This sounds overwhelming. How could any of these people get better?

My understanding of what happens is that some patients remain stuck and never do improve. But many do reach some sort of resolution of their pain and move on. Sometimes they find a doctor who provides the missing ingredient. More often, they realize doctors really don’t know what to do — they’re on their own. As they “get used to” their pain, they stop fighting. The pain diminishes, and other problems take its place.

Still others have a life crisis that demonstrates how emotionally distressed they really are. As they begin to accept the need to work on themselves and acknowledge the issues facing them, the pain simply goes away.

Here are some lessons I’ve learned from treating patients with chronic pain:

  • Those who yell the loudest they have “real” pain actually have the most severe psychological issues preventing improvement.
  • The cause of chronic pain is usually a complex mixture of genuine physical issues plus emotional distress and poor coping. You need to work on all of it.
  • Sometimes there is a simple medical explanation and a simple treatment that cures everything.