I'm scheduled to have a tonsillectomy in a couple of weeks. At my age, 45, I'm being told repeatedly that the post-op pain will be excruciating. ("You will want to die" is the exact quote.) Why is this? If the pain's so excruciating, why are painkillers not prescribed in amounts that will control the pain? If the pain is not controlled, doesn't this set up a dangerous situation that could result in chronic pain? Are doctors paranoid about prescribing effective relief? I find the thought positively intolerable, and I am no stranger to post-op pain -- this will be my ninth operation.

Deb

I have never read a convincing explanation as to why the postoperative pain from tonsillectomy increases with age. Most ear nose and throat doctors (ENTs) assume that the nerve supply to the throat must change with age, but I do not think that this has ever been proven.
Arguably, a more interesting question is whether this phenomenon is even real. Do kids tolerate pain better than adults? Do adults whine more than their children? Pain is very much a "brain phenomenon." As we say in the biz, "no brain, no pain." Example: Under general anesthesia, the patient experiences no pain, because the patient experiences nothing at all. Nevertheless, the body reacts to surgical pain. Surgeons commonly inject local anesthetic agents before making their first incision on a patient under general anesthesia. Why bother, if the patient is unconscious? Because the patient's body still reacts to pain. By injecting a local anesthetic, the surgeon makes the anesthesiologist's job easier, because the anesthesiologist does not have to deal with the great fluctuations in heart rate and blood pressure that are associated with surgical pain.

The adult brain is a great deal different than the toddler brain, which is different from the older child's brain, and so forth. Does the same injury (a 1cm incision on the back of the hand with a scalpel, for example) entail the same degree of pain for a four-year-old as for a 40-year-old?

I suspect that a great deal depends on fear, anxiety and depression. When we tell our adult tonsillectomy patients that they are going to be in a world of pain, is this a self-fulfilling prophecy? In other words, do we provoke so much fear and anxiety in the patient as to predispose him or her to a more painful outcome?

Sorry to rant, but your first question is thorny and only stimulates a variety of other questions, all of which are, I suspect, unanswerable. Your other questions are a great deal more approachable.

Can your doctor prescribe pain medications sufficient to control your pain? Certainly. You will need to be very clear with your doctor ahead of time that this is extremely important for you. I would ask, "What are you going to prescribe for me? And if that doesn't work, what will you prescribe for me?" Make it clear that you will not tolerate inadequate pain management. Given this forewarning, your doctor will probably make absolutely sure, ahead of time, that your medications are adequate. Otherwise, he'll have an angry patient (bad for business) who will call him at all hours to complain about her pain (bad for the doctor's mental health).

Can undertreatment of pain lead to a chronic pain syndrome? Theoretically, yes, but I have yet to see this occur following tonsillectomy.

Are doctors paranoid about prescribing effective pain relief? Absolutely. In times past, doctors used to be afraid that they were "creating addicts," and consequently there was a tendency to underprescribe narcotics. This sort of prejudice still exists in the medical community, but most caregivers now realize that narcotics are not addictive if they are used only to relieve pain. Nowadays, we're not as afraid that we're creating addicts.