Escaping from chronic pain

By LORI WEISBERG
COPLEY NEWS SERVICE

Chronic pain, put in the simplest of terms, is like an alarm bell gone amok.

Once triggered, it will not shut off, and little by little it eats away at the nervous system, unleashing a cycle of torment that is not limited to just physical discomfort.

Such is the pervasive affliction that is believed to affect more than 50 million Americans, often leading to severe depression, loss of self-esteem, unemployment and sometimes, financial ruin. By some estimates, pain results each year in $100 billion in medical costs and lost work.

"Leaving that pain alarm ringing chronically sensitizes the entire nervous system so that it becomes dysfunctional and leaves people with an intractable pain syndrome," said anesthesiologist and psychiatrist Scott Fishman, who heads the pain medicine division at the University of California Davis and is author of the book "The War on Pain."

"The problem with pain is you really can't prove or not prove that someone has pain. But ignoring pain has its own set of risks, and we need to know that if we don't treat it there are terrible outcomes that occur not only in human suffering but also in disease."

Visit any message board on at least a dozen Web sites devoted to chronic pain, and the torment is inescapable: "Where does it all end?" one entry laments. "I just want my life back" is the plea of another. "There has to be a better way. There just has to be."

Where intractable pain was once regarded as an inevitable consequence of some underlying disease or injury, increasingly it is being recognized as a separate malady that requires sophisticated specialists to treat it.

While chronic pain clearly comes in many forms - recurring headaches, lower back injuries, arthritis, nerve disorders - it typically is defined as pain that outlasts the normal healing period.

While hard statistics remain skimpy, a 1999 Gallup survey found that close to 42 percent of Americans experience pain daily and, on average, people with moderate to severe pain have lived with it for close to 11/2 years. Not surprisingly then, pain management has become a huge growth industry, spawning throughout the country special clinics, centers and multidisciplinary programs devoted exclusively to the treatment of chronic pain.

Treatments can vary from cortisone injections and surgical intervention to biofeedback, hypnosis, psychological counseling and physical therapy. Finding the right medication - and dosage - to fit the patient also is a key component of pain management.

At the University of California San Diego's pain center, which is housed in the department of anesthesiology, the patient count is approaching 10,000 visits a year, reported the director, Dr. Mark Wallace.

In many cases, such clinics are a place of last resort for chronic sufferers who believe their complaints have been ignored by their doctors or their pain undertreated.

"Oftentimes, one of the most powerful things you can do for a person at a pain clinic is to relate to them and acknowledge the suffering they're in," said Dr. Sandra Chaplan, who teaches at the University of California San Diego School of Medicine and is a scientist with Johnson & Johnson Pharmaceutical Research and Development. "Sometimes it's just enough to have someone with a white coat hold their hand and say, 'Yes, I believe you, and I totally affirm what you're saying. You're not a wimp; you're not a malingerer.' "

In spite of the huge demand for pain services, only recently have physicians been getting training in the specialty field. That may explain, argue some patient advocates, why chronic pain sufferers often are ignored or simply undertreated.

Last year in California, the Legislature approved a bill requiring most physicians to obtain continuing education credits in pain management and end-of-life care as a condition of renewing their medical licenses. In addition, California medical schools, as of a couple years ago, are required to include pain management as a part of the curriculum.

"Most doctors know how to treat a medical problem, whether it's an organ or bone problem, but if that underlying illness is not treatable or there's residual pain, they don't really have the background on what to do," said Steven H. Richeimer, director of the University of Southern California pain management program.

"The choice of the word 'management' is controversial in our field. When I see a patient, I never tell them all we can do is to try to help you cope (with the pain). By working on other techniques, such as stress management, by using the mind over the body, you reduce the actual source of the pain."

But, typically, relief often comes in the form of medication, such as anti-inflammatories, such as ibuprofen or narcotic painkillers, such as Vicodin, codeine and OxyContin.

Controversy, though, has swirled around the potential abuse of such narcotics to the point where a backlash from all the publicity has made some physicians more skittish about prescribing the drugs for the patients who need them most, suggest some pain doctors.

Yet other pain specialists acknowledge they shy away from potent painkillers, fearing problems with dependence and tolerance to the medication in which higher and higher doses may be required. The notion that chronic pain sufferers can become addicted to these opioid medications is simply a myth, insisted UCSD's Wallace.

"There's less than a 0.1 percent risk of addiction if the medication is being taken for the treatment of pain," he said, basing his conclusion on studies he's seen. "Movie stars become addicted when they use it as an escape mechanism for their stress, whereas with chronic pain patients, when the pain goes away, they go off the drug."

Dr. Jerome Stenehjem, director of Sharp Memorial Hospital's rehabilitation center in San Diego, however, is concerned that continued use of the stronger medications can be counterproductive in patients whose chronic pain is frequently heightened by the anxiety, stress and depression that he said is typically associated with this intractable condition.

The mind, he argued, can in fact be a powerful ally in helping extinguish those sensations and hence calm painful muscle tension.

"People come to me with what I think is muscle-based pain and they're taking opioids to mask the symptoms, while the underlying disease is worsened by the medication," said Stenehjem, a specialist in physical medicine. "I convince them we have to reconnect their brain to their muscles and in so doing they reconnect to their families and communities.

"But many patients can't (initially) accept the conservative approach. They'd like a quick fix."

Not everyone, though, can quell their pain with conventional pain-management techniques, countered Skip Baker, a militant activist in the war on pain. He has long depended on narcotic medications to relieve the pain he suffers from a progressive, debilitating spinal and joint condition.

He launched his American Society for Action on Pain in the mid-'90s to combat
what he said is the under-treatment of pain by physicians fearful of losing their medical licenses for prescribing painkillers.

"I had a doctor who told me there was nothing wrong with me, that it was all in my head," said Baker, a former commercial photographer who lives in Williamsburg, Va. "I only had half a bottle of pain pills left, so I stopped at a store to buy a 12-gauge shotgun because I thought I'd end it all. This is why I started this group. There have been so many people who've written and said, 'If I hadn't found your Web site, I'd be dead by now."'

Wallace, who teaches a fellowship program in pain management, understands well the frustrations of the chronic pain sufferer.

"In the beginning, I tell the doctors (in the program) if you're a suspicious person, you don't belong in pain medicine," said Wallace. "You can't see pain, you can't measure it.

"Rule No. 1, believe the patient, give them the benefit of the doubt."

http://www.sj-r.com/sections/news/st...09302002,e.asp