PAIN! Throughout time, the burning, stabbing, tearing universal phenomenon we call pain has captured our attention like almost no other human experience. Pain or fear of pain is part of birth, is used in torture and intimidation, and is the focus of palliative end-of-life care in hospices. Another being (human or animal) in pain seems to elicit near-universal sympathy and efforts to help. It is a part of most of our lives, our sickness as well as our healing, and of our efforts to move the body into higher levels of function ("no pain, no gain"). It is also seen as an almost inevitable part of illness, old age, and death. Pain all too often seems a mystery to patient and health-care provider alike. It can’t be seen or measured objectively. In fact, the best measure of pain severity is simply what the sufferer says it is. What do we really know about this ubiquitous and feared human experience? What works for relief?
First a disclaimer. The author has biases. I direct a general hospital multidisciplinary pain clinic in Chicago. I have spent more than twenty-five years working as a psychologist with chronic pain patients in standard medical settings. I read the standard medical research literature on pain and belong to the American Pain Society. I also am a chronic pain patient (back pain and trigeminal neuralgia) and have done a lot of research on myself. I also am a long-time advocate of and consumer of alternative and complementary therapies. I have strong opinions that reflect this mix of traditional and nontraditional attitudes. I have come to believe that an integrated combination of approaches from standard medicine, mind-body modalities, and the alternative/complementary spectrum produce the best results in pain treatment. Read the article with these biases in mind. Further, the topic of pain relief is so large that no short article can cover it adequately. This is only a small slice of the information available on the topic. My focus will be on some of the chronic pain problems that afflict forty-eight million of us.
Pain Is Everywhere
Everybody’s family has pain stories. In 1953, I was witness to my paternal grandfather’s agony when he developed phantom limb pain after amputation of his leg above the knee due to vascular disease. No pain medicine seemed to help and he gradually withdrew into a fog of clouded consciousness, claiming that it felt like someone was twisting his nonexistent foot. Later, my brother lifted a grain feeder and fell to his knees in pain — a cracked vertebra in his lower back, which required orthopedic surgery to fuse the bone. He’s suffered from back pain off and on ever since. In 1963, my new wife had a siege of monthly migraine headaches that would knock her down for two to three days of vomiting, lancing pain over one eye, and light sensitivity. We later discovered all her sisters, mother, and maternal grandmother had the same syndrome. Genetic predisposition plus birth control pills are a powerful combination. Two of my daughters have occasional migraines.
I lifted my wife in play in 1965, which resulted in pain in my back and down my right leg, a problem that has periodically reappeared over the years. In my dad’s last years, the wear and tear of farming brought back pain (degenerative arthritis of the spine) and a dependence on codeine that made him fearful of addiction. My mother, at 85, has arthritis pain in a variety of joints, and suffers the side-effects of repeated steroid treatments, with her pain fluctuation unpredictable, controlled barely by the latest in anti-inflammatory drugs. I have personally developed trigeminal neuralgia (severe lightning-like pain over the lower jaw and face) three times.
This litany is not just to describe one family’s painful odyssey but to point out how common painful afflictions are in contemporary life. According to the American Pain Foundation, about 50 million Americans suffer from chronic pain at any given time and another 25 million experience acute pain each year from injury or surgery. Back pain (26 to 36 million persons) and headache (up to 40 million persons) are the most common forms of chronic pain. More than 25 million Americans suffer from migraine and 90 percent of us will have at least one nonmigraine headache within a year’s time. Back pain is the leading cause of disability in adults under 45 years old. Pain-related absences from work end up costing American employers more than $3 billion a year in wages alone for the 50 million lost work days, according to a study done by Louis Harris and Associates. If you doubt the ubiquity of pain, just take a look at the pain relief section of your local drugstore where Americans spend $3 billion yearly. Marketing for prescription and over-the-counter pain medications can run in the hundreds of millions of dollars. We will buy anything that promises relief, from aspirin to magnets.
Pain Treatment — Past and Present
Pain (the direct sensation usually associated with tissue damage) and suffering (the negative psychological and emotional reactions to pain) seem to be a normal, if unpleasant, part of life. We spend a large percent of our time, money, and effort in health care to remove or control their impact, and with good reason. Thankfully we are getting better at it. Only 150 years ago, surgery was done without anesthesia and analgesics were pretty much limited to opium and willow bark. Now we know that good pain relief in any acute pain situation reduces complications, speeds recovery, and reduces the chance of long-term disability. If the acute pain is well controlled, the nervous system doesn’t get overloaded by pain signals and less frequently goes on to develop the long-term conditions collectively called chronic pain syndromes.
Modern acute pain control is a big part of health care. Pain is coming to be called the "fifth vital sign," to be monitored as closely as heart rate, blood pressure, respiration, and temperature. Recognition that pain is a whole-person problem with profound psychological and emotional components in cause, course, and cure is more common. Virtually every hospital has a pain service — ranging in complexity from a specially trained nurse who works with acute pain, cancer pain, and postoperative patients to a full-bore, accredited multidisciplinary center with a staff of twenty or more professionals. The World Health Organization’s pain control guidelines are called the WHO Ladder approach, and are widely followed in American hospitals, giving a universally effective and easy-to-use model for pain medication use. Appropriate use seems to allow more than 80 percent of patients to get good pain relief in cancer pain and acute pain settings.
On the down side, 70 percent of patients with pain, including cancer patients, are judged to have inadequate pain control. The technologies are there, the knowledge is widely available. What’s wrong with the picture? Physician-assisted suicide for pain relief remains a hot topic. The 34 million pain patients with chronic nonmalignant pain are almost routinely stereotyped as neurotic malingerers or suffering from compensation neurosis. We don’t trust pain that doesn’t go away and we don’t trust potent analgesics. Caregivers of dying cancer patients are still afraid of addiction to narcotic pain medications, despite morphine’s excellent effects and safety. Many physicians and nurses still think this way. They ignore and misunderstand the mind/body aspects of pain, choosing instead to focus only on physical sensations.
Chronic Pain
Chronic nonmalignant pain conditions, defined as noncancer pain that lasts longer than six months and is unresponsive to standard medical procedures, remains a huge, expensive problem. Headaches, back pain, arthritis, neck pain — all can become chronic problems in living and treatment.
Human beings are not well designed to "live with it." The average or "normal" condition of a chronic pain sufferer after six months to years of poorly relieved suffering can be described easily — emotionally exhausted, irritable, sleep-deprived, withdrawn from social and recreational activities, physically deconditioned and fatigued, confused and frustrated, and often ashamed of the feelings of helplessness they experience. They also may have been subjected to extensive diagnostic tests, standard treatments that didn’t work, even surgery, without relief. Financial difficulties from lost time on the job and medical bills add to the overall stress burden. The workers compensation system for on-the-job injuries can be a nightmare of frustration, restrictions, and limited treatment. Clinically depressive symptoms are almost universal after six months of pain.
Since the automatic reflex to pain is to brace muscles, spasm and constriction increase the pain and promote hard, tight, painful muscles all over the body. This confuses the symptom picture, making diagnosis difficult. Multiple medical consultations may also confuse the situation with different diagnoses and diagnostic tests may not show much in the way of fixable pathology. Even magnetic resonance imaging (MRI) or other sophisticated radiology procedures may give confusing and unreliable results. "Bulging or ruptured discs" in the back are commonly blamed for back pain but just as many persons without back pain have this condition. More confusion. The success rate for back surgery is not encouraging in chronic conditions and pain medications may provide some relief but no cure.
In addition to the psychological problems caused by pain, preexisting stresses only get worse after chronic pain sets in. Old emotional wounds act up, and complicate the recovery process. Histories of trauma and abuse can be found in as many as half of chronic pain patients. The psychological effects of pain medications present another problem. Problems with alcohol and other drugs can get out of hand as the pained person tries to cope. Chronic pain truly is a whole-person catastrophe.
How Do You Find Good Chronic Pain Treatment?
For chronic pain conditions, the problem of finding relief is more complex and difficult than for acute pain. First, make sure your primary care physician is taking you seriously about needing answers and relief if the pain doesn’t subside within a normal healing period. Insist on adequate pain medication during the acute phase to help prevent chronic pain problems from developing. Get a really good evaluation by a specialist in the area of pain locus (neurologist, orthopedist, neurosurgeon, gastroenterologist) and a pain specialist if this acute consultation doesn’t get results. Don’t rush to surgery, no matter how confident the surgeon is, unless nerve damage creates an emergency.
Self-Care
Do your homework about your condition. Hit the library or your local bookstore. There are masses of informative and self-help publications. The Internet is a whole world of information, good, indifferent, and just plain wrong. Let the buyer beware and cross check what may be biased or incomplete information on a single site. Go first to the authoritative medical sites like the American Pain Society or the American Academy of Pain Medicine. Major medical centers often have pain-oriented consumer information areas on their Web sites. The consumer movement is extremely active in pain, with advocacy and support organizations abounding. Look at several on the Web to see if there is a consensus for your particular pain problem. The American Pain Foundation is a good place to start. Be an informed pain patient.
Become an expert on your own pain pattern. Keep a pain diary. When, where, how does it hurt? How did it change over time? What helps, what makes it worse. Is there a time pattern? Use the standard medical pain reporting system of "0 to 10," with 0 equals no pain and 10 equals as bad as it gets for you. Try different home remedies such as ice, heat, over-the-counter medications, hot baths. Pay attention to stress and tension effects. Stay active without overdoing. Bed rest usually makes chronic pain worse. Read and try self-care advice. Learn relaxation techniques. Keep up social relationships, recreation, and hobbies as much as possible.
Standard Medical Care
What is the standard of care for chronic pain? There are guidelines in standard medicine, but remember that the standard medical treatments for chronic or complex pain problems are generally limited to three options: medications (including injections), surgery, and physical therapy. Pain treatment programs vary enormously. The basic pain clinic will be a single medical practitioner, usually an anesthesiologist, who is a specialist in a range of pain blocks and medications. At the next level is a solo or group practice with options for medication, surgery, pain blocks, and physical therapy. There are also specific clinics for single types of pain. Headache clinics, for example, offer a wide range of emphases from holistic teams to medication only. Rehabilitation oriented pain programs may have physician specialists in rehabilitation medicine, exercise physiologists, physical therapists, vocational counselors, and psychologists, with a focus on increased function, reduced pain, and return to employment in workers’ compensation patients.
The most complex and most effective is the interdisciplinary pain center, featuring a multidisciplinary team of practitioners. The team typically features specially trained pain physicians of a variety of specialties, most commonly anesthesiology, rehabilitation medicine, or neurosurgery. Fellowships in pain medicine or board certification from the American Academy of Pain Medicine are common. The treatment team might include nurse educators, physical therapists, psychologists, pharmacists, recreational therapists, occupational therapists, chaplains, and vocational rehabilitation counselors. Research often is a part of the program. A holistic biopsychosocial model is the norm with some centers offering alternative modalities.
Norman Harden, M.D., director of the Center for Pain Studies at the Rehabilitation Institute of Chicago (RIC), quotes studies that point to increasing recovery rates as one moves up the ladder from single therapies via injection (35 percent) to those which add psychological care (55 percent) to the interdisciplinary center (65 percent). He is a strong advocate of the multidisciplinary model, suggesting judicious use of medications, pragmatic use of psychological approaches, and a careful return to normal activities, supported by physical and occupational therapies. He also considers nontraditional exercise approaches like Feldenkrais and Pilates to be standard modalities.
A brief note about pain medications and chronic pain management. Expect to receive a variety of medications, only some of which seem to be for pain. Antidepressants are often used to restore sleep and raise pain thresholds. Antiseizure drugs can be very effective for nerve pain. Opiates (narcotic analgesics) are increasingly being used for noncancer pain. Addiction is uncommon in chronic pain patients but physical and psychological side-effects are very common. Opiate use in chronic pain is still very controversial and not all pain physicians are comfortable with it. Medications by themselves are not a solution to chronic pain. A comprehensive program will include several interventions in addition to pharmacology — psychological care, physical therapy, and pain injections.
The Alternatives to Pain
The biggest applications of alternative and complementary health care are for pain. Recognition is coming from standard medicine. Chiropractic care for acute back pain has research support as efficacious. Biofeedback and relaxation techniques are in the approved guidelines for chronic pain treatment. Acupuncture is highly regarded for nerve pain and musculoskeletal pain. How do you fit it together?
Acupuncture and the other Oriental medicine modalities have wide applications in pain conditions. Besides needling, herbals can have anti-inflammatory and pain relief effects. Qi gong, particularly external chi healing, has an excellent record among pain patients.
For back and neck pain, body manipulation therapies speed recovery. Often used in combination with natural and standard medications, they can provide significant relief by reducing muscle pain, releasing spasm, and promoting normalization of circulation. Cranial sacral therapy, derived from osteopathic techniques, is widely used for chronic back and neck problems. Physical therapists are learning this approach in addition to their more traditional tactics. Massage, chiropractic, and particularly deep structural manipulation like rolfing can aid all types of muscular and skeletal pain.
An almost indispensable part of treatment of any chronic pain problem is a psychotherapist trained in mind/body techniques. Relaxation techniques work, and they are enhanced by modern training techniques of biofeedback. Biofeedback is a specific for the chronic headache conditions. Meditation has an excellent research record for reducing pain, and is the center of a very successful pain program developed by Jon Cabot Zinn. Get his books and use them and/or find a local practitioner who is a graduate of his training program. The more controversial psychodynamic psychological emphasis of Dr. John Sarno (see sidebar article) provides relief for many pain sufferers.
Many pain patients begin with a false hope that being inactive will help. This couldn’t be further from the truth. Exercise is a necessary part of the road back to function. Tai chi, yoga (suitably modified to the pain patient), Qi gong, and Feldenkrais exercises are good additions or alternatives to physical therapy in many cases. Don’t forget swimming and water exercises.
The bioenergy therapies (Therapeutic Touch, Reiki, external Qi gong, and related techniques) are general-purpose pain interventions. The research on energy healing and pain is acceptable and the anecdotal data is impressive. Use the most experienced practitioner you can find, preferably one who also does bodywork. Expect to have several visits before you see results beyond relaxation.
Summary
A chronic pain problem can be a confusing and expensive odyssey. Check your insurance coverage carefully and get preapprovals where needed. If you decide to use alternative practitioners, check for coverage. Many policies cover chiropractic visits in part and many chiropractors do interventions besides manipulation — acupuncture, for example. Check with your pharmacist about less expensive generic medications or alternatives.
Try to match your pain problems to the selection of standard medical care and alternative and complementary modalities. Remember that multi-modality approaches work better since you will need to address all of the levels of the pain — mind and body. For example, migraine responds well to self-monitoring of headache triggers, diet changes, medications (preventive and abortive), biofeedback, herbs, and manipulative interventions to the neck. Back pain responds to psychological care, manipulation, medications, exercise (standard and alternative), self-knowledge, bioenergy therapies, and patience. The list goes on.
The combined treatments for arthritis pain would fill another whole article. For this common problem, start with the American Arthritis Foundation’s self-help course of information, relaxation training, exercise, and coping techniques. You might consider consulting an expert in diet and supplements as well as a bioenergy therapist. Find a water exercise program.
The basic advice is "Be informed!" Knowledge is a powerful medicine. Use your head to help your health and relieve your pain. Use anything that works for you. Do your stress and psychological work. Never give up. There is a solution.
Jerry E. Wesch, Ph.D., Health Psychology Consultations, Chicago, IL. Contact him at 312-495-0158 or e-mail to jwesch@iwic.net, or jwesch@schosp.org.
Pain’s Dirty Little Secret