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.
