How can doctors feel your pain?

Countless people will benefit if caregivers learn to better manage chronic pain and its effects on body, mind and soul


By SHAFIQ QAADRI


Tuesday, April 9, 2002 - Page R6


TORONTO -- 'And that's how I lost my hand, doctor," said a tearful 42-year-old patient, explaining how his right hand had been severed in an industrial accident. He had been in agony since his trauma six weeks earlier. "Even 10 painkillers a day, just takes the edge off the ache."

Somewhat reluctantly, I wrote a prescription for a regulated substance, long-acting morphine, the strongest of all pain medications.

"Treat chronic pain NOW," proclaims one militant U.S. pain advocacy group, which wants to see more patients, not just amputees, receive such narcotic prescriptions. These groups have legions of pain sufferers as members, and have seen how chronic pain robs people of a full and dignified life. They want caregivers to take such patients' complaints seriously, and they are becoming more vocal.

Their research has revealed that many chronic-pain patients remain undertreated: women, members of minorities, the elderly, the disabled and workers on compensation. "Why is there so much unnecessary suffering?" they ask on behalf of the 15 per cent of the population with chronic pain. And their media campaigns and political activism are changing practices.

"People are no longer willing to take two Aspirins and call their doctor in the morning," said Robert Charles, a U.S. pain advocate. The American Pain Foundation has "new guidelines that affirm that physicians have a responsibility to aggressively treat pain." And Mr. Charles wants to see chronic pain treated with the same diligence as hypertension or diabetes.

In Canada, when Allan Rock was health minister, he authorized the use of medicinal marijuana. The Canadian Arthritis Society, which estimates that four million Canadians have arthritis, published a Patient Bill of Rights, in which the right to live as pain-free as possible is entrenched. Yet, despite such publicity, caregivers are just beginning to get the message.

The foundation of doctors' neglect of chronic pain is laid in medical school, as pain is considered a short-term phenomenon, and the management strategies focus on acute disorders.

"Many doctors assume that pain relief is a simple task for which no special training is required," said Dr. Howard Fields, an anesthesiologist at Massachusetts General Hospital. "And this perception interferes with the ability to accept, evaluate and treat chronic pain."

The American response to this educational deficiency has been to create a new specialty: You can now become a pain-management specialist certified by the American Board of Pain Medicine.

But the problems go beyond medical education.

For example, doctors treat terminal cancer pain aggressively, hoping to make a patient's remaining days comfortable. But the vast majority of chronic-pain patients suffer from non-fatal but debilitating pain, and they generally remain undertreated and underrecognized.

Why is non-cancer pain so challenging for physicians? Pain advocates cite many reasons besides doctors' lack of knowledge: Physicians are reluctant to prescribe regulated medications; patients can develop tolerance, dependence and addiction; some people fake their pain to obtain prescription narcotics; the drugs have significant side effects, and no doctor wants to be the agent of a patient's suicide.

To deal with these considerations, the Canadian response has been to create specialized pain clinics, which use a multidisciplinary approach. The Victoria Pain Clinic, for example, has physicians, nurses, psychologists, counsellors and biofeedback experts on staff. With such pooled expertise, the staff strives to deliver optimal and innovative care: The clinic, for example, runs "transformational residential programs for chronic pain," which have long waiting lists.

So what makes chronic pain so different from acute pain?

Pain is the body's signal of imminent harm and demands an immediate response. Everyone has had a needle puncture, burn, electric shock, cut, torn ligament or fracture. You know that the pain, even if severe, is time-limited: Once the wound heals, the sutures are removed or the cast comes off, the discomfort will dissipate. And for most people, it does.

But for some, the pain continues for months. And then it begins to take on a life of its own.

Some patients even refer to their pain as their companion. "It takes me and my pain two hours to get going in the morning," said a 63-year-old woman who suffered a hip fracture due to osteoporosis. "Then we're going to take my granddaughter shopping."

The pain advocacy groups are concerned about people whose pain has become a routine part of their daily plans. They often suffer psychological consequences: the chronic-pain syndrome.

"I spend most of my waking hours just feeling the discomfort," said a 67-year-old woman suffering from a shingles virus infection. "I can't get past my pain."

Patients with the full syndrome feel depressed, anxious, fatigued and are housebound for prolonged periods. Their pain affects their enjoyment, work, socializing and marital and family relations, and they become helpless. These are the very patients who seek repeated surgery and the care of several doctors, often becoming dependent on their drugs.

Such patients display "mental fog," the cloudy thinking resulting partly from the pain but also from the medications and depressed outlook. "I was taking eight Percocets a day and sleeping pills too," said a 45-year-old man with fibromyalgia, a condition that can lead to debilitating muscle aches. Eventually, such patients become prisoners of their pain, and some may even attempt suicide.

What makes chronic pain so difficult to assess and manage?

There is no single illness that leads to chronic pain: It is the common endpoint of hundreds of conditions. The vocabulary used also varies from disease to disease, and person to person. And each person's experience and pain threshold is different: One patient's discomfort is another's agony.

Consider the pain of various diseases: Arthritis causes morning stiffness and joint swelling and is aggravated by cold damp weather; the diabetic patient with nerve damage experiences a tingling, needle-prick effect; patients with fibromyalgia feel cramped and achy all day; spreading malignant cancer pain is relentlessly consuming.

One of the most difficult sorts of pain to alleviate is a disorder known as phantom limb pain: Amputees can continue to feel pain in a lost limb. Just because the limb is gone doesn't mean that all the wiring has been removed: The brain circuitry still functions, and patients feel real pain in the lost appendage.

Besides the number of painful conditions, caregivers can also be overwhelmed by the rich vocabulary patients use to communicate their discomfort. A patient with spreading prostate cancer said, "I'm being eaten alive -- it's a deep drilling pain."

McGill University researchers have tried to make sense of the pain descriptions, but the questionnaire they designed has more than 80 adjectives, including: burning, cramping, tingling, lancinating, throbbing, shooting, stabbing, gnawing, aching, boring, heavy, tender, splitting, radiating, piercing and excruciating. The terms, once sorted out, offer clues about the nature, location, intensity and extent of illness.

Another perplexing aspect of pain management is the fact that each patient's experience is unique. Unlike blood pressure, sugar or cholesterol levels, a person's pain, and how much it affects them, is not measurable.

This leads to the puzzling phenomenon of a person having less disease but more pain, or the reverse.

These variations on the pain theme highlight the difficulties of pain management. The variables confuse and confound caregivers, which affects treatment.

Many patients and even some caregivers incorrectly assume that pain management is only about drug therapy. Though medications are the mainstays of chronic-pain control, there are several ancillary methods. Ideally, a multidisciplinary team approach works best for the patient, as this addresses the physical, emotional, psychological and social consequences of the chronic pain experience.

The most important member of this team is not the doctor, but the patient. Each intervention should be tailored to fit the patient's discomfort, coping strategies, schedule, tolerance and budget. This can be as simple as finding a helpful relaxation tape, orthotic shoes or a more comfortable mattress.

One wish that pain patients seem to share is for their doctors to listen to them more. "My neurologist spends more time writing in my chart than talking to me," said a 37-year-old woman with recurrent migraine headaches.

An intriguing aspect of pain management is that patients who practise a faith -- of whatever brand -- seem to endure their pain better. Engulfed by chronic pain, some patients (re)discover their faith, finding it a source of comfort.

Others attend formal pain support groups. Such self-help groups, run out of hospitals or pain clinics, can become a patient's extended family.

"When chronic pain descends on your life," said Pat O'Reilly, who attends a self-help group in California, "it leaves a path of destruction that is far and wide. Our support group teaches us how to live a better life."

Patients see how other members cope with crises and exchange survivor stories, anecdotes and straight talk about doctors, therapies and medications.

"Take control," said Helen Tupper of the Canadian branch of the North American Chronic Pain Association, which advocates self-empowerment through discussion. "It's your responsibility to tell your doctor you're in pain . . . and speak up if the treatment isn't working."

Clinical hypnosis is another formal pain treatment. A type of psychotherapy, it makes use of the power of the imagination and the layers of awareness below consciousness.

Therapists use a variety of techniques: imagery of a warm beach with healing waves, shifting attention away from the pain, reliving a past triumph, reattending a happy occasion, such as your fifth birthday, or recalling a time when you were carefree. Patients who have practised this guided imagery can recreate feelings of warmth, contentment and health, and this stimulates the brain's natural pharmacy to release its pleasure chemicals, the endorphins -- literally, the "inner morphine."

However, the basis of chronic pain control is still medication.

Unfortunately, the ideal drug -- one that revielves most pain, has no intolerable side effects, is not addictive, does not cause recreational highs and has no street value -- has yet to be discovered.

Once you have exhausted over-the-counter options, you enter the realm of prescription drugs. There is a growing list of drugs to choose from and most physicians will adopt a step-care approach, increasing the strength and quantity of medication as needed.

The new generation "super-Aspirins," including Celebrex, Mobicox and Vioxx, help to reduce joint and muscle inflammation -- the heat, tenderness and stiffness -- and are as effective as older medications, but better tolerated.

Stronger than these are the narcotic painkillers, such as the well-known brands Tylenol 3, Percocet and Percodan. With ever more potent codeine derivatives, these agents cause stomach burning and Olympic-class constipation.

Most physicians have also received phone calls from pharmacists asking to confirm a prescription for one of these narcotics -- a prescription that the doctor didn't write, for a patient he never saw. Doctors are usually cautious when prescribing these agents.

Morphine and its cousins are generally reserved for cancer patients, and there is a constant duel between adequate pain control and side effects.

"I want to be there for my three teenagers," a 47-year-old woman with breast cancer said, "so I don't want to be a zombied-out on the pills all the time." She prefers morphine patches, which she can remove to minimize side effects.

Finally, patients with chronic pain often benefit from antidepressant medications, which help to reduce anxiety and make the discomfort more tolerable. "At least I can get a full night's rest with [the anti-depressant]," said a 52-year-old man who suffered a disabling back injury while skiing.

Chronic pain patients deserve timely advice, targeted medication and management, and genuine compassion and support. This is the goal of quality health care and is becoming part of the law in many jurisdictions.

Caregivers can no longer say: "Sorry, but you'll have to learn to live with the pain."

Dr. Shafiq Qaadri is a Toronto family physician with a special interest in continuing medical education.

Painful conditions

Arthritis

Joint pain and degeneration that affects four million Canadians; most common joints involved are the knees, lower spine and hips; a major source of pain, disability, absenteeism and health-care utilization.

Burns

Third-degree burns destroy the tissue to the bone, and can cause excruciating pain long after the surface skin has healed.

Cancer

Malignant cells, especially once they have spread beyond their primary site (for example, lung cancer invading bone) can lead to constant severe pain.

Diabetes

Excess sugar in the blood damages nerves, and leads to a burning, tingling discomfort.

Fibromyalgia

Causes widespread muscle aches, fatigue and stiffness; many trigger points in the upper back, shoulders, or lower back.

Migraine headaches

More common in women, migraines can cause incapacitating throbbing pain, often accompanied by nausea and visual disturbances.

Phantom limb pain

As brain wiring is still intact, patients continue to feel pain in a lost limb; this type of pain is notoriously difficult to control.

Sciatica

Pressure on the sciatic nerve, often caused by a degeneration of the cushion (the disc) between vertebrae; pain radiates into the thighs, legs, ankles and feet.

Shingles

After infection with the shingles virus (herpes zoster), a patient may experience a longstanding nerve irritation, which leads to a blazing, burning pain.

Trauma

Includes fractures, tears, and amputations caused by industrial, sport, or motor-vehicle accidents.

-- Adapted from The American Pain Foundation

Interventions

Acupuncture

Biofeedback

Braces, canes, walkers

Chiropractic

Clinical hypnosis

Hydrotherapy

Massage

Physiotherapy

Psychotherapy

Relaxation training

Support groups

Yoga

Medications

Over-the-counter: Tylenol Extra Strength, Advil, Robaxacet

New anti-inflammatories ('super-Aspirins'): Celebrex, Mobicox, Vioxx

Patches: Duragesic, Emla

Injectables: Demerol, xylocaine trigger-point injections, nerve blocks

Narcotics: Tylenol #3, Percocet, Percodan

Morphine derivatives: Morphine, oxymorphone, hydromorphone, oxycodone, methadone