Giving Chronic Pain a Medical Platform of Its Own
By TARA PARKER-POPE
Stuart BradfordMost doctors view pain as a symptom of an underlying problem — treat the disease or the injury, and the pain goes away.
But for large numbers of patients, the pain never goes away. In a sweeping review issued last month, the Institute of Medicine — the medical branch of the National Academy of Sciences — estimated that chronic pain afflicts 116 million Americans, far more than previously believed.
The toll documented in the report is staggering. Childbirth, for example, is a common source of chronic pain: The institute found that 18 percent of women who have Caesarean deliveries and 10 percent who have vaginal deliveries report still being in pain a year later.
Ten percent to 50 percent of surgical patients who have pain after surgery go on to develop chronic pain, depending on the procedure, and for as many as 10 percent of those patients, the chronic postoperative pain is severe. (About 1 in 4 Americans suffer from frequent lower back pain.)
The risk of suicide is high among chronic pain patients. Two studies found that about 5 percent of those with musculoskeletal pain had tried to kill themselves; among patients with chronic abdominal pain, the number was 14 percent.
"Before, we didn't have good data on what is the burden of pain in our society," said Dr. Sean Mackey, chief of pain management at the Stanford School of Medicine and a member of the committee that produced the report. "The number of people is more than diabetes, heart disease and cancer combined."
For patients, acknowledgment of the problem from the prestigious Institute of Medicine is a seminal event. Chronic pain often goes untreated because most doctors haven't been trained to understand it. And it is isolating: Family members and friends may lose patience with the constant complaints of pain sufferers. Doctors tend to throw up their hands, referring patients for psychotherapy or dismissing them as drug seekers trying to get opioids.
"Most people with chronic pain are still being treated as if pain is a symptom of an underlying problem," said Melanie Thernstrom, a chronic pain sufferer from Vancouver, Wash., who wrote "The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering" (Farrar, Straus & Giroux, 2010) and was a patient representative on the committee.
"If the doctor can't figure out what the underlying problem is," she went on, "then the pain is not treated, it's dismissed and the patient falls down the rabbit hole."
Among the important findings in the Institute of Medicine report is that chronic pain often outlasts the original illness or injury, causing changes in the nervous system that worsen over time. Doctors often cannot find an underlying cause because there isn't one. Chronic pain becomes its own disease.
"When pain becomes chronic, when it becomes persistent even after the tissue and injury have healed, then people are suffering from chronic pain," Dr. Mackey said. "We're finding that there are significant changes in the central nervous system and spinal cord that cause pain to become amplified and persistent even after the injury has gone away."
The institute emphasized the importance of prevention and early treatment, a novel concept for many doctors who try to diagnose the source of pain before treating it or advise patients to wait it out in the hope it will go away on its own.
"Having pain that is not treated is like having diabetes that's not treated," said Ms. Thernstrom, who suffers from spinal stenosis and a form of arthritis in the neck. "It gets worse over time."
Ms. Thernstrom compared the effect of chronic pain on the body to the rushing waters of a river carving out a new tributary. Pain, she says, also changes the body's landscape.
"My pain is at the level where it's manageable," she said. "I do wish I had gotten aggressive treatment in the first year. There is a window of time to intervene, because pain changes your nervous system and pain pathways develop"
The report also acknowledged the "conundrum of opioids," noting that doctors are conflicted about how to treat pain because of worries about drug addiction. But the group noted that proper use of the drugs early in a pain cycle can resolve pain problems sooner, and stated that opioids are also particularly useful for pain management near the end of life.
The pain report is only a first step for the community of medical professionals who treat pain. It will be up to medical schools to begin better education of doctors in the treatment of pain, and the National Institutes of Health to decide whether to promote research into chronic pain. Patients, too, need to be educated about the importance of early treatment of pain rather than gutting it out or waiting until it has become severe and chronic.
"Some people were expecting a cure within the report," Dr. Mackey said. "There's no immediate cure. But I've seen a lot of patients who have said, 'Finally they are putting out a report that helps others understand what I'm going through.' "
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9 Readers' Comments
So tragically true. We docs harbor the tenacious notion that only objective reality--what can be seen, touched, measured--is "real."
When I was in med school, I heard that pronouncement from, of all people, a professor of psychiatry. It confused me. I asked, "But what about thoughts? Humor? Love?" He said, "You can't prove any of that is real."
Excuse my very different take. To paraphrase actor Alfonso Bedoya in "Treasure of Sierra Madre," "Prove? Prove? I don' need to stinkin' prove." The hard fact is that it's unimaginable to live without these unprovables, life's very juice.
That's not my point, though. The puzzle of how to treat patients in pain with no known physical source is one docs confront daily. Analgesics can help, of course, but their longterm administration can become problematic. It makes one wonder why medical schools don't feature courses in simply addressing suffering.
My guess is that it's too radical a departure from the "hard" science medicine claims to be. Maybe it's time for a science of the subjective.
Jeff Kane MD http://healthcareasthoughpeoplematter.blogspot.com/
Cheers
This is enough, right here, to confirm my intention to never have surgery except to save my life. My sister-in-law has had a half-dozen elective surgeries in the past ten years and now lives in chronic pain from several of them. No, thanks!
The obstacles faced by people are particularly difficult because the pain can suddenly become unbearable at any time, often forcing them to go to the ER when their regular doctor isn't available to vouch for the reality of their condition. As a result, they get labelled "drug seekers" and are refused much-needed pain medication.
I hope the medical establishment continues to re-examine its views on pain and sees that it is a serious condition in its own right. We see the beginnings of this in California where medical personnel are required to ask if you're in pain when you see your GP, even if pain wasn't the reason for making the appointment.
Thank you so much for bringing this important issue to everyone's attention.
Toni Bernhard
http://www.howtobesick.com
Oh and I'm not drug seeking... I've never asked the doctors for opoids, I just wanted an explanation and wanted to rule out potentially serious reasons for the pain.
The theories about the nervous system mentioned in this article are interesting, but I worry that it will give doctors more reason to say its "all in your head."
The combination of (1) a subjective complaint, (2) an unclear etiology, and (3) high-risk treatments, makes this a veritable minefield for clinicians. I wish I had some answers, but I don't. Perhaps opioids should be taken off the table entirely for non-cancer chronic pain. Once you start a patient on opiate pain-killers, it is near-impossible to switch to another type of treatment. (Similar to treating anxiety with benzodiazepines.)
I was happy to see addition of Pain Medicine residencies. I think we need more specialists who can approach this as holistically as possible.
You can also argue that poor sleep (due to insomnia, sleep apnea, insufficient sleep, etc.) can also predispose a person to chronic pain, once something triggers it, such as surgery, an accident, or weight gain.
In my practice, people who have chronic pain tend to have the following: can't sleep on their backs (especially when they were young), excessive dental extractions, and strong parental history of snoring......
http://doctorstevenpark.com
At first I was frustrated with my long time doctor who follows my injury that he'd prescribe different drugs, adjust levels, with really no effect. Finally my doctor said 'there's really no medicine that can help you'....it was a shock but I appreciate his honesty.
The American medical system is so backward and recalcitrant on the issue of proper pain that they have allowed the ya-hooze at the DEA and geniuses who gave us the misbegotten War on Drugs to be the tail that wags the dog that has resulted in massive suffering and under-treatment of pain, both chronic and acute.
I suppose that if you want to believe that suffering pain is some how macho or ennobling there isn't much you can do for such voluntary masochism.
But doctors need to realize how callused or inured many have become to the suffering of their patients. That so many million continue to suffer pain needlessly in a country that spend more on medical care than ANY OTHER COUNTRY IN THE WORLD is shameFful and blight on the character of our medical establishment. We may have those gazillion-dollar shiny machines that go "PING" but our attitudes toward pain relief are back to the primitive days of dunking witches and belief that a primary cause of illness was foul odors.
This much is true: America's medical system's competence at effectively treating pain STINKS!!
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