New strategies taking the hurt out of pain 'epidemic'

By William J. Cromie

Gazette Staff

Pain is personal. It escapes the objective measurements of science and hides among the slippery subjective slopes of personality, attitude, beliefs, and emotion.

A pain that one person shrugs off sends another to the emergency room. Some people who take a dummy pill that they believe is a strong painkiller report relief from their distress. It's well known that those who are anxious and depressed feel more pain than those who are emotionally comfortable.

This inability to put a logical handle on pain is becoming increasingly frustrating as doctors struggle with multiplying medical syndromes and insurance claims.

"Disability from pain has exploded in the past 50 years," says Robert Jamison, assistant professor of anesthesia and psychiatry at the Medical School. "It's become an epidemic."

No one knows exactly why, but Jamison, who works at Brigham and Women's Hospital's Pain Management Center, is willing to take an educated guess. "Perhaps we've become softer, not as accustomed to hard work and hardship, so that discomforts we once ignored now hold our attention," he says. "Also, we're living longer. We undergo more surgeries and have more disabilities. There's more opportunities to experience pain."

Technology for treating pain has proliferated in the past 50 years and doctors have become smarter about using it. They also are taking more advantage of alternate treatments like relaxation, biofeedback, acupuncture, opium-based drugs, and even exercise, especially in the past 10 years.

"In the past decade, we've gone from trying to fix chronic pain to helping people live with it," Jamison explains. "We've learned more about what causes the trouble and who benefits from what treatments. Many large hospitals have opened pain centers."

In such centers, patients are treated by a team consisting of a doctor trained in pain medicine, a psychologist or other mental health professional, physical therapists, and other therapists and nurses. These professionals administer a broad range of treatments, including electrical nerve stimulation, medication, exercise, relaxation, massage, and positive thinking. They help patients to manage sleep, sexual problems, stress, weight, and depression.

That kind of care can be expensive, $5,000 to $10,000, but Jamison believes the results are promising enough that insurance companies and health management organizations can be convinced to pick up the tab.

He and his colleagues studied 315 patients treated by this multidisciplinary approach in Boston, Atlanta, and Brookfield, Wis. The majority said that their pain feels less severe, they get more sleep, and their activity levels and coping skills have improved. A number of them returned to work, and fewer than expected needed surgery or hospitalization for their pain.

"The multidisciplinary approach results in significant improvement," Jamison says. "However, many people continue to experience pain that affects their mood, sleep, sexual activity, and ability to work and socialize. There is still a great deal to learn about what causes pain and what can be done to relieve it on an individual basis."

It won't relieve many aches and twinges, but the American Academy of Pain Medicine has come up with a new name for those who specialize in trying: algologist, from the Latin algos, meaning "pain."

Weather Effects

Jamison wrote a book called Learning to Master Your Chronic Pain (Professional Resource Press, 1996) to describe what he and others know about managing pain. "I was answering the same questions over and over, so I decided to write down the answers," he says.

Doing the same things again and again prompted many pain centers to start group therapy sessions to lower treatment costs. Weekly sessions for a period of ten weeks cost about $500 at the Brigham and Women's pain clinic.

Jamison and his colleagues at this center and elsewhere are working to expand their understanding of what causes pain and why various treatments do or don't relieve its torments.

On cold, rainy days, the waiting rooms of pain centers fill up with more people than on warm, sunny days. Jamison and some colleagues gave questionnaires to hundreds of people in cities with notoriously changeable weather (Boston and Worcester) and warm, stable weather (San Diego). Most of them said that changes in weather affect them.

Cold, damp conditions bring on the most complaints, but in the majority of patients, the aggravation begins before the actual weather shifts. "This leads me to conclude that changes in barometric pressure are the main link between weather and pain," Jamison says. "Low pressure is generally associated with cold, wet weather and an increase in pain. Clear, dry conditions signal high pressure and a decrease in pain." (See the Gazette, Sept. 26, 1995.)

Testing Drugs

Jamison and colleagues at the Medical School also are finishing a two-year study of the use of opioid drugs, such as morphine and codeine, to relieve long-term pain, mostly due to backaches. A small number of patients whose agony went unrelieved by other treatments received set or self-controlled doses of opioids that included morphine. They monitored their pain, movements, moods, and medications on a daily basis with a handheld computer.

"According to preliminary results, the drugs decreased pain and improved mood," Jamison notes. "Patients said they were less anxious, depressed, and irritable. The most important finding, however, was what didn't happen: no one became addicted or had problems with withdrawal."

These findings convince Jamison that "people with chronic pain use opioids in a biologically and psychologically different way than addicts and people who take them for recreational purposes. Those in pain experience no euphoria, so they do not abuse the drug or take it in the absence of pain. They say they don't need it to get high or escape reality, just to get on with their lives. This matches the experience of people with terminal cancer who took massive amounts of the drugs then recovered from their illness without an addiction."

Opioids, however, are no miracle cure. While some improved significantly and came off the medication, others couldn't tolerate side effects like dizziness, nausea, drowsiness, and restlessness. Some patients who didn't take narcotics were as functional as those who did.

"It's still controversial," Jamison admits. "But more pain specialists are willing to use opioids now than 10 years ago, especially when patients can be closely monitored. I certainly think it's a viable option for people who have exhausted all other possibilities."

Acupuncture

Jamison and Stephen Birch of Yale University School of Medicine also studied the potential of acupuncture. They split 45 people into three groups; one got acupuncture at sites believed to be involved in their pain, another received acupuncture at irrelevant sites, and a third took nonsteroidal anti-inflammatory drugs like Motrin. All had chronic neck pain, such as results from whiplash. The patients took 14 treatments over a period of three months, then they were followed up for six more months.

"Those with relevant acupuncture showed more improvement than those with the nonrelevant variety, and both did better than the group that got none," Jamison says. "These findings add to a growing body of evidence that acupuncture can help control pain."

Some HMO's now cover the procedure, and many doctors working in pain management are training to do acupuncture. Jamison sees this as part of a growing trend of patients and pain centers to try alternate treatments such as massage therapy, Tai Chi, humor, and meditation.

"Each technique is another weapon in an arsenal that should help us obtain a better understanding of what causes pain and how it best can be managed," Jamison comments.

Asked if women feel pain more than men, Jamison notes that women go to pain centers, and to doctors in general, more often than men. "They also show more anxiety, and anxiety is closely tied to pain," Jamison points out. "However, no evidence exists that men tolerate pain better than women, although many men like to think they do. Any gender differences are easily overridden by individual differences."

The same is true of race. "Asians pay fewer visits to pain centers, and some ethnic groups, including the Italians and Irish, are more verbal about their grief," Jamison says. "But such cultural differences don't have much meaning as far as treatment goes."

And as far as it does go, it must be tailored on an individual basis. Compared to 10 years ago, algologists have become smarter about the tailoring. "In the past, people might have had 6-10 surgeries to fix back pain," Jamison says. "Now, it's hard to argue for a third surgery after two failures."

Jamison himself suffers from migraine headaches, and a note of frustration creeps into his voice as he speaks about the inability to "fix" pain. "The U.S. has the best health care in the world but we still don't have fewer pain problems than other nations. We can transplant hearts and kidneys and put men on the moon, but we must be content to live with some pain, at least for now."