Treating Pain Without Breaking Something Else

By Andrew Esch

The Palliative Lens

THE QUESTION THAT DOESN’T GO AWAY

There’s a moment in almost every clinic day where I feel it.

It’s not uncertainty, that’s always there.

Something more.

A quiet, persistent question:

Am I helping… or am I just choosing which harm I’m more comfortable with?

PAIN IS NOT A NUMBER

Pain in serious illness isn’t theoretical. It’s not a slide deck. It’s not a guideline table.

It's always fascinated me that we choose to measure something so individually unique, so complex, on linear scales.

It’s a 26-year-old sitting across from you who didn’t expect their life to look like this.

It’s a phone call at 9:30pm because the pain broke through again.

It’s the look, not the number, when someone tells you their pain is “a six,” but you know it’s an eight, maybe a nine, and they’re just tired of saying it out loud.

And every decision you make lives in tension.

WHAT WE ARE TAUGHT TO FEAR

We are trained to fear opioids.

And we should be.

We’ve lived through the rise of Opioid Use Disorder. We’ve seen what happens when good intentions meet bad systems. We’ve inherited a culture where prescribing can feel like crossing a line you can’t uncross.

So we hesitate.

We lower the dose.

We try one more adjuvant.

We tell ourselves we’re being careful.

WHAT WE DON’T TALK ABOUT

But then there’s the other side.

The side we don’t talk about as loudly.

The patient whose pain is undertreated because we’re trying to be “safe.”

The one who stops sleeping.

Stops eating.

Stops being themselves.

Because we were worried about what might happen later, and ignored what’s happening right now.

THE NO-WIN SPACE

And then there’s the part that feels like failure no matter what you do.

If they become sleepy?

You went too far.

If their mental status changes?

You missed something. Or caused something.

If they call after hours in pain?

You didn’t go far enough.

If their pain score is still high at follow-up?

You failed.

There is no clean win.

Just tradeoffs.

THE 26-YEAR-OLD PROBLEM

And it gets harder when the patient is young.

A 26-year-old.

With a cancer history.

Maybe technically “in remission.” Maybe not.

But still in pain.

Still needing something.

And now you’re not just treating pain.

You’re making a decision that could follow them for decades.

Do I start long-term opioid therapy?

Do I not?

What am I protecting them from?

What am I abandoning them to?

WHERE METRICS FAIL

This is the part of medicine that doesn’t fit into metrics.

There’s no quality dashboard for this.

No clean denominator.

Just you, a patient, and a decision that will almost certainly be imperfect.

WHAT PATIENTS ACTUALLY SEE

And here’s the part that gets me every time.

Even when I walk out of the room feeling like I missed it...

Like I didn’t get the dose right.

Like I didn’t fix the pain.

Like I’m just managing decline, not changing anything....

They say thank you.

Genuinely.

Not politely.

Not performatively.

They thank you for showing up.

For trying.

For seeing them.

HOW WE GRADE OURSELVES VS. HOW THEY DO

It’s disorienting.

Because in our heads, we’re grading ourselves on outcomes.

• Pain scores.

• Side effects.

• After-hours calls.

But patients?

They’re grading us on something else entirely.

• Did you listen?

• Did you care?

• Did you stay?

THE ILLUSION OF CONTROL

We are taught that good medicine is about control.

Getting the variables right.

Optimizing the plan.

Avoiding harm.

But in serious illness, control is mostly an illusion.

Pain evolves.

Disease progresses.

Bodies change faster than our prescriptions can keep up.

STAYING IN THE TENSION

So maybe this isn’t about getting it right.

Maybe it’s about staying in it.

Holding the tension.

• Accepting that treating pain means accepting risk.

  
  

• Accepting that avoiding risk has its own consequences.

  
  

• Accepting that sometimes both paths feel like failure.

And still choosing to sit down.

Still choosing to treat.

Still choosing to care.

WHAT THIS REALLY IS

Because even when it feels like we’re not doing enough, or doing it perfectly-

To the person in front of us, we are not failing.

We are showing up in the one place most people won’t.

Right in the middle of the hard thing.

And sometimes, that’s the treatment.