Find Out The Type Of Your Pain To Get Best Relief
James Murphy is only 26, but some days, he
can hardly get out of bed. Three years ago,
Murphy, a Massachusetts man who used to fix
power tools for a living, damaged a disc in
his back while lifting a steel workbench. The
injury allowed the jelly like material that
cushions vertebrae to ooze out and press on a
nerve. Pain raged through his lower back and
shot down his right leg.
Today, his pain is even worse, despite
surgery, cortisone injections, pills and
numerous visits to a major Boston pain
clinic, where, he says, he was told it was
all in his head.
A year ago, Murphy got so disgusted that he
started a Web site (come.to/painsupport). It
now gets 400 hits a week from people -- some
suicidal -- whose lives are ruined by pain.
Chronic pain, defined as pain lasting more
than three months, affects 35 million to 40
million Americans, says Dr. Russell Portenoy.
head of the American Pain Society and of pain
medicine and palliative care at both Israel
Medical Center in New York.
And researchers now know that, far from being
all in one's head, chronic pain is an
all-too-real physiological phenomenon, though
the specifics vary, depending on whether it's
caused by damage to nerves, as in shingles or
diabetes; by inflammation, as in arthritis:
or by other things, such as spreading cancer.
With a nerve injury, for instance, chronic
pain may be the body's way of learning to
avoid future injuries. When you injure nerves
in your finger, nerves in the spinal cord
"reorganize to amplify pain and remember it,"
says Dr. Daniel Carr, a professor of
anesthesia at New England Medical Center.
But despite a growing understanding of
chronic path, millions' still suffer "because
doctors don't believe patients' reports,"
says Dr. Kathleen Foley, a cancer-pain
specialist at Memorial Sloan-Kettering .
Cancer Center in New York.
There's also the persistent fear that
patients -- even those who are
dying -- might become addicted to opioids,
such as morphine. And doctors fear
drug-enforcement officials.
In reality, opioid abuse is rare in pain patients. In one study of 12,000 patients, only four became addicted. Another study found that not one of 10,000 burn patients became addicted. In yet another study, of 2,000 patients, only three became addicted. What does happen is that people don’t get enough medication. A major 1995 study showed that 50 percent of dying patients had pain in the last three days of life.
Another found that only 12 percent of cancer patients in nursing homes received the basic pain care recommended by the World Health Organization. And a New England Journal of Medicine study of 1,000 cancer doctors showed that half their patients had bad pain -- and the doctors didn't know what to do about it. And it's not just dying patients whose pain is inadequately addressed. In a Roper survey of 805 people without cancer and with moderate to severe chronic pain, 40 percent said their pain was out of control. Nearly half had switched doctors at least once, and half had been in pain for more than five years. Much of that suffering can be avoided, and the first step is to get an evaluation to see exactly what type of pain you have.
If you have arthritis pain, traditional NSAIDS (nonsteroidal anti-inflammatory drugs) and newer ones, called COX-2 inhibitors, may help. If your pain is from cancer, opioids, such as morphine, hydromarphone, oxycodone, codeine, methadone or fentanyl often help. These drugs all work through a special type of opioid receptor in the brain, called mu.
If you have nerve pain, drugs that work through a different receptor, called NMDA, may be the answer. Examples include dextromethorphan and ketamine; another drug, d-methadone, also shows promise.
Chronic pain also makes many people
depressed, and antidepressants help, not just
by elevating mood but by fighting pain
directly.
Older antidepressants,
including Elavil, reduce transmission of pain
signals up the spinal cord and rev up
transmission of pain-killing signals that go
down it. Newer antidepressants, such as
Paxfl, control pain through a different
mechanism.
Anti-convulsants, such as Neurontin, can also
block the firing of nerves that have grown
new sprouts in response to injury.
Anti-anxiety medications, such as Valium,
Ativan and Klonopin, block transmission of
signals along pain
nerves, as well.
Researchers are also finding better ways to deliver painkillers in patients who can't swallow or don't want injections. Fentanyl now comes in patches and lozenges.
If pain is intractable, doctors can implant pumps in the spinal cord to supply morphine or "snail slime" (a substance called SNX-111 that mimics a chemical put out by ocean snails).
In some patients with back pain steroids injected near the spinal cord help, as can injections of local anesthetics into nerve ganglia in the neck or lower back. In other [ cases, doctors put electrical devices in the brain or spinal cord to block pain, Doctors can also destroy pain nerves surgically or chemically, but this is usually done only if a patient has a short life expectancy, because new pain nerves can sprout, notes Dr. Douglas Merrill, chairman of the committee on pain management for the American Society of Anesthesiologists. The bottom line is, there's help available, but you may have to fight for it. You may also have to fight your tendency to let pain become "a way of life," says Merrill. The solution may be to find something to do with your life other than watch TV and wait for six hours to go around to take your pills again."
Judy Foreman is the health columnist for The Boston Globe
