How easy it is to fix pain doesn't equate how severe the pain is. Difficult to treat and severe pain both deserve sympathy.
Difficult to treat severe pain
I want to start by acknowledging that oftentimes severe pain is difficult to treat and vice versa.
These two characteristics are correlated because if pain is not severe than weaker painkillers are likely to be effective.
Additionally the OTC painkillers Tylenol and ibuprofen are actually extremely versatile meaning they work well on most types of pain. In contrast many "stronger" pain medications like SNRIs, muscle relaxants and nerve pain medications only work on specific types of pain.
Obviously, the worst type of pain is severe and untreatable. But it is important to remember that untreatable pain and severe pain both cause significant and unique impairment and challenges.
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Severe treatable pain is still severe
Oftentimes there is a misconception that if pain responds strongly to painkillers it is less severe. For example, if your headache responds to Tylenol it wasn't that bad.
But while one reason for pain to respond well to a pain killer is lack of severity, another is when it has a very effective medication match.
For example, dissolvable aspirin (something available OTC) is often one of the most effective treatments for cluster headaches. However, cluster headaches are one of the most painful conditions known. The reason dissolvable aspirin works for some patients and not for others is unknown but it does not seem to correspond to headache severity.
Likewise, some migraines respond to triptans and others do not. This likely has to do with the underlying pathology of migraine. Something poorly understood. Responding more strongly to triptans does not always correlate with pain intensity.
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Untreatable pain is not necessarily more severe
While severity of pain does affect how treatable it is, certain types of pain are more responsive to medications than others. If pain is not responsive to medication it may take very large amounts of painkillers to make any difference in overall pain levels.
It is often assumed by doctors that the reason pain is not responding to painkillers is the dose is not high enough. This is especially true when doctors prescribe opioids. But some types of pain respond very minimally to opioid medication. For example, my migraines barely respond at all to opioid medication.
This assumption that lack of response is due to severity and not a match between class of drug and pain type harms patients because it can lead to side effects worse than the pain the doctors are attempting to treat.
Untreatable pain is awful because it cannot be addressed. But we should not assume the level of someone's pain just based on how treatable it is.
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Drug Demonization
If you go online you will find lots of people who demonize prescription painkillers. I believe these people suffer from untreatable non-severe pain. In short, their pain was not that debilitating, but it responded poorly to medications so their doctor kept prescribing more to "get it under control."
Non-medication pain control methods like heat and ice, massage, physical therapy and so forth work well on both medication responsive and medication-unresponsive pain. So when these patients finally try something other than medication they get relief, without the massive list of side effects from their high medication dose (which was high not because of severity but because medication was not very effective).
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Drug Idolization
In contrast, there is also a large group of patients who minimize the struggle of painful conditions as only a lack of pain management.
"If the doctors would just prescribe us the drugs we need, no one would have to live in pain." This group claims.
Like the last group, these people also write from personal experience. The pain they experiences was genuinely severe. It was debilitating and disabling and without their medications they wouldn't be able to function.
But the problem is that untreatable pain does exist. Both severe and minor. Pain that cannot be fixed with the drugs we have. It is wrong to simply push these patients onto more and more drugs.
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Matching Issues
It is important to note that there are a substantial number of patients for whom pain relief is available but who are given ineffective pain relief due to poor doctoring. For example, someone being prescribed opioids for migraines when triptans and preventatives might be much more effective. Or taking massive amounts of Tylenol and ibuprofen to mask the pain of a muscle spasm disorder.
Pain medication is not a monolith and when possible pain should be treated by treating the underlying cause, not masking the effects. Arthritis treatment should not be opioids it should be anti-inflammatories that stop the joints from degrading in the first place.
While obvious, our medical system is often more preoccupied with making a patient go away than making a patient get better. GPs in particular are prone to prescribing general pain killers when they do not have the expertise to treat the underlying condition.
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Quality of Life = Treated Pain Level + Medication Side Effects
Our goal should be to optimize this equation. Avoiding assumptions about the correlation of pain severity and medication effectiveness is essential to doing this.
If you assume any pain is a sign that you are undermedicated than you may end up with more side effects than benefit.
If you assume that a strong response to medication means the pain was not that severe you may undervalue how important a patient's prescription is. (For example, just because someone's pain responds really strongly to the lowest dose of opioid or CBD doesn't mean that Tylenol will be good enough for them.)
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Medication Is A Neutral Tool
It is not an inherently good or bad thing to take medication. If medication helps you, you should take it. There is no such thing as a normal amount of pain. Most chronic pain patients do not medicate to zero pain. But that doesn't mean you shouldn't if doing so gives you the best quality of life.
Likewise, you shouldn't feel pressured to take medications for pain if you prefer how you feel off of the medication. Pain meds can cause cognitive dysfunction, drowsiness and fatigue. Some people prefer functionality over comfort and this should be respected.
For chronic pain, however, data shows that we consistently under treat and under-medicate. Being dependent on pain medication because you have chronic pain is not being addicted to pain medication. It is essential that we remember that responding to treatment doesn't make a patients underlying condition go away and thus a good response to pain medication is not a reason to undermine belief in the severity of the original pain.
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Things to remember
Just because your pain responded well to a medication doesn't mean it wasn't severe.
If your pain didn't respond to a medication don't just try more of the same thing. Consider alternative classes of pain killer.
Just because a medication doesn't work for you or caused you more side effects than benefits doesn't mean it is evil.
You should take however much medication is required to maximize your quality of life.
Your pain being treated effectively doesn't mean it wasn't/isn't bad.
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Pain Management is a complex topic and can be made difficult by severe pain, chronic pain and untreatable pain. All three of these are different issues.
Severe pain is pain that is intense and disruptive to daily life. acute pain may be more functionally disruptive whereas chronic pain may be less visible due to functional adjustment but in either case all efforts should be made to relieve pain and improve quality of life.
Untreatable pain refers to pain that is not treatable with modern medicine. While some people mistakingly believe all pain can be alleviated by high enough doses of medication this is not always true. In some patients such as those with MCAS or MCS the strongest painkillers like opioids may be contraindicated. In hospice and palliative care patients, painkillers may simply be insufficient to mask the extreme pain caused by illness. In some patients with fibromyalgia and CRPS, migraine and allydonia all painkillers simply fail.
Severe pain is more likely to be untreatable. But that does not make all untreatable pain severe, or all severe pain untreatable. When only one of these conditions is met and medicine treats the two as interchangeable it can lead to poor patient outcomes.
Additionally, while untreatable pain is rare, pain that does responds only to a select few classes of painkillers is common. Therefore, it is extremely important that doctors do not simply adjust dosages when pain is not responding but also the correct class of painkiller. Past history by the patient of which painkillers are most effective can also provide valuable insight into what sort of condition may be causing the pain. For example, a strong response to NSAIDs might suggest an autoinflammatory issue.
Remember: the goal of pain management is optimal quality of life. In chronic pain patients, studies show that we consistently under prescribe and under manage pain. Painkills and patients deserve the right to choose how to balance medication side effects and pain relief.
