As I’m sure everybody has noticed by now, I’ve had a lingering case of Internet Fatigue. I can’t seem to make myself write much of anything — posts, comments, emails, all of them are like pulling teeth and consequently most of them aren’t happening at all. But sometimes teeth are worth pulling, and I think the last week and a half is worth turning into a blog post, in part because it’s been so eerily thematic. In reverse order, which is also how I’m going to write about it, this is what happened: I went to a terrific, illuminating class on pain management; my sweet, beloved, elderly dog died; and I started reading the Dalai Lama’s new book. Oh, and I heard a number of stories about people struggling with their practices.
I went to the pain management class somewhat unwillingly. Last year, the Oregon Medical Board created a new requirement for everyone who holds a health care license to both do a short online course in pain management, and also to get 6 continuing education hours in a pain management class or classes. Now, for an acupuncturist, practically every CEU class you can take could be described as pain management, so fulfilling the requirement in the letter of the law was not hard. But something about it kept nagging at me, so I actually signed up for the community college class that the Medical Board recommended when they posted the new requirement, because I kept wondering if maybe there was something more that all of us WCA acupunks should know about the topic. I was the only acupuncturist in the class, almost everyone else was a nurse, but everyone was there because of the requirement, braced for boredom with cups of coffee and laptops.
We didn’t need the bracing, or the coffee. The State of Oregon has a Pain Management Commission, and one of its members, Teresa Keane, was teaching the class. Teresa is a psychiatric nurse practitioner who works at the Kaiser Pain Clinic, and she is a terrific presenter. She began the class by explaining the history of the Medical Board requirement: a state legislator in Oregon moved from an urban area to a rural area; she had chronic pain, and she quickly discovered that nobody wanted to renew her prescription for the medications that controlled it. This legislator experienced first-hand some of the realities about pain: pain is misunderstood and undertreated; pain patients are stigmatized; and chronic pain can ruin your life if it isn’t adequately addressed. 30% of Americans suffer from chronic pain, and pain presents as a symptom in more than 80% of physician visits.
I was worried about spending six hours in a class to meet a bureaucratic requirement, but actually I was interested the entire time. It turns out “Pain Management for Health Professionals” at Portland Community College is a covert tutorial on the human condition. I can’t sum up all six hours, but I’ll try to get the important stuff. Pain is a chemical electrical signal interpreted in the brain. There is a big difference between acute pain and chronic pain; they are actually distinct neurological conditions. Acute pain is like an alarm, and chronic pain is like an alarm that is broken. Acute pain is the impulse that keeps you from injuring yourself further, what makes you yank your hand off a hot stove; chronic pain is what keeps you from functioning. One of the most important things that chronic pain patients can do in order to improve their quality of life is to exercise — but in order to exercise, they somehow have to persuade themselves to ignore the alarm in their brains that is screaming at them to stop. They have to persuade themselves that hurt is not harm.
Nobody really understands why some pain switches from acute to chronic, but research indicates that people who have a history of childhood violence are much more likely to suffer from chronic pain. One extremely creative pain researcher, Dr. Sean Mackey, got funding to do functional MRIs on chronic pain patients; his studies allowed people to watch their brains react to signals and to see what parts light up in response to pain. You can actually measure that people interpret pain — especially people with histories of childhood violence — through the brain centers of emotion, trauma, and memory. Chronic pain always has a strong emotional component, and not only because being in pain for a long period of time can cause anxiety, depression, guilt and shame.
Besides exercise, the next most important thing that chronic pain patients can do to improve their quality of life is to get in touch with, and then learn to have some control over, their mechanisms of attention. Fear of pain increases pain. Stress and pain travel up the same pathways to the brain. Giving up pleasurable activities because of chronic pain will ultimately make the pain itself worse. The goal of behavioral modalities, such as cognitive behavioral therapies, relaxation techniques, and spiritual counseling, is to reduce the intensity of pain through changes in attention and perception. Researchers have measured that meditation can reduce pain and heal the brain; the same goes for love.
The goal of pain management is to improve quality of life and ability to function. As Teresa explained it, pain clinics do not promise patients that they will get rid of their pain. In part, they teach patients to live a lifestyle that will manage their pain. That means different things for different people. The goal of a pain clinic is often to help patients to keep their pain below a 6 on a scale of 10 — 4 out of 10 is better, but 6 out of 10 is the limit, the equivalent of a diabetic checking his blood sugar and realizing he has to have an injection, right now. Many pain scales relate the numbers on the scale not only to intensity of pain, but ability to function, because activities are what determine quality of life. Kaiser Permanente NW defines a 4 as “constantly aware of the pain but can continue normal activities” and a 6 as “pain preoccupies thinking; must give up many activities due to the pain”. Teresa tells patients, “the only time you can manage your pain is in the present”.
As I was listening, I kept thinking about how often acupuncturists feel like failures when they can’t make someone’s pain go away for good. How often we feel we should be able to manage someone’s pain for them, not only in the present, but in the future, with that one perfect treatment-if-only-we-could-figure-it-out. How we tend to blame ourselves, or blame acupuncture, when pain persists — and how little perspective we have on pain, how little understanding, despite the fact that pain management is 80% of our job. It’s not like we have hours to spend on patient education about pain, but just approaching the problem from a more realistic context would probably make us a lot more effective. What if, every time a patient who was suffering from chronic pain said to us, “It’s not any better, I’m totally miserable” instead of hanging our heads and thinking furiously about possible new acupuncture point combinations, we said, “Tell me one thing that you do that is pleasurable.” And then, whether we came up with a great new point combination or not, what if we asked them to spend 15 minutes doing the thing that made them feel good, before their next acupuncture appointment. Doesn’t it seem like there are a lot of tiny adjustments we could make that might add up to better support for our patients?
During a break I introduced myself to Teresa and asked her if she would be willing to work with me to design some classes for acupuncturists. Her eyes lit up. “Working Class Acupuncture! We love you guys! We send you patients all the time! Sometimes you get really amazing outcomes, don’t you?” It turns out that she tries to get all of her patients to get acupuncture — and she tells them to give it 12 treatments before they give up. So here’s another issue with perspective — eight years ago, when we first opened, I think I would have given my right arm to get an endorsement — not to mention a constant stream of referrals — from a nurse practitioner at Kaiser’s Pain Clinic. And yet there was no way I could have made that happen. There was nothing to do except keep treating patients, keep being accessible to people year in and year out, until without realizing it WCA turned into a significant community resource. And being a significant community resource doesn’t mean being able to work miracles for everybody, it means offering people who are struggling to manage their pain one more option, one more tool, one more choice.
Because the bottom line is that life is suffering.
Part of the Pain Management class was reviewing medications and their effects — another thing I think would be helpful for acupuncturists, just so that when patients tell us what they are taking, we know what they mean. I knew what a couple of the meds were only because I had spent the last two weeks giving them to my thirteen year old dog — hiding them in food when he was eating, forcing them down his throat when he wasn’t. We took him to the vet when he suddenly couldn’t stand up on his own anymore. He went from robust late middle age to very frail and very old in a matter of days, with no warning at all. Bloodwork showed that his pancreatic enzymes were all wonky, which is never hopeful. The options were hospitalization or hospice, and we chose hospice, on the basis of, it’s what we would want if our positions were reversed, if he were the one calling the shots and we were the ones who couldn’t get up off the floor. The vet sent us home with a bottle of Tramadol, one of those drugs that doctors are often unwilling to prescribe to people in chronic pain.
Mostly it was not bad. Mostly he did what he did before, which was to be wherever we were and sleep. The big difference was that if we went to another room, or outside, we had to pick him up so he could go with us. Never in his life did he like acupuncture, so we were grateful for the drugs, and they seemed to work. The last day of his life was very, very hot, so we weren’t concerned that he was panting; in hindsight, of course, it wasn’t panting, it was labored breathing, one of the symptoms of active dying. I went to work at 4 and he and Skip went to take a nap. Skip listened to him panting for awhile until he finally took a deep, deep sigh and rolled on his side. Skip thought, oh good, he relaxed; but of course when Skip looked at him fifteen minutes later he was gone.
When I got home from work, I saw immediately what Skip meant. Gone is unmistakably gone, when you’re talking about an old dog body with no one in it anymore. It was like looking at a husk, or a burnt out match. It was immediately clear that he had stayed with us as long as he possibly could, until he used up every last ounce of his life. That’s one of the things I loved about him: he gave all of himself, all of the time, he never held anything back. We buried him in the garden. I would not have thought that shovelling dirt on top of my dog would be a bearable thing, but actually it seemed pretty normal, under the circumstances.
I’ve been around a lot more death than most Americans my age, but for some reason, all the people I’ve known and even been close to who died did not carry the message home to me in the way that one elderly flat-coated retriever did. The message is: everybody dies. Everybody. No exceptions. It’s not necessarily a mistake or a tragedy or a problem. It’s just how it works. Nothing has to be WRONG for it to happen. That’s what makes it feel really inevitable.
Most people are in pain, and everybody dies.
And the Dalai Lama can really talk about it in a way that makes sense.
Apparently, just as there’s no one pain management strategy that works for everybody, neither is there one religion or philosophical system that works for everybody, and the Buddha knew it, and so he taught a variety of doctrines, even to his own followers, based on what he thought was appropriate. “Based on their mential outlook, ” His Holiness writes tactfully, the Buddha taught some of them to concentrate only on peace and happiness for themselves, and prohibited them from ehgaging in many activities and many purposes. I was happy to read this, since at various times in my life I’ve been chided by spiritual people for not being detached enough, for being too busy, for getting too involved in the world — the assumption being, I guess, that if I were clear about the nature of reality, I wouldn’t care so much. I’ve felt vaguely guilty and defensive about that, because I’ve been meditating for twenty years, really I have, and yet it hasn’t made me more detached. Maybe I’m doing it wrong? I always wondered, so it was pretty exciting to hear the Dalai Lama say that’s not the whole story: “indeed, in terms of yourself you need few activities and few purposes, but in terms of the well being of others you need many.”(pg 48, Becoming Enlightened).
I feel like Nagarjuna got it right: “You are living amidst the causes of death/Like a lamp standing in a strong breeze”. But what are we supposed to do with that? “Sometimes when people come to accept that they might die at any time,” His Holiness explains, ” they draw the mistaken conclusion that planning for this life is useless, so they do not really accomplish anything. However, this is not the point; we just need to place less emphasis on our own happiness, on living a long time, accumulating more and more wealth, building a house beyond what we really need, and the like. Instead we need to engage in activities for the welfare of society as a whole, such as building schools, hospitals, and factories; we need to base our lives on altruistic concern.” (pg 67) Or, even more simply: “Focusing only on yourself is the problem; being concerned for others is the solution.” The solution to: most people are in pain, and everybody dies.
In the midst of my thematic week and a half, I heard a few reports of people struggling with their practices: with their patient numbers, with the people they work with, with their self-image as acupuncturists. People getting discouraged. It got me thinking about the sunny side and the shady side, you know that description of yin and yang? Yang is the sunny side of the hill, and yin is the shady side. Same hill.
There are so many ways to motivate and encourage people from the sunny side of the hill, and at one point or another, I’ve used them all. A lot of CAN is about the sunny side. Analyze the dire situation of acupuncture in this country with your bright left brain and make some
common-sense adjustments, and things very quickly look much more hopeful. There really are a lot of people who want acupuncture, and they will find you eventually, if you make it possible for them to afford you. Acupuncture really does work beautifully when people can get enough of it. Nurse practitioners who work in pain clinics will become fans of yours without you having to do anything extra to make it happen, if you just hang in there, I promise. You will have lots and lots of patients who love you. You can market yourself to the people you know without cringing. You can have comraderie instead of competition with other acupuncturists. Viva la revolucion! I could go on and on with the sunniness, all of it true.
But at some point I think you need the truth of the shady side, or maybe I just need to be on the shady side because that’s where my dog is buried. A lot of what I’ve heard in people’s discouragement is some version of: uncertainty is really hard; community acupuncture is great, but is this whole thing going to work out for ME? Am I going to get what I want?
Well, per the Dalai Lama and my dog, no. Ultimately, it isn’t going to work out for you. You’re not going to get what you want. Because that’s not what life is.
Or maybe, you need to make some adjustments to what you want, given that business about being a lamp in a strong breeze.
I think practicing community acupuncture is a good, constructive response to the problem of most people being in pain and everybody dying. But it’s not something you should do because you think it’s going to work out well for you or give you what you want. Remember how part of what shook Prince Siddhartha into becoming the Buddha was seeing a sick person? A suffering person? You have to be able to hang out all day on the shady side, with sick and suffering people, with people in pain. If you do community acupuncture, do it because life doesn’t work out, it isn’t supposed to. Do it because compassion is sanity. Compassion is refuge. Compassion is pain management for all the pain you’re never going to get rid of, your own and everybody else’s.