Pain

Good Times
Wendy Haaf

“Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria.” – Naomi Wolf

“I’m off to fire my surgeon,” announces the woman on the other end of the telephone. The reason the outspoken senior is taking such a radical step isn’t an operating room error, poor surgical technique, or even bad manners. It’s what happened – or didn’t – following a cancer operation that convinced this plucky patient to deep-six her doctor. “I was in such incredible pain,” she recalls. When the woman told her physician the medications she had been given to minimize post-surgical discomfort weren’t working, he not only failed to provide any alternatives, but he pooh-poohed her pain and pronounced that she must be exaggerating.

Pain Hurts Health
This patient wasn’t whining about being denied some sort of health care frill. Pain actually unleashes hormones that depress immune system functioning; conversely, adequate pain control appears to speed healing after surgery, and may even influence long-term survival in cancer patients. Failure to treat pain appropriately can result in longer hospital stays, boost the odds of complications, increase degree of disability, and may even trigger a spiral of long-term pain and depression.

Nonetheless, under-treatment of pain persists. Experts estimate that in the US, up to two-thirds of nursing home patients, and one half of cancer patients are under-treated for pain. (In fact, in one study, only one quarter of nursing home patients with cancer received sufficient pain treatment – one quarter received none at all.) Nor does Canada fare much better. According to statistics from the Canadian Institute of Health Information, in 1998/99, one quarter of Canadians aged 75 and older suffered chronic pain that affected at least a few of their activities; and the National Canadian Pain study suggests one in ten Canadians suffers chronic pain that has resisted treatment with prescription medication.

Members of the Canadian Pain Society want to change these numbers. This dedicated group of scientists, physicians, psychologists, nurses, and other pain experts is working hard to publicize the fact that most pain can be minimized using combinations of medications and non-pharmacological treatments so patients won’t assume nothing can be done for their discomfort.

To this end, in May 2001 the Society launched the “Patient Pain Manifesto”, a “bill of rights to communicate to hospital patients and their families their rights regarding treatment of pain resulting from surgery, treatments or illness,” according to a statement by CPS president Dr. Celeste Johnston, professor of nursing at McGill University. “Studies show a surprising number of patients believe that suffering is part of being in the hospital and being ill. We want to make sure that patients with pain are fully aware that they have a right to receive treatment that will keep their pain under control, and help them reclaim their lives.”

‘Fifth Vital Sign’
But the fact patients expect hospital procedures to be painful and affect a stiff upper lip is only one of the problems underlying the under-treatment of pain, notes Dr. Gary Rollman, a professor of psychology at the University of Western Ontario and the president-elect of the Canadian Pain Society. Advocates at the CPS and its US counterpart, the American Pain Society, believe pain has such a profound effect on physical and emotional health that it should be put on equal footing with other critical measurements of a patient’s well-being, to become the ‘fifth vital sign’.

“We’re going around constantly monitoring temperature and blood pressure and respiration and heart rate, but the medical community could do a better job of assessing pain, and in fact, has a moral responsibility to do that,” Rollman asserts. “One needs to offer adequate pain relief, and the first way to determine whether you’re doing that is to assess pain; to see that pain assessment is done routinely in hospitals, nursing homes, and other institutions.”

Asking patients whether they are experiencing any pain, and if so, to rate the severity of that pain, is a simple but powerful intervention that can easily be incorporated into a standard physical exam. And thanks to the efforts of the CPS and the APS, it’s a notion that’s catching on. In the US, many large health care providers have adopted the ‘fifth vital sign’ approach to assessing pain and at least one state has passed the resolution into law; on this side of the border, pain assessment was included in the national hospital accreditation process for the first time in 2001.

However, assessing pain is only the first step in achieving adequate pain control. The next – deciding on treatment – can be fraught with difficulty, depending on what type of pain is involved, and how much experience a practitioner has in treating pain.

Acute Pain
Acute, short-term pain caused by an injury or surgery, is usually much easier to treat than more chronic pain conditions. A variety of medications, ranging from simple acetaminophen to opioids such as morphine, can often rein in the pain. However, even in the management of short-term pain, misinformation still abounds. Patients may mistakenly believe medications should only be taken when discomfort becomes unbearable, when in fact, much smaller doses of drugs are needed to control pain before it rampages out of control. Media scares over medications such as Oxycontin have rendered both physicians and patients fearful of opioids, despite the fact pain experts believe these effective medications are rarely addictive when used appropriately, and can even be used on a long-term basis to treat some types of chronic pain.

Chronic Pain
However, treating chronic pain is often much more complex than simply administering medications. While physicians have traditionally viewed pain as a symptom and assumed it would disappear when the underlying condition was diagnosed and treated, causes – and thus, treatments – for painful disorders such as fibromyalgia have as yet eluded scientists. At the same time, researchers have recently begun to understand that while short-term pain is valuable – it’s part of the ‘alarm’ that pulls your hand away from a flame – paradoxically, persistent pain may pain ‘rewire’ the nervous system. In effect, frequent or continuous exposure to pain may ‘short out’ the circuitry, triggering chronic pain that doesn’t necessarily reflect underlying injury or damage.

Consequently, medical professionals have begun to view pain that persists six months or more as a ‘disease’ in itself, which has sparked a new approach to treating chronic pain, incorporating many different disciplines and therapies that encompass both mind and body.

Mind-Body Link
Why is treating the whole person so important in chronic pain? Dr. Angelica Fargas-Babjak, professor of anaesthesiology and director of the Acupuncture Pain Clinic at McMaster University, explains.

“It is a misconception that we can separate the mind from the body,” she says. While patients may bristle at the idea of relaxation therapy or other psychologically-based measures, in one sense, all pain is ‘in the head’. “I say to my patients, if you didn’t have a head, you wouldn’t have pain,” Fargas-Babjak points out. “Processing of pain occurs in the brain, and it’s influenced by all kinds of input.”

While sensory input – such as intensity of the pain – obviously plays a key role, emotions exert a powerful pull on pain perception as well, according to Dr. Allan Shapiro, a psychologist at London Health Sciences Centre in London, Ont., who specializes in helping people deal with chronic pain. According to one prominent researcher, Shapiro explains, a person’s emotional response to pain is divided into two stages.

“The first-stage response is dependent simply on how intense the pain is – the more intense the pain, the more you’re suffering. The second stage has to do with the meaning that’s ascribed to the pain – what the pain means to the person, and the other thoughts that occur in association with the pain. It’s in this secondary aspect of suffering where where psychological factors potentially play a role.”

“For instance, one thought might be, what does this pain mean?” Shapiro elaborates. “There may be a lot of fear, especially if the pain is new, and no-one has been to explain why it is occurring. In chronic pain, the secondary thought process may include fears about how long an increase in pain will last, or fear about what this pain means for the future. Will I be able to work? If I can’t work, what does that mean for family finances?” Dwelling on these thoughts can trigger anxiety — which significantly influences pain perception.

Anxiety may also interfere with sleep, which itself profoundly affects pain. “It has been shown that even healthy people who are deprived of sleep experience more pain,” when a spot on the skin is pressed, compared to well-rested control subjects, Fargas-Babjack notes. Lack of sleep can spur depression, a condition that eventually strikes the majority of people who suffer from chronic pain. Add in behavioural changes people often make in response to pain – such as avoiding exercise, which stimulates the body to release natural pain-killing chemicals – and you have a prescription for disaster.

“If you avoid exercise, you become depressed; when you become depressed, you don’t sleep; and when you don’t sleep you have more pain,” Fargas-Babjak asserts. “It’s like a vicious circuit. And when someone has pain which can’t be explained, they become anxious, depressed, and avoid the everyday activities which keep us sane and healthy.” Decreasing physical activity also leads to atrophied muscles that protest even minor exertion. Fear of pain becomes a self-fulfilling prophesy.

Breaking the Cycle
This is the reason that clinics specializing in pain treatment try to break the pain cycle by attacking it at several different points, beginning by educating patients about pain to decrease fear and change destructive behaviours.

“People need to understand the body functions behind what is happening,” Fargas-Babjak believes. “If they understand, ‘if I do this, I’m creating a muscle spasm, and that spasm will cause mechanical obstruction of the nerve coming from my spine, and I will get numbness’,” the person can not only avoid actions that cause the muscle spasms, if numbness does occur, he or she won’t respond with the same degree of anxiety spawned by ignorance.

Using relaxation therapy to notch down anxiety levels is another important aspect of treating chronic pain. While different practitioners use approaches ranging from ‘mindful meditation’ and guided imagery to progressive relaxation (sequentially tensing and then releasing muscles from head to toe), the principle is the same.

“The majority of people say, ‘I’m not a tense person’,” Dr. Fargas-Babjak notes, “but inducing relaxation increases your awareness of how you react to things.” Even if you don’t feel ‘tense’, you may be holding tension in your muscles, which elevates pain levels. By learning to recognize that tension, and induce a relaxation response, patients can take some control. Several studies – including a paper published recently in the journal General Hospital Psychiatry – suggest meditation and other forms of relaxation therapy can improve physical functioning and quality of life, reduce pain, and help cope with the stress of chronic illnesses ranging from AIDS to depression and cancer.

How does relaxation help?
“When we function normally, two systems called the sympathetic – which is the ‘fight or flight’ response – and parasympathetic, which is the ‘quiet’ system that helps healing and functions while you sleep – are in balance,” Fargas-Babjak states. Pain stimulates the sympathetic nervous system, which is further fed by fear and anger. “When you relax, you are increasing parasympathetic output, slowing down the heart rate, and opening blood vessels. That helps the pain. It’s like sleep – if someone goes to sleep, usually the pain decreases. The same thing happens with relaxation.”

However, rest and relaxation must be balanced with some exertion. Physical therapy, consisting of a gentle exercise regimen, keeps muscles strong and flexible, allowing a person to keep up everyday activities. In fact, in conditions such as low back pain, osteoarthritis of the knee, and fibromyalgia, exercise is extremely effective for lowering levels of pain, and improving function; exercise is also a potent depression-fighter, and boosts the refreshing quality of sleep. However, just as important as exercise is the notion of ‘pacing’ – interspersing activity with rest periods — since chronic pain saps the body’s ability to bounce back from overexertion and exhaustion.

These non-pharmacological approaches to pain management, which can be used in conjunction with countless other therapies, don’t offer a panacea for pain. But what they do offer is almost as powerful – an antidote to feeling helpless when surgery and medical therapy don’t offer hoped-for answers.

“Sometimes people feel completely powerless, and they say, I cannot do anything, I cannot help myself,” Fargas-Babjak observes. “If somebody has a chronic problem, they have to learn to manage it themselves.” To this end, she teaches many of her acupuncture patients acupressure techniques they can perform at home. Putting the reins back into the patient’s hands, she asserts, has a powerful effect on pain.

“It’s well documented that even increasing understanding of what’s happening in the body helps pain control. By regaining this ability to address the problem, people feel better already – they have less pain.”