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    Managing Pain

The following quotations are from Dr Paul Brand and Philip Yancey’s book, “The Gift of Pain” published in 1993.

 

“It is a distortion to picture the human being as a teetering, fallible contraction, always needing watching and patching, always on the verge of flapping to pieces; this is the doctrine that people hear most often, and most eloquently, on all our information media.... The great secret of medicine, known to doctors but still hidden from the public, is that most things get better by themselves.” Lewis Thomas

 

No matter how well we prepare, pain almost always comes as a surprise. I bend over to pick up a pencil and suddenly it feels as if a spike has been driven into my back. Instantly my concern changes from pain preparation to pain management—--and the difference between the two is the difference between a San Francisco practice drill and an actual earthquake. No amount of planning can fully equip us for the time when, without warning, the ground shifts.

I have expressed my suspicion that, in Western countries at least, people have grown increasingly less competent at handling pain and suffering. When pain’s emergency sirens sound, the average person trusts his or her own resources less and the “experts” more. I believe the most important step in pain management is to reverse that process. We in medicine need to restore our patients’ confidence in the most powerful healer in the world: the human body.

Doctors tend to exaggerate their own significance in the scheme of things, and for this reason I love the revisionist scene described in The Healing Heart. In the emergency room of a hospital, the Dean of the UCLA School of Medicine stands alongside the school’s top cardiologists to await the arrival of a VIP patient suffering from heart failure. Suddenly the doors swing open and a stretcher rolls through. The patient—--Norman Cousins—--sits up, grins, and says, “Gentlemen, I want you to know that you’re looking at the darnedest healing machine that’s ever been wheeled into this hospital.”

I know of no doctor who would seriously disagree with Cousins statement.* Franz Ingelfinger, the distinguished editor of the New England Journal of Medicine for many years, estimated that 85 percent of patients who visit a doctor have “self-limiting illnesses.” The doctor’s role, he said, is to discern the 15 percent who really need help as opposed to the 85 percent whose ailments the body can handle on its own.

When I first studied medicine, in the days before penicillin, we had limited resources to offer and by necessity a doctor functioned more as an adviser or counselor. Without question the most important person in the transaction was the patient, whose willing participation in the plan for recovery would largely determine the outcome. Now, in the patient’s view at least, the tables have turned: the patient tends to regard the doctor as the important party.

Medicine has become so complex and elitist that patients feel helpless, and doubt whether they have much contribution to make in the struggle against pain and suffering. Too often the patient sees himself or herself as a victim, a sacrificial lamb for the experts to pick over, not a partner in recovery and health. In the United States advertising further feeds the victim mentality by conditioning us to believe that staying healthy is a complicated matter far beyond the grasp of the average person. We get the impression that, were it not for vitamin supplements, antiseptics, painkillers, and a trillion-dollar annual investment in medical expertise, our fragile existence would soon come to an end.

 

The Doctor Within

Many patients view their own bodies with a sense of detachment or even hostility. Once pain has announced that a part of the body has broken down, the affected person, feeling helpless and irritated, seeks out a mechanic-doctor to repair the broken part. A young man who came to me with a very minor ailment illustrates the modern attitude. A beginning guitar player, he complained to me about tender spots on his fingertips. “Can’t you do something about these sore spots?” he asked. “I can only play for half an hour before I have to quit. At this rate I’ll never learn to play the guitar.”

As it happened, I had personal experience with that very problem. One year in medical school I spent the summer sailing on a schooner on the North Sea. The first week, as I pulled on heavy ropes to hoist the, sail, my fingertips became so sore that they bled and kept me awake at night with the pain. During the second week calluses were forming, and soon afterward thick calluses covered my fingers. I had no more trouble with tenderness that summer, but when I returned to medical school two months later I found to my chagrin that I had lost my finer skills in dissection. The calluses made my fingers less sensitive and I could scarcely feel the instruments. For a few weeks I worried that I had ruined my career as a surgeon. Gradually, though, the calluses disappeared with my sedentary life, and sensitivity returned.

“Your body is in the process of adapting,” I told the young guitarist. “The calluses show that your fingers are getting used to the new stress of being drawn across steel strings. Your body is doing you a favor by building up extra layers of protection. As for the tenderness, it’s only a temporary phase, and you should be grateful for it.” I told him of insensitive leprosy patients who had badly damaged their hands trying to learn the guitar or violin because they had no pain warnings to prevent them from over-practicing. Others adhered to a restricted timetable of practice so as to allow their tissues a chance to build up callus. (Skin tissue responds to the stimulus at a local level even though the brain never receives the pain sensations.)

I failed to sway the guitarist, who left my office disappointed that I had not “fixed” his hand. In an odd way, vaguely reminiscent of my leprosy patients, he seemed estranged from his own body. His hand was an object—--a nuisance, really—--that he had brought to me, the body specialist, for repairs. Such an attitude has become almost typical of modern patients.

Sadly, medical professionals sometimes foster such an attitude. I frequently meet with groups of students in medical school ask about their frustrations in the field. The most common response I hear centers on the clumsy word depersonalization. As one bright young woman told me, “I chose medicine out of a sense of compassion and a desire to relieve suffering. But more and more I find I have to fight off cynicism. We don’t talk much about patients here; we talk about ‘syndromes’ and ‘enzyme failure.’ They encourage us to use the word ‘client’ rather than ‘patient,’ which implies that we’re selling services rather than ministering to persons. Some of the younger teachers speak of patients almost as if they were adversaries. They say, ‘Watch out for older patients—--they’re chronic complainers, and will eat up too much of your time.’ And we spend hours studying the latest MRT and CAT scan diagnostic techniques, but I haven’t had a single class session on bedside manner. After a while, it’s easy to forget that the ‘product’ we’re dealing with is a human being.”

I cringe when I hear such words, and think back with gratitude on my old-fashioned professors: H. H. Woolard, who treated even cadavers with reverence, and Gwynne Williams, who would kneel by a patient’s bedside so that, at eye level, he would appear less intimidating and thus help the patient relax. The current biomedical approach, which narrows the focus from the patient to the disease itself, has taught us much about hostile organisms, but at the risk of devaluing the patient’s own contributions. We dare not let technology distance us from patients, because certain things technology cannot do. It cannot hold your hand, inspire confidence, make you a partner in the recovery process. Used wisely, technology should be a servant of the human side of medicine: by handling facts and data, it can free the physician to spend more time with the patient so that he or she can apply the compassionate, humane wisdom that can only come from a human mind.

On the surface a doctor’s task may resemble an engineer’s—-- they both repair mechanical parts—--but only on the surface. We treat a person, not a collection of parts, and a person is far more than a broken body in need of repair. A human being, unlike any machine, contains what Schweitzer called “the doctor within,” the ability to repair itself and to affect consciously the healing process. The best physicians are the humblest ones, those who listen closely to the body and work to assist it in what it is already instinctively doing for itself. Indeed, in pain management I have no choice but to work in partnership: pain occurs “inside” the patient, and the patient alone can guide me.

I have learned about pain management primarily through hand surgery, in which all parties involved must tune in to pain. If you injured your hand and came to me for surgery we would both look to pain to help steer the recovery process. I could artificially dull the pain before therapy sessions to make you more comfortable, but if I did so you might well (like my leprosy patients) exercise too vigorously and tear out the transplanted tendons. On the other hand, if you avoided any movement that caused even a little pain, your hand would become stiff, for scar tissue would fill in the spaces and immobilize the hand. Together, we must seek the boundary of pain and then push through it and just beyond it.

The best rehabilitation takes place, I have found, if I can convince you of the truth that you are doing it all yourself. I have done my job by rearranging the muscles and tendons. Everything else depends on you. Your body will have to reunite the nerves and blood vessels I have cut, and deal with scar tissue and collagen. I attached the tendons to their new sites with flimsy stitches; your fibroblasts will provide strong, permanent attachments. Your muscles will gauge the new tensions and add or subtract tiny units called sarcomeres, covering the mistakes of the surgeon. Your brain will have to learn new programs to order movement. As the wound heals, it is you who must start to move the hand. The hand belongs to you, and only you can make it work again.

At the Carville clinic we make available instruments that patients can use as a kind of biofeedback of the healing process. By using a thermistor probe, for example, they can monitor the changing temperature of joints: the temperature goes up with activity and then down after rest, but stays up if the patient exercises too strenuously. We tell patients how much swelling to expect, then give them a measuring jar to dip the hand into. The rise in water level will show whether the patient has done something to cause excessive swelling, even something as simple as letting the injured hand hang below the waist. In these ways we teach patients to take personal responsibility for their own healing even when they have lost the internal monitor of pain.

No instrument, however, can measure what is beyond doubt the most important factor in hand therapy: the patient’s will to recover. The mind, not the cells of the injured hand, will determine the final extent of rehabilitation, because without strong motivation the patient simply will not endure the disciplines of recovery.

My least favorite hand surgery patients are those involved in litigation as a result of injury on the job. These men and women have a powerful incentive not to gain full recovery of the hand, because a permanent disability means a larger financial settlement. Their pain threshold often seems to get lower and lower until at the first twinge of pain they pull back from the physical therapy exercises. If they successfully avoid all pain, they will likely have a permanent disability. (One 1980 study showed that people in Great Britain injured through industrial accidents returned to work at a rate 25 percent slower than those who sustained comparable injuries through road accidents. The suspected reason: in that country, injuries from industrial accidents are compensated better, giving the patient less incentive to recover.)

In contrast, one of my best patients was an inmate of the state penitentiary in Louisiana whose hand had been so damaged by a bullet that I had to devise some new tendon transfer techniques during the surgery. I assumed the patient would have to undergo extensive therapy, with no guarantee of success. But, as we later learned, this prisoner had a powerful incentive to recuperate quickly. During the period of postoperative hospitalization he removed the plaster cast, filed off his shackles, and escaped. Three years later I saw him at another hospital, still on the loose. The damaged hand had healed perfectly: his urgent need to regain active use, moderated only by pain, had provided the perfect environment for full recovery.

The reason subjective issues like “incentive to recover” carry such weight in pain management traces back to the three stages of pain: signal, message, and response. After surgery, a hand patient has the overpowering sensation “My hand hurts.” But as we have seen, that sensation is a clever invention of the mind: what really hurts is the felt image of the hand stored away in the spinal cord and brain. Since pain involves all three stages of perception, effective pain management must take into account each of these stages.

 

Signal

Most of us attack pain first at stage one; we open the bath room cabinet and select a medication designed to block pain signals at the site of damaged tissue. Aspirin, the most widely used drug in the world, works at this stage. Although an aspirin like substance was extracted from the willow in 1763 and used for treatment of rheumatism and fever, it took two hundred years for scientists to figure out what makes aspirin so effective: it prevents the production of something called prostaglandin in damaged tissue, hence suppressing the normal responses of swelling and hypersensitivity.

Other common drugs work directly on the nerve endings, interfering with their ability to send pain signals. Sunburn sprays and topical treatments for cuts, wounds, and mouth sores often contain these chemicals, as do the more powerful local anesthetics used by dentists and doctors in minor surgeries.

I am slow to interfere with pain signals from the periphery. Having spent my life among people who destroy themselves for lack of pain, I treasure these signals. A harried executive who swallows a handful of aspirin and tranquilizers after a hard day’s work, much like the athlete who accepts a painkiller injection before an important game, is overriding a fundamental principle of the pain system. Pain signals at stage one report in loudly and insistently so that their message will seize consciousness and bring about a change in behavior. To silence the signals without changing behavior is to invite the risk of far greater damage: the body will feel better while getting worse. Certainly painkillers like aspirin offer benefits, such as a good night’s sleep and a reduction in inflammation, but in every case I believe we must first consider the positive use of pain, and then act in a way that achieves the proper balance.

Once again, my experience in hand therapy comes to mind. Unless we can persuade our patients to accept a little pain as part of their rehabilitation, the joints will freeze up and the hand go rigid. “Just give me some drugs to keep it from hurting, and I’ll do my exercises gladly,” some patients say. They are quite right. Modern surgeons, before closing up the hand, may leave a tiny catheter next to the nerve so that a local anesthetic can be dripped into the wound; their patients then do exercises they might other wise balk at, speeding recovery. I do not oppose this practice, but I have learned to reserve it for my most careful and cooperative patients. Most patients need pain’s boundary of inhibition; without it, they tend to move too strongly and break the wound open. The key in pain management is to recognize the links between the stages of pain. I will block pain signals at stage one only if I have confidence that my patients will take responsibility at stage three, conscious response. Will they follow the precise instructions of the therapist even in the absence of pain?

When I confront pain personally I prefer to counteract all three stages at once. It seems appropriate to give a unified response to a sensation that involves my body so inclusively. A few years ago I had a problem with my gallbladder. When I first felt the urgent pain signals (stage one) from my upper abdomen, I had no idea what danger they were trying to alert me to. It was an intense and cramping pain, far too severe for indigestion. Antacids had no effect. Its location made the gallbladder or pancreas the possible site. My age was about right for cancer to appear and by the time I visited the doctor I had worked myself into a churning state of fear and foreboding.

An X-ray revealed that I had gallstones, not cancer, a painful condition to be sure but one easily treatable with surgery I felt foolish about my panicky reaction. The abdominal attacks kept occurring, but right away they seemed less painful. Although the pain signals themselves did not diminish, my perception of them (stage three) surely changed as my anxiety lessened.

Because of scheduling difficulties I had to delay the gallbladder surgery for a few months. Pain from gallstones and kidney stones ranks very high on the intensity charts, and I now understand why. I had many opportunities to practice my mastery over pain (and many opportunities to reconsider my “Thank God for pain” philosophy!). I suppose I have never outgrown the boyhood spirit that made me resist the temptation of an aspirin, because I consistently tried to avoid running to the medicine cabinet for Demerol.

Night attacks were the worst. I remember one especially difficult night when I got out of bed, slipped on a robe, and walked around the paths of the leprosarium in my bare feet. The Louisiana night was steamy, and alive with sound. Frogs bellowed out their choruses in the pond, with crickets and other insects filling in the notes they missed. Nell, our frisky mongrel dog, ran ahead of me, delighted by the unscheduled walk at such a strange hour.

I deliberately chose to walk on the paths made of shell gravel dredged from southern beaches. These shells are very sharp, and painful to bare feet. I had to select my steps with care and ease my feet down gingerly, and I alternated by walking on the wet grass. As I walked along, I also picked up small tree limbs and stones and fingered them. All these minor acts helped to combat the pain: the flood of sensations from shells on my bare feet competed with and partially drowned out the pain signals from my gallbladder. The pain I felt now was quite different—--and much more tolerable—--than what I had felt in a dark, quiet bedroom.

I’m not sure when the singing began. I think I spoke at first, expressing aloud to God my wonder and appreciation for the good earth around me and the stars blazing overhead. Then I found myself singing a few bars of a favorite hymn. Birds started and flew away in disorder. Nell cocked her ears and looked quizzical. I glanced around, self-conscious, suddenly aware how it would look if a night watchman caught the senior staff surgeon outdoors at 2:00 A.M., barefoot, wearing pajamas, and singing a hymn.

That bayou evening still shines in my mind. At other times, especially when I needed a full night’s sleep, I did take some painkiller to quiet the pain I felt in the dark and stillness of my bed room. But that night I marshalled my whole body in a counterattack on the pain that had rudely got me out of bed. By walking on the shell path, I generated new, more tolerable stage one signals of pain which had flooded the spinal gate, affecting stage two. And attentiveness to the world around me influenced stage three, bringing about a state of calmness and serenity. The muscle spasm and with it the colic finally subsided and I climbed back into bed a new man, and slept through the night.

 

Message

If I had been willing to invest several hundred dollars in a Transcutaneous Electrical Nerve Stimulator (TENS), I might have stayed in bed. The TENS represents a quintessentially modern approach to pain management. A battery-powered device about the size of a ‘Walkman radio, it generates a small electrical current that passes between two carbon-rubber electrodes. Strapped to the skin and positioned directly over a nerve, the TENS produces a slight tingling sensation, which the wearer can adjust up or down depending on the intensity of the pain. (Other devices deliver electrical current directly to platinum electrodes implanted beside nerves or even in the spinal cord, but the skin stimulating models usually win out because they avoid the complications of surgery.)

Is it due to sheer old-fashionedness that I prefer bayou sounds and the feel of shell gravel to a tingling electrical sensation? Both techniques work partly by generating new nerve signals that overwhelm the spinal “gate.” As the spinal gate-control theory explains it, nerves from the spinal cord pass through a relatively narrow channel just below the medulla oblongata of the brain, and when that bottleneck becomes clogged with extraneous sensations, pain messages tend to diminish. Drowned out by the competition, fewer pain signals are converted into messages and forwarded to the brain.

The effectiveness of TENS varies from patient to patient, but I have noticed one positive benefit. When a chronic pain patient learns that he or she has a measure of control over pain just by turning a dial on a machine, the pain suddenly seems less threatening, more tolerable. In this way TENS, a pain treatment directed at stage two, also has an impact on pain perception at stage three. It reduces fear and anxiety two common intensifiers of pain. Over time, the patient may stop using the machine entirely. The patient has, if not befriended the pain, at least learned to live with it. I wholeheartedly approve of this training exercise in pain mastery, though I admit to a bias toward midnight walks, hairbrushes, and hot baths as means to achieve the same end.

The field of dentistry is also experimenting with TENS. Since most patients regard the needle as the most unpleasant part of dental care, researchers keep looking for ways to provide anesthesia without needles. In one technique, a dentist using TENS places a thin electrode on a patient’s hand, another behind the ear, and a third wrapped in cotton beside the tooth requiring dental work. For a majority of test subjects, a mild current at 15,000 cycles per second can provide pain relief equivalent to novocaine.

Many prescription drugs likewise address pain at the message stage. The painkilling properties of opium have been recognized for most of recorded history, and varieties of the poppy plant grow all over the world. Only recently, however, was it discovered that the drug works directly on the spinal cord as well as on the brain. Opium-type molecules (the opium family includes the powerful drugs codeine, morphine, and heroin) lock on to opiate receptor sites in the spinal cord, slowing the rate at which cells fire and reducing the number of messages conveyed to the brain. New epidural techniques drip the narcotic directly into the spinal canal, affecting the sensory nerve roots on the way into the spinal cord, a precise anesthesia that can provide relief for such excruciating conditions as pancreatic cancer.*

The most radical pain management technique is invasive surgery, and surgical procedures aimed at stage two seem the most promising, albeit not foolproof. Surgery for pain at stage three, within the brain itself, involves much risk, and frequently fails to solve the problem: after a short relapse, the pain reappears. Cutting the peripheral nerves that produce the pain signals at stage one may relieve some chronic pains, especially facial neuralgia, but there is no guarantee that blocking pain at the site of its origin will end it.

The complex phenomenon of pain cannot easily be “fixed,” not by the best surgeon in the world. I have read one report of a race car driver who lost his left forearm in a racing accident. The man suffered phantom limb pain, and, after electrical implants on the local nerves did nothing to relieve it, his surgeon opened up the spinal cord. To his great surprise, he found that the nerves running from the arm to the spinal cord had already been severed by the accident. Pain signals could not possibly be coming from the periphery; the spinal cord itself was generating a message that the brain interpreted as “My left arm is hurting.”

Not even surgery on the spinal cord itself, however, gives a permanent guarantee against pain. As an act of mercy; surgeons may remove a section of the spinal cord from a cancer patient who has a short life expectancy; but if the patient lives more than eighteen months the pain sometimes returns. Either the brain or another part of the spinal cord mysteriously finds a way to resurrect the pain messages.

I am not a neurosurgeon, and I can only recall a few times when I agreed to treat pain surgically. The most memorable involved an Indian woman named Rajamma, who suffered from the bedeviling condition of tic douloureux, a severe neuralgia of the face. Unpredictably, spasmodically, she would be jolted by a fiery shot of pain to one side of her face. She came to me in desperation after trying many alternative treatments.

“I had all the teeth removed from one side of my face, but the pain did not go away,” Rajamma said. “Then I let a local medicine man scar me with burns.” She pointed to the scar marks on her left cheek. “The pain got worse. Now, any small movement or sound may bring on an attack. My children cannot play near the house. We keep the chickens penned so they will not fly up and startle me.”

I knew that the procedure for treating tic douloureux involved a delicate exploration of the gasserian ganglion, located where the fifth cranial nerve enters the brain, and should only be attempted by a trained neurosurgeon (if the nerve twig to the eye were cut accidentally, the loss of eye sensation could lead to the loss of the eye). But I was in South India, where no neurosurgeon was available. First I tried deadening the site with an anesthetic, which failed. Rajamma and her husband begged for me to attempt the surgery; even if it meant blindness, even if it meant death. “What kind of life do I lead now?” Rajamma asked. “Look at me.” She was already dangerously thin. “I dare not chew,” she explained. “I live on fluids.”

Finally, I did attempt the surgery, and located two tiny nerves, fine as cotton threads, that seemed the most likely carriers of her pain. I held them in my forceps for a few seconds before cutting them. Could these thin wires be the source of the tyranny? What if I had the wrong nerves? I snipped them, and closed the wound.

I am sure that my tension was as great as Rajamma’s as I sat with her in the ward and mapped the area of her cheek that now had no sensation. Haltingly, she began to attempt the movements that had previously triggered spasms of pain. She tried a slight smile, her first intentional smile in years, and no attack came. Her husband beamed back at her.

The surgery proved a success and, little by little, Rajamma’s world fell into place. When she returned home, chickens were welcomed into the house again. The children began to play without fear of hurting their mother. In ever-widening circles, the family’s life returned to normal. Pain, gone wild, had at last been tamed.

 

Response

Transcutaneous stimulators, epidural blocks, spinal cordotomies—--these techniques may help persistent, long-term pain, but in many cases the body finds a new avenue and the pain returns. For this reason, chronic pain centers have learned to attack pain on all three fronts: signals from the injury site, messages along the transmission routes, and response in the mind. Actually, attending to a patient’s psychological health and family environment may have as much effect on the pain as prescribing analgesic drugs or a TENS device. As one Boston psychiatrist puts it, “Half the people who go to clinics with physical complaints are really saying, ‘My life hurts.’ Pain is really an existential expression.”

In my own approach to pain, I give highest priority to the third stage. That may seem odd, since I have spent so much of my career working with leprosy patients, who suffer from the lack of pain signals in the periphery (stage one). But the very fact that they do “suffer” proves the importance of the mind in the pain experience. Leprosy patients helped me understand the difference between pain and suffering. “I’m suffering in my mind because I can’t suffer in my body,” is how my patient Namo had put it.

In more advanced cases of leprosy, my patients felt no “pain” at all: no negative sensations reached their brains when they touched a hot stove or stepped on a nail. Yet all of them suffered, as greatly as any people I have ever known. They lost the freedom that pain provides, they lost the sense of touch and sometimes sight, they lost their physical attractiveness, and because of the stigma of the disease they lost the feeling of acceptance by fellow human beings. The mind responded to these effects of painlessness with a feeling that could only be called suffering.

For the rest of us, pain and suffering often arrive in the same package. My goal in pain management is to seek ways to employ the human mind as an ally, not an adversary. In other words, can I prevent “pain” from becoming undue “suffering”? The mind offers wonderful resources to accomplish just that.

In my days of medical training, I was mystified by some of the puzzles of pain: the “Anzio effect” response to battlefield wounds and the mysterious powers of placebo, hypnosis, and lobotomy. At the time, science had no explanation for these phenomena; like the Hindu fakir’s mastery over pain, they belonged more to the field of magic than of medicine. In more recent years, researchers have unlocked some of the secrets of the brain’s alchemy. It seems the body manufactures its own narcotics, which it can release upon command to block out pain.

The brain is a master pharmacologist. Its tiny opiate etorphin has ounce for ounce ten thousand times the painkilling power of morphine. Neurotransmitters such as these modify the synapses of the brain’s neurons, literally changing the perception of pain as it is being sorted and processed. The soldier who reacts spontaneously to the excitement of battle and the fakir who exercises an acquired discipline have probably found ways of tapping into the brain’s natural painkilling forces. The peripheral nerves are sending signals, the spinal cord is transmitting messages, but brain cells alter that message before it becomes pain.

Once discovered (in the 1970s), brain neurotransmitters opened up the possibility of intriguing new approaches to pain management (1) perhaps the brain’s neurotransmitters could be artificially produced, allowing us to manage pain better by outside intervention; (2) perhaps we could teach the brain to dispense its elixirs on demand, whenever we want them.

The first line of inquiry is still in its infancy. Researchers have synthesized several powerful enkephalins, but major barriers remain. For one thing, protective enzymes intercept most foreign chemicals as they try to pass from the bloodstream into the brain, and a painkiller that must be injected directly into the brain has obvious drawbacks. Also, the synthetics tend to be addictive: the brain stops producing its own enkephalins in the presence of the artificial ones, leaving the user with a choice of permanent addiction or an agonizing withdrawal.

The opposite approach, to stimulate the brain’s own painkillers, has nearly unlimited potential. Inside the ivory box of skull, psychology and physiology come together. We know that a person’s response to pain depends to a very large degree on “subjective” factors, such as emotional preparedness and cultural expectations, which in turn affect the brain’s chemistry. By altering these subjective factors, we can directly influence the perception of pain.

Pain accompanying childbirth provides an excellent example. Societies that practice couvade give dramatic proof that culture plays an important part in determining how much pain the delivering mother perceives. To all appearances—--and the appearances defy comprehension for women who have gone through painful deliveries themselves—--the mothers in couvade societies do not experience much pain. In Western culture, however, childbirth ranks as one of the highest pains. Using the McGill Pain Questionnaire, Ronald Melzack interviewed hundreds of patients and determined that mothers rated labor pain during childbirth higher than pain from back injury cancer, shingles, toothache, or arthritis.

Yet Melzack also found that second-time mothers rated their labor pains lower. Their prior experience helped to lower the threshold of fear and anxiety and subsequently the perception of pain. First-time mothers who had prenatal training, such as classes in the Lamaze method, also rated their pains lower. The Lamaze method can in fact be viewed as a wide-scale attempt to change the perception of childbirth pain. Lamaze teachers stress that childbirth entails hard work, but not necessarily pain. They reduce fear and anxiety (stage three) by educating pregnant women about what to expect. And they teach concrete, practical ways of coping with pain at stages one and two: the breathing exercises and the father’s assistance in pressing on the back during labor contractions all help counteract pain at the spinal gate.

The Lamaze course employs one simple exercise that any of us can do at any time to modify pain at stage three: conscious distraction. I first learned of the effect of distraction from Tommy Lewis’s research. When bells were rung and adventure stories read aloud, the laboratory volunteers had much greater tolerance for pain. Lab assistants using radiant heat machines were surprised to see blisters swell up unnoticed on volunteers’ arms as those subjects concentrated on counting backward from fifty to one.

A few years ago, American dentists had high hopes about the potential of audio techniques in controlling pain. Patients who wore earphones and listened to loud stereo music, or even artificial “white noise,” sat contentedly without painkiller while dentists probed and drilled. Stereo equipment would replace the hypodermic needle, some predicted. At dental conferences, dentists cited Melzack’s spinal gate-control theory as a way to explain the phenomenon. But when Ronald Melzack himself tested the findings against those for a placebo stimulus—--a worthless sixty-cycle hum that should have had no effect on the patients—--to his surprise even the placebo noise diminished pain. Melzack concluded that the key element in the audio machine’s success was the value of conscious distraction. As long as the subjects concentrated on the music or noise, and as long as they had knobs and levers to operate, they felt less pain. They were attending to something else.

In the book Living with Pain, Barbara Wolf tells of her long struggle against chronic pain, an odyssey which included having subcutaneous neural transmitters implanted in both hands. After trying a host of methods, she decided that distraction was the best and cheapest weapon available. She used to cancel activities when she felt pain, until she noticed that the only time she felt completely free of pain was during classroom hours when she taught English. Wolf recommends work, reading, humor, hobbies, pets, sports, volunteer work, or anything else that can divert the sufferer’s mind from pain. When pain strikes with fury in the middle of the night, Wolf gets up, maps out the day ahead, works on a lecture, or completely plans a dinner party.

Pain need not necessarily dull the mind. Blaise Pascal, plagued with acute facial neuralgia, worked out some of his most complex geometry problems while tossing uncomfortably in bed. Composer Robert Schumann, suffering from a chronic illness, would get out of bed and correct his musical scores. Immanuel Kant, his toes burning from gout, would concentrate with all his might on one object—--for example, on the Roman orator Cicero and everything that might relate to him. Kant claimed this technique succeeded so well that in the morning he sometimes wondered whether he had imagined the pain.

When I confront intense pain, I look for activities that will fully absorb me, either mentally or physically. I go out for a walk or work at my computer. I dredge up tasks that I have avoided out of busyness: I clear out a closet, write letters, go bird watching, weed the garden. I too have found that conscious distraction and the discipline of activity can be helpful tools in combating pain.

One specialist at a chronic pain center told me that many patients want to wait until the pain subsides before they resume normal functioning. But he has learned that coping with chronic pain depends on a patient’ willingness to exercise and increase productive activity despite the feeling of pain. Chronic pain management succeeds when the patient accepts the possibility of living a useful life in the presence of pain.

We in the West, who rely on pills and technology to solve our health problems, tend to discount the role of the conscious mind. After meeting Dr. Clifford Snyder, I can never again under estimate our inherent power to alter pain perception. This gentle man, a respected plastic surgeon and former coeditor of the Journal of Plastic Surgery, has learned to harness the mind’s amazing capacity for pain management. After several trips to China to investigate acupuncture, Snyder became convinced that much of the potency of acupuncture in relieving pain was due to a person’s mental belief in it—--a glorified placebo effect. A few years later, he had a chance to test his conviction about the mind’s power.

Snyder needed surgery on his hand, a complicated procedure to strip away the synovial lining covering his wrist tendons. It involved deep cuts in an area of many nerve endings. Snyder had a busy schedule the next day, with a major address to deliver, and he did not want to risk general anesthesia, which could leave him groggy. He decided to will away pain, with no resource but the power of mind.

The attending surgeon, whom I also know well, agreed to honor his colleague’s peculiar request. He allowed Dr. Snyder a few minutes to gather his thoughts, tied a tourniquet around the upper arm, and then without the application of any anesthesia proceeded to perform the surgery. Through sheer autosuggestion, Snyder concentrated on feeling no pain. He remained conscious throughout, and he insists that he felt absolutely no pain until about an hour after the surgery. The surgeon on the other end of the scalpel verifies his account.

Afterward, Dr. Snyder tried to incorporate what he had learned about pain management into his medical practice. “I always try to divert my patient’s attention to something pleasant,” he says. “I talk about football, or the president’s recent news conference, and avoid expressing any alarm. I try to calm my patients. I touch and rub the site of injury especially with children, and always tell them exactly what I’m going to do. I never lie to them. I want their complete trust.”

Snyder reports remarkable results among some of his patients. One schoolteacher who came in for removal of a ganglion became so involved in a conversation with a medical student that Snyder removed the ganglion without even applying a local anesthetic. A teenage boy with severe acne came in to have his face “sandpapered” with an abrasive. “Doctor I’ll give you one hour,” he said. “I don’t want anything for the pain.” He lay still for sixty minutes and showed no sign of pain. Then he held up his hand and said, “Now it’s beginning to hurt. You’ll have to stop.”

Not everyone can master the skill of autosuggestion over pain. But the examples cited should encourage us to believe that, even if we cannot abolish a specific pain, we can probably make it hurt less and thus eliminate the need for drugs. They confirm the amazing capacity for pain management that all of us carry around atop our necks.

 

Worst Case

I once met with nuns, caregivers, and a few pain specialists from around the world at a conference in Dallas, Texas. In a televised interview afterward, I explained my personal philosophy of pain based on gratitude and appreciation for pain’s benefits. “The system of pain is good,” I said, “even though there will surely be times when individual pains are not good.” I mentioned the pain that sometimes accompanies terminal cancer, a debilitating pain that serves no helpful purpose—the patient knows death is coming soon—and frustrates most of the pain management techniques I have described in this chapter.

“The challenge of medicine in such a case,” I said, “is to give enough medication to quell the pain, but not so much as to cloud the patient’s mind. Yet if the pain persists, as an act of mercy it may be necessary to give so much medication that the patient may not be conscious enough to communicate.”

I heard a sudden eruption at the other end of the table and turned to face a slim, distinguished-looking Englishwoman. Dr. Therese Vanier had almost jumped out of her seat. “I’m sorry; Dr. Brand, but I must strongly disagree! I am a physician at the St. Christopher’s Hospice in London, and this is not the philosophy of our hospice! We promise our patients that they will be free of severe pain but also will remain lucid. We can almost guarantee that.”

The vigor of Dr. Vanier’s response startled me, and after the interview I sought her out. She invited me to visit the hospice founded by Dame Cicely Saunders in 1967, in order to observe what they had learned about worst-case, terminal pain. Several years later I made the trip. St. Christopher’s is, in essence, a place where people go to die. Forty percent of its admitted patients die within their first week.

“The majority of patients come to us in severe pain, in the final stages of their illness,” Vanier explained during my visit. “Pain from a terminal disease is unique. Pain from a bone fracture, sore tooth, childbirth, or even postoperative recovery has meaning, and there is an end in sight. Pain from progressive cancer has no meaning except the constant reminder of approaching death. For many of the patients who come to us, pain fills the entire horizon. They can’t eat, sleep, pray, think, or relate to people without being dominated by pain. Here at St. Christopher’s we try to combat that particular kind of pain.”

After visiting with Vanier, I met with Dr. Cicely Saunders, who told me the origin of the hospice movement. She had founded the first hospice, she said, after seeing how poorly the medical profession handled death. For the sake of a patient with some prospect of recovery, a modern hospital would go to any length. But a patient without hope was an embarrassment, a shameful emblem of medicine’s failures. Doctors mostly avoided terminally ill patients, or spoke to them in platitudes and half-truths. Treatment for their pain tended to be grossly inadequate. In the midst of busy, crowded hospitals, terminal patients died afraid and very much alone.

The standard treatment of terminal patients offended Saunders’s deep Christian sensibilities. A nurse at the time, she enrolled in medical school at the age of thirty-three for the express purpose of finding a better way to minister to the dying. After working at a home for the dying run by the Sisters of Charity she wrote, “Suffering is only intolerable when nobody cares. One continually sees that faith in God and his care is made infinitely easier by faith in someone who has shown kindness and sympathy.” She went on to found St. Christopher’s, and out of that sprang the worldwide hospice movement. Saunders notes that hospice actually resurrects a theme from the Middle Ages, when the church counted care for the dying as one of the seven cardinal virtues.

     Working together, Saunders and Therese Vanier pioneered the “preventive” approach to pain from terminal disease. In many hospitals the standard order for pain medication says “PRN” (for pro nata, “as needed”). That order leaves medication to the discretion of the health worker, who has been sternly warned about the dangers of addiction. As a result, if the pain returns before expected, a patient in agony may have to plead for the next injection. Saunders tried a different approach. She carefully determined dosages in advance, then made them available to the patient at regular intervals so that the pain never returned at all. A steady blood level of medication, she found, helps to prevent both severe pain and over sedation. Saunders also tested patient-controlled dosages and discovered that terminal patients rarely overmedicate. Under supervision, they usually come up with a program that controls pain around the clock without mental clouding.

The design of St. Christopher’s reflects Saunders’s wisdom about care for the dying. Most patients live in four-bed bays, not private rooms, with space enough for family members to stay overnight. Dividing curtains permit privacy as needed, but the presence of other human beings allows for a kind of community to develop, a community based on seeing others face death in an atmosphere of trust and not cringing fear. Rooms are filled with furniture purchased from a department store, not an institutional catalog. Front windows frame a park manicured in fine English tradition; rear windows overlook a flower garden and goldfish pond.

A visitor to the hospice sees signs of life everywhere: staff gathered around a bedside singing “Happy Birthday,” artwork hanging from every blank wall space, a mini jungle of potted plants, a patient’s pet cocker spaniel frolicking on a visit. Every two weeks or so the staff organizes a concert, with a string quartet or harpist or children’s hand bell choir visiting the wards. Volunteers transport able patients to the local McDonald’s or pub, depending on their preference. As much as possible, St. Christopher’s functions at the convenience of patients, not staff.

My day at St. Christopher’s convinced me that Therese Vanier’ outburst on the panel in Dallas was fully justified. Even the worst pain imaginable, the severe pain that accompanies terminal illness, need not debilitate. It struck me that Dame Cicely, Dr. Vanier, and the others at St. Christopher’s have incorporated nearly everything I have learned about pain management and more. They allow for diversion and conscious distraction. They help soothe the subjective factors (fear, anxiety) that contribute to pain. They work hard to make the patient feel like a partner, not a victim, one who retains control over his or her own body. They create a caring community

In a word, the hospice movement has shifted the focus of medicine from cure to care. Daniel Callahan has criticized contemporary medicine for precisely this failure.

The primary assurance we all require is that we will be cared for in our sickness regardless of the likelihood of cure. . . . The greatest failure of contemporary healthcare is that it has tended to overlook this point, has become distracted from it by the glamour of cure and the war against illness and death. At the center of caring should be a commitment never to avert its eyes from, or wash its hands of, someone who is in pain or is suffering, who is disabled or incompetent, who is retarded or demented; that is. . . the one commitment a healthcare system can almost always make to everyone, the one need that it can reasonably meet.

 

St. Christopher’s, which grew out of one woman’s deep Christian compassion, shows what can be done. Many church and community groups have followed Dame Cicely’s model and now extend loving care to the terminally ill who have chosen against artificial methods of prolonging life. By definition, these patients are beyond the range of medical cure. Yet hospice has found a way to treat this most distressing human condition with dignity and compassion. Dame Cicely takes pride in the fact that fully 95 percent of the patients at St. Christopher’s have been able to stay both alert and free of pain. She has demonstrated it is possible to disarm the last great fear most of us will face, the fear of death and the pain which accompanies it.(239-259)

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