As recently as 20 years ago, people with chronic pain were too often dismissively told that their problem was "in their heads" or that they were hypochondriacs. But in the last decade, a handful of dedicated researchers learned that chronic pain is not simply a symptom of something else -- such as anxiety, depression, or a need for attention -- but a disease in its own right, one that can alter a person's emotional, professional, and family life in profound and debilitating ways. Today, doctors have yet to fully apply this knowledge.
Some 50 million Americans have chronic pain and nearly half have trouble finding adequate relief. But the outlook is good: Ongoing research is revealing the promise of novel treatments, including new medications, devices and injections, alternative therapies such as biofeedback and acupuncture, and an all-encompassing mind/body approach. The point? If patients' whole lives are affected by pain, the treatment must address their whole lives.
I sat down with Scott M. Fishman, MD, to find out what's new in pain management -- and what doctors still need to learn to help their patients. Fishman is the president and chairman of the American Pain Foundation; he is also the chief of the division of pain medicine and professor of anesthesiology at the University of California, Davis. He wrote The War on Pain: How Breakthroughs in the New Field of Pain Medicine Are Turning the Tide Against Suffering. A University of Massachusetts Medical School graduate, he is board-certified in internal medicine, psychiatry, and pain and palliative medicine.
Q: About chronic pain: have researchers learned anything new about the origins of chronic pain that might lead to better diagnosis or treatment?
A: Absolutely -- we know exponentially more today than we knew even 10 years ago and much more than we knew 50 years ago. For one, we've learned a great deal about how pain is produced and transmitted and perceived. Fifty years ago, when someone hurt, we thought it was just a symptom of something else. But we now know the symptom of pain can become a disease in and of itself, and that disease is similar to other chronic conditions that can damage all aspects of someone's life.
New information has emerged in the last 10 years from one of the most active areas of pain research, neuroimaging. Functional MRI (magnetic resonance imaging) scans that look at brain activity when it's in pain or when it's receiving a pain reliever now tell us that when someone is in chronic pain, the emotion centers of the brain are more activated than the brain's sensory centers, which are more involved in acute, not chronic, pain. That's why pain is likely an emotional experience.
For all we've learned, however, we have not translated most of these advances to the frontline of medicine. Every time we take one of these discoveries and treat accordingly, we find unwanted side effects because pain is so pervasive. For instance, it's very hard to give someone pain relief without making them sleepy. It's very hard to turn off the nerves that transmit pain without producing the risk of seizure or heart rhythm problems.
But we're making advances. We're learning more about the electrical channels involved in nerve function. And we have many more candidates to target, and we're very hopeful that's going to translate into drugs with far fewer side effects.
Q: How can these chronic pain discoveries effectively help patients?
A: We need to use the full range of treatments available, not just drugs and surgery but mind/body, alternative, and psychological therapies as well.
Usually, a person in chronic pain is not suffering from just one perspective. One has to understand what pain does. We're designed so the alarm of pain grabs our attention and we prioritize that over other things. When your attention is absorbed and you can't attend to all the other things that are meaningful in your life, a downward cycle sets in.
Say a person has a painful arm; before long, he may not be able to sleep, may not be able to exercise, and may become deconditioned -- which may lead to arthritis problems or obesity or sexual inactivity and a deterioration in his intimate relationship. He no longer can support his family. He becomes depressed and anxious and ultimately may become suicidal. Chronic pain undermines all aspects of quality of life.
Therefore, we have to attack the problem from more than one perspective. Often the patient in pain needs to be treated both medically and psychologically, socially, and culturally. That's really what I would call a holistic approach, not an alternative approach -- one that addresses the whole person. I think where we're headed is a re-evaluation of how we are delivering fragmented pain care and possibly redefining the field so it can integrate, so that patients can get the best of all that's available from a single doctor.
Q: What new chronic pain treatments are you particularly excited about?
A: One has to do with teaching patients how to overcome their pain. We know that the human mind can create pain but that it also has enormous power to take it away; we can teach people skills that were known to Buddhists hundreds or thousands of years ago.
It's the same focusing technique athletes use to help them improve their performance. Take Lance Armstrong on that last hill of the Tour de France. Even though his legs are burning, he can divert his attention from the pain to the goal of performance. And you can do this with many different techniques. In this case, he's used a cognitive technique to change the internal message, "I'm hurting, I better stop" to "I better keep going but perform differently." A pain psychologist teaches these techniques.
What I tell my patients is that pain psychologists are really coaches. They're not there to diagnose an illness but to help you learn techniques to use your brain better -- just like you would go to a physical therapist to learn techniques to use your body better. It's the same thing.
Q: You're describing a mind/body way of dealing with chronic pain.
A: Yes. You can't have pain without a mind, so it's all connected. My patients are always afraid I'm going to think their pain is all in their head, that they have a mental illness rather than a physical illness, and ignore the real problem. I try to counsel them that it's quite the opposite, that any pain requires a mind and you can't have pain without a head; so recognizing that opens up all sorts of opportunities to help cope and reduce suffering.
I think of mind/body approaches as techniques that tap into the body's own pharmacy. Things like mindfulness and biofeedback and cognitive behavioral retraining, or guided imagery, even self-hypnosis. Things like acupuncture and massage. We don't know how these things work but we're certain they're helpful.
Q: What new chronic pain drugs are in the pipeline?
A: I'm very pleased we are coming up with ways to deliver drugs that are less of a burden on patients. There are now several long-acting (also called sustained-release) products that patients don't have to take every three or four hours and be constantly thinking about when to take the next pill.
I'm also excited about new drugs coming out for nerve damage pain. There are all sorts of ion channels in the body we didn't know existed five or 10 years ago but that we are now targeting as potential pain relievers. New drugs aim to target these ion channels, which are involved in moving electrolytes in and out of the nerves to make them fire and send a pain message to the brain. If we can impact that channel, we can stop the nerve from firing. The key is to be able to do it without tripping all the nerves in the body, just those involved in the problem we're trying to treat. But the future is bright, and these drugs are in the pipeline. We'll be seeing some in a few years.
As for drugs already available, many are very useful but we could benefit from using them more wisely. They range from opioids and antidepressants to anticonvulsants and other novel agents. They all have special properties and we're still learning about them; for example, we're still not sure how antidepressants work to help chronic pain.
Q: About pain medication, are doctors being better educated about this in medical school?
A: Pain is the most common reason a patient goes to a doctor, and sadly we train doctors, clinicians, and nurses very little on pain and pain care. We now recognize that we have a public health crisis of undertreated pain, but we also have a public health crisis of prescription drug abuse. Some doctors overprescribe and some feel they [painkilling drugs] should never be prescribed. Frankly, neither of those situations should be allowed to exist and wouldn't exist if doctors were trained up front. They may be better trained today but only marginally so, and we need to bring education back to the medical school and to practicing physicians as well.
Q: Narcotic opioids and other painkillers are in the news, and patients and physicians do grapple with this issue a lot.
A: Right. The bottom line is that opioids can help people but they also can harm people. We do want to use them properly because they can be problematic, including their addictive properties. But many patients fear that any addictive drug taken long enough can make you an addict, and that just isn't true.
The big question is, "What's the proper use?" And how would you know that someone is having a problem with an opioid? The answer is they would not have a good response -- that is, real pain relief. When the intense focus on pain is taken away, their function improves. Contrast that to the patient with an addiction, which is the compulsive use of the drug that produces dysfunction. So if a doctor is watching a patient and treating him or her rationally and safely, that doctor will see that happen and stop the drug.
Q: What about using supplements for chronic pain? What works?
A: Supplements are interesting, and several do seem to help. Fish oils, for example, have omega-3 fatty acids, which have potent anti-inflammatory effects as well as other health benefits. Others are glucosamine and chondroitin and evening primrose oil, which is a lipoic acid supplement that helps nerves function properly. It can be very helpful for patients with neuropathic [nerve] pain.
The problem is that people think of supplements as side-effect free. But they are potent medications that really do have impact -- both positive and negative. For example, people may not know that supplements such as fish oil or garlic or vitamin E are blood thinners, and if you take them together or with other blood thinners you can have problems.
Q: Anything new about treating migraine pain?
A: Migraine pain is a highly prevalent and widespread problem, but we really don't know yet what causes migraines. New information in neurochemistry and neuroimaging is helping to change that. In the last 15 years, we've seen a revolution in treatment with triptans and other drugs that can stop a migraine rather than just numb the pain.
Q: What's ahead for treating osteoarthritis pain?
A: Osteoarthritis is a kind of wear and tear, and we're recognizing that has much to do with use and disuse. If we keep people in fit condition, they rarely get this severe osteoarthritis. We're also learning more about the role inflammation plays in osteoarthritis. Recently, some anti-inflammatory drugs were taken off the market because they caused heart problems. Now, we are learning about this issue with all anti-inflammatories, and probably none of them is exempt. So in the future we'll find out what that problem is, and we'll be able to tailor drugs away from it.
Q: Fibromyalgia for many years was somewhat maligned as a diagnosis. Has this changed? And since this condition can be difficult to treat, where are we with treatment today?
A: I think we're pretty sure now it exists but we have to be honest. We're not sure what "it" is. And it may not be one thing. It may be multiple disorders that lead to a global deconditioning disorder. In terms of treatment, I don't think we're terribly far along. I think we can help people with fibromyalgia but we're nowhere near curing it.
Q: So many people have back pain. What's new in this area?
A: We're learning more about all the different small structures in the spine that can cause back pain. For example, there are now targeted treatments, usually injections, that put medication right into the area of the nerve causing the pain.
No question, back surgery can be very effective but it can also be devastating and harmful, so we have to resolve who is a good candidate and who isn't. New studies now coming out are helping us to better predict this. We're also asking new questions, such as, why do certain regions of the country have more back surgeries than others? I think within the next decade we'll have many more answers.
I'm especially excited about spinal cord stimulation. An electrode, much like a pacemaker, is threaded into the spine and uses the "language" of the nerve (the electrical signals nerves use to communicate) to jam the pain signal. This technique works very well for pain from back surgery when nerves have been injured during the procedure.
The caveat is that spinal cord surgery stimulation is for only a minority of patients, but it can be very successful. After a useful stimulation treatment, my patients say good-bye and we don't see them again until they need adjustments to the stimulation intensity or a new battery. They send me a Christmas card.