Pain’s Promise, and the Problem with Pills


Recently, I was watching a game on the tube when a Prilosec OTC commercial came on, featuring a portly Larry the Cable Guy (an actual user).  As with previous TV spots, he indicated that one Prilosec a day removes all heartburn and “lets me enjoy all the foods I love” (insert grill and fried food) without the pain.

As the commercial ended, a question quickly flashed in my mind.  “Instead of taking the daily pill, why wouldn’t he just stop eating the foods that caused recurrent heartburn?”  Of course, just as quickly as the question came, answers quickly followed:  food tastes really good and provides a quick reward and comfort, everyone else is eating it, it’s cheap, and so on.  As the days passed, though, I found myself coming back to this issue.  Besides the fact that repeated heartburn might be a sign that more healthy habits are needed, maybe the heartburn is alerting Larry to something else just as important.

A couple of years after I started graduate school, I began to notice some dull discomfort in my knees.  Despite playing a variety of sports through high school and into college (intramurals), I had been one of those fortunate souls to not have any knee issues.  But as the weeks went by, the aches persisted, and so I finally decided to consult a physician.  When the issues arose, my activity was largely confined to periodic cycling and volleyball, with an occasional jog thrown in.  After medical testing indicated that nothing was seriously wrong, the orthopedist (who happened to be a trainer for the college athletes) suggested that I look at developing a weight routine that could strengthen the muscles in my legs, especially my quads.  Ibuprofen was offered if the pain persisted, but I felt there was much to learn before considering this route.  Years later, I would eventually invest a decent amount of money in a leg press machine, which still gets much use in our basement today.  Along the way, regular strength training became just part of my typical week.

A few years after, I found myself in my final year of graduate training, as an intern in Louisville.  As I detailed in my book “Into the Rising Sun,” I began to experience dizziness, heartburn, and overall fatigue a few months in.  Again, I consulted a local physician.  Again, I was told that all tests were normal.  Medications were offered (both of a physical and psychological variety), and although at some point I took a heartburn med, I eventually had a sense that there was more to learn and I deferred on any drugs.  I started to realize that my activity was largely confined to good weather, that my diet was not as healthy as I thought, that my two-a-day Coke habit (free in the lounge) might be a problem.  Water became my drink of choice.  Slowly, the symptoms started receding and when I ran (as I started to do more), the chest pain that had me thinking about an early grave no longer persisted in the same way.  Fast forward to the following year.  Our first children (twins) were a couple of months from being born.  I was approaching Market Street near the midway point of my first half-marathon.  I had felt a twinge of that old chest discomfort that persisted in the first few miles.  But as I turned left and headed out towards Forest Park, suddenly I felt the discomfort disappear.  I was on my way.  Although it would return from time to time in the decade that followed, I effectively left the pain behind that had taught me so much, the pain that I had feared and wished it would go away instantly, but seemed to stick around long enough to make sure the lessons had been learned.

Meanwhile, as I grew stronger and more active, my knees still reminded me that they were there in various ways.  But just like the heartburn of old, something curious happened.  I began to wonder what they were teaching me, and what there might be to learn.  I started to look at ways to grow leaner, to walk, run, bike, and swim more efficiently and ergonomically, to use my body in ways that seemed more consistent with the amazing gift that it was.  I added regular stretching to my day, looked at no impact ways to strengthen the muscles and other structures that supported the knee.  I discovered the remarkable design of the foot, and how it could be better utilized to handle the impact of running.  Soon it moved from an “I” to a “we,” and Amy and I shared in the engaging search to live a healthier, holistic existence.  It became the lifestyle that we share today.

Fifteen years ago, I simply wanted to understand what was going on with my knees.  I would have never fathomed that sitting here today, I would have been blessed with an Ironman finish, three 50 mile+ runs, a half-day 200 mile bike ride, many century rides, and more endurance events than I can readily remember.  Amy just finished her 2nd marathon this past spring and her first half-Ironman last summer.  All of this has somehow occurred with kids (now 6) in tow, other than that first unlikely half-marathon back in St. Louis.  It has been quite a ride, and even more of a godsend though challenges always persist.  But in reflecting on that heartburn commercial, it is clear to me.  What I believe is truly a divine gift would likely have not occurred without the promise of one thing:  pain.

Equating pain with promise may sound strange, and even uncaring, to all who experience it — especially to a significant, chronic degree.  To clarify, I am not minimizing the horror that pain is for millions of people, and the need to provide compassionate care for those whose pain negatively affects their lives.  But I firmly believe that for almost all of us, pain is a mechanism that exists for many reasons — it is not something we should necessarily attempt to extinguish without first giving adequate consideration to the messages that it may be sending.  Doing so not only further jeopardizes our well-being.  It may also prevent us from realizing a richer, more meaningful, grateful course than we ever imagined.  It has for me, and I know I am not alone.  But if we simply see it as an obstacle to disable, we are missing the promise that it may hold in the heart of its unwelcomed presence.

My knees still bother me today regularly although every time I have consulted my orthopedist about my concerns, I have left feeling very fortunate to have the knees I have.  Right now, I have some mild inflammation on my right knee cap that may be a residual from crashing into the pavement after my bike slipped on wet, diagonal railroad tracks years ago.  Or it seems that the training for my most recent ultramarathon likely aggravated it, calling for an extended period of more modest miles by foot.  I still don’t like the discomfort that presents at times.  It would be great to go back to those early years when knees just did their job, and remained silent.  But what I have come to know is that although I will probably will never have the exact answer I desire about this joint, the discomfort I feel motivates me to keep learning, keep innovating, and keep pursuing an active existence decades from now.  For the first 20+ years of my life, I took my health and movement for granted.  Less than a year from 40, I am grateful for it every day.  I still don’t like pain.  It still makes me nervous about what is to come.  But with all apologies to Larry the Cable Guy and Prilosec, I know the answer isn’t just to take a pill.  I must be willing to listen to what pain might have to say, if I am to learn to bear what comes my way.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


  1. I don’t see what your example of physical pain has to do with emotional pain, the focus of this website. Clearly in this society physical pain is much more tolerated and empathized with than emotional pain. You never would have gotten pathologized or stigmatized for knee pain but plenty of Americans get pathologized or stigmatized for emotional pain. Americans are like Cro Magnons when it comes to how we view emotional pain.

  2. kwb1965:

    Ever hear about the mind/body connection? Western medical doctors are the only healers in the world who do not diagnose and treat individuals holistically. Instead, they divorce the mind from the body to the detriment of their patients. Haven’t you ever had a chronically painful condition that caused you to become depressed? Some people with chronic debilitating pain become hopeless and even suicidal. Of course, this article is related to the focus of this blog! Many individuals seeking physical pain relief, such as fibro-myalgia, go to their doctor only to receive an SSRI or in some way are told “It’s all in your head”. On the contrary, many individuals suffering from a spiritual emergency or the after effects of childhood trauma may reject the one-size-fits-all psychiatric approach (“label and medicate”) only to be told from alternative healers that they have a dietary allergy, inflammation, etc. Either way, individuals cannot have enough exposure to recovery stories so that they can make good treatment decisions that fit their situation and their bodies. This is a recovery story and a good one at that! If the writer of this article had gone down a different path, say by taking pain-killers, who knows where he would be now, maybe with the other million or so Americans wondering how they can get off the pain med merry-go-round.

    Furthermore, the little old lady who died of an opioid over-dose is a potential ally of the psychiatric survivor/consumer. After all, both have something very important in common: the problem of the undue influence of the pharmaceutical companies on public health policies, billing practices, clinical decision-making, etc. Jeesh.

    I can see how some who are reading this article may be hard pressed to relate to an individual who participates in an “Iron-man finish”; many like me, are overweight, slightly depressed, suffer from chronic physical pain. I can barely run or swim without gasping for breathe. But I am very inspired by this person’s story and am delighted that he published it in this blog.

  3. Hi James,

    problem for me is if I start listening to what my body is telling me, they say i’m hearing voices and need an anti psychotic lol. Pill for every ill?

    I know that when I was younger and playing sport that an injury to a knee if ‘braced’ to get through could result in a ‘traveling’ injury. I once sprained my ankle, strapped it to get through and before I knew it had both knees and the ankle strapped, and hips that felt like they were coming loose. Covering pain to get through is a short term solution with consequences that are easy to ignore.

    Kind regards

  4. Thank you, James. This is such an important theme, and very nicely laid out here, and really inspiring.

    It also converges with some of my own recent thoughts and I thought I’d toss out a bit of writing I did just a couple of days ago–perhaps these musing on emotional pain will be interesting along with yours on physical. Here is what I wrote, with the main point starting in the second paragraph. The only thing I’d add is that antidepressants kept me from realizing all this for many years by tamping down pain that needed to be felt.
    – – –
    Sitting in silent meditation at Quaker meeting, what arises in my mind, up through a peaceful stillness, is a thought exercise I use to help my students in environmental studies see the importance of alternate perspectives, even on issues that might seem clearcut. The exercise goes like this. Climate change is the one issue that all of us should be able to agree must be a top priority— right? There are, of course, “climate denier” close to home, often with ulterior motives, but consider also, I say to my students, that you are a young child in a poor country and you spend your days, long boiling hot days, scavenging through the steaming stinking piles of a giant garbage dump, a landfill that holds the worthless refuse of millions. You do this to stay alive, perhaps among orphans, a small society of small people, or perhaps to help your family in the only way you can. There are many real children who live such lives, I tell them. Consider what you might say, if you were such a child, about a looming climate catastrophe that can not be seen or felt but only imagined according to the warnings of scholarly experts with great computers in faraway places, projected out in decades that exceed what is likely to be your own short life. That child inhabits a personal universe that is a small subset of the Earth, which in turn is a small part of a much bigger universe. So: what matters? It all depends. We are not as right as we like to think. I use this exercise not to argue against the importance of climate change, but simply to suggest that we should always consider, and try to imagine, the experience and feelings of others, especially those who have, through sheer bad luck of the draw, not ended up in positions of privilege and power, as we have.

    I am surprised to find that what comes next to mind is something very personal and even more uncomfortable: that we must become aware of our own pain and that I must, in some fashion, speak of my own pain, out of my own little universe, even knowing that there are far worse things happening elsewhere to others. There is no particular reasoning behind this thought, just an intuitive clarity. And suddenly a voice that is both my own and not my own, that comes from inside and from outside all at once, says, deep, driving, powerful, echoing—I can feel it vibrate through my body—“How dare you?” How dare you suggest such a comparison, how dare you elevate your own suffering in this way? And another voice, this one entirely my own, pushes back against that thunderous mountain of prohibition and says, with a much quiter force, “No, we must do exactly that; I must do exactly that.” It is the still, small voice from the bible that my mother used to speak of and that I have heard mentioned at this meeting.

    In the moment, that is as far as it goes; it is simply an assertion, contrary to my own patriarchal conditioning, that all suffering matters and must find a voice—not necessarily loud or public, but some meaningful voice. Later, what comes to me, in relation to my own work with environment and social justice, is a quote from Lilla Watson, the Australian aborigine artist and activist. She says, “If you have come here to save me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together.” If we are not in touch with our own suffering, we will always be coming at those children from above and it is no good. Related but more fundamental is the emergence of our own otherwise burried humanity that comes with the ability to feel and express pain. Pain is the dark night to the bright daylight of joy, and without that contrast neither one would exist in our experience. Pain is what tells us something is wrong and needs to be changed, or what needs are not being met, and so it is something to listen carefully to. Pain also, when unrecognized and unheard, tends to burrow down into the Jungian shadows and to morph into malignancies, aggressions that must go either inward, into self-destructive depression and neuroses, or outward into the world. As Bruno Latour has written, “The repressed returns, and with a vengeance.”

  5. The scientific data supports your approach. Pain management takes many forms. One form is forgiveness and accepting the challenge and moving forward, the example of the injured knee. The other form is to blame the pain, and seek chronic pain management. I am not sure this is an easy choice.

    I think that we are conditioned to the stimuli around us. Only aerobic outdoor exercise offers:

    1) No conditioned place preference
    2) No psycho-stimulant cross sensitivity
    3) Attentuation

    Fatty foods and sugar are substitutes for stimulants that people crave, including pain medication and sensationalism. Enrichment is much like Aerobic activity, but is sensitive to conditioned place preference, which is why we go to the movie theater to watch movies when we could stay at home.

    The reality is that exercise is a lot like the lottery, you have to “be in it to win it”.

    I recently had a patient with a panic attack, and the patient had been offered Zoloft. I asked if the Zoloft worked, and he said that Zoloft did not work. I explained that I can treat the panic in the short term, but the best treatment for anxiety is to get outside, go to the park, and walk for one hour a day. This was recently demonstrated on fMRI at Stanford. There is a difference in walking on a busy street and in the Open Space.

    The point is that the science demonstrates that aerobic activity decreases our desire for stimulation. When we exercise, we no longer need stimulants, and we learn to accept our challenges. The real challenge is that physical activity attenuates, so it is very hard to prescribe. Personally, I would rather go for a mountain bike ride than take vitamins, but I recognize that I am not in the majority. The mountain biking trail is empty, and the vitamin aisle is full of customers. Pharmaceuticals remain a tremendous business model, that in the age of poly pharmacy continue to grow in economic and social importance. Ask yourself, “Today are people thinner?” and the answer is no. Pharmaceutical companies have developed a pill for that, but everyone knows that people eat more to compensate.

  6. I would love to see what the author would learn from an incurable degenerative condition like Ehlers-Danlos Syndrome, Trigeminal Neuralgia, or Complex Regional Pain Syndrome. The problem I have with articles like this one is that in not one place does it mention any of us. It is as if we don’t exist. We are the “other,” not worthy of consideration, as if he assumes that we are a fringe population and/or aren’t intellectually capable of reading his message. This makes it appear that he has a secret target audience in mind: “normal” people like him, which raises uncomfortable implications, as obviously, disabled people have been at the receiving end of at least one major genocidal program in the West less than a century ago. This idea that we are outliers is thus very dangerous. His concept of pain is overly simplistic: his knee pain was caused by improper gait, and could be solved simply by changing his behavior, an idea that runs parallel to his earlier opinion that Americans are causing their own stomach problems through improper diet. The thesis is clear, if not openly stated: people are responsible for their own suffering. While this may often be true in the cases of the two examples he mentioned, most statisticians would question his sample size. This came off to me as condescending ableism from the type of person who considers themselves and their friends to be “normal.” Articles like this lend credence to the epidemic of horrible advice that us sick people get from the population at large, all the time, every day of our lives. We DO exist, and when you add us all up, we’re not a “minority,” no matter how much our eugenist society may wish to see us relegated to the shadows, or, in many cases, to our graves. My EDS is caused by father’s Agent Orange poisoning in Vietnam, and it is one of the most painful conditions in existence. There are tens of thousands of others like me out there, but the government doesn’t take any responsibility for our healthcare because, like you, they feel that we don’t exist. What should I do instead of taking medication to make my pain go away, James?