Pain Is More Than A Symptom

More clinics focus on the relief of suffering

If you think life is one long vale of tears, full of pain and suffering to be borne stoically, then read no further. Most people, though, are grateful for any pain relief they can get. The problem is, they are not getting enough. The scandal of our advanced health-care system is that chronic and acute pain are habitually undertreated.

Recent studies have found that 40% to 50% of cancer and AIDS patients and two-thirds of nursing home residents are undertreated for chronic pain, even though effective analgesics are available. One recent study found that some 41% of elderly disabled U.S. women with severe pain take little or no medication to relieve the suffering. "Undertreatment of pain is a huge, huge problem," says Dr. Russell Portenoy, chairman of pain medicine at Beth Israel Medical Center in New York. "As pain clinicians, we see the failures of the health-care system on a daily basis."

BIG BREAK. It doesn't have to be that way. Many major hospitals around the country have come to recognize that pain should be treated as a disease in and of itself, and are establishing pain clinics staffed with specialists who focus solely on the relief of suffering. That's a big break with medical tradition, which emphasizes treatment of the underlying disease or injury rather than its symptoms.

Pain clinics also break with another medical tradition--reluctance to prescribe morphine, even though it can virtually eliminate severe pain such as postoperative and cancer pain. Despite its proven effectiveness, morphine and other narcotics such as methadone, codeine, and demerol are chronically underutilized because of a huge fear of addiction on the part of doctors, patients, and state drug regulatory boards.

But study after study shows that this fear is misplaced--the risk of narcotic addiction at the dosages prescribed for pain management are minimal to nonexistent. Although patients may develop a dependence on opiates to control pain, it is no different than relying on a drug to treat high blood pressure. Dependence does not equal addiction, with its constant craving for more and more "fixes." If managed properly, the most serious side effect of opiates tends to be constipation. Most patients on morphine can function fully and even drive a car safely. Still, the myth of addiction, combined with concerns about criminal misuse of narcotics, continues to limit their use, laments Dr. John Farrar, a neurologist at the University of Pennsylvania Medical Center: "I think to deny access to narcotics to people in pain is absolutely criminal."

Undertreatment of pain is not just a quality-of-life issue. Prolonged pain can rewire the entire nervous system, causing patients to fall victim to lifelong, chronic pain that is less likely to respond to analgesics. Just ask Rose Katzman, a 65-year-old former real estate broker in Manhattan. She has spent the past decade in agony from a condition called arachnoiditis, damage to the nerves in the spinal cord from unknown causes. On her worst days she is in agony from the most innocuous stimulus. "If material touches my arm, I can go off the wall," she says. She tried a number of doctors and powerful drugs, to little effect. "The doctors treat you like you're an addict, or they say don't be a baby," she says.

It wasn't until 1996, when she started seeing Portenoy, that she gained some relief--from a drug many people would be horrified to even consider. Portenoy prescribed methadone, more typically used to wean addicts from heroin. "Now my life has some sort of normalcy," she says.

Pain clinics are particularly well suited for sufferers of chronic pain like Katzman. Hard-to-treat conditions such as chronic back pain, shingles, arthritis, and neuropathic pain, caused when nerves are damaged, demand innovative approaches. A pain clinic will assess the degree of suffering and develop a multidisciplinary, tailored approach involving anesthesiology, neurology, psychiatry, and physical therapy.

NEW DRUGS. Pain clinics also treat suffering early and often, ignoring the standard practice in medicine of doling out analgesics on an as-needed basis. They don't just prescribe narcotics, either. There are a whole range of new pain treatments available, including antidepressants, which can sometimes relieve pain whether or not the patient suffers from depression; the new cox-2 drugs that mitigate arthritis suffering without some of the side effects associated with aspirin; and capsaicin, a cream made from a red pepper extract that can lessen skin sensitivity.

None of these newer treatments is as effective as morphine, but they may have fewer side effects or be more suited for specific ailments. Gabapentin, for example, an epilepsy drug sold under the brand name Neurontin, is used by some specialists to treat diabetic neuropathy, an excruciating condition that arises when diabetes damages nerve endings. The drug does not completely eliminate the pain, but it has few side effects. Gabapentin "has been very effective in improving things like sleep patterns, energy levels, the ability to do more things with the family," says Dr. Keith Edwards, director of the Neurological Research Center in Bennington, Vt.

That's no small benefit. Pain is a vicious circle. The more debilitating the suffering, the more depressed and incapacitated the patient becomes, so the pain continues to worsen. If you find yourself falling down this black hole, you don't have to grimace and bear it. "Once patients know something can be done," says Edwards, "they have a whole fresh outlook on life." That alone is enough reason to seek out aggressive pain therapy.