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All That Is Necessary For The Triumph Of Evil
Is That Good Men Do Nothing

Wednesday, June 15, 2005

Chronic Pain

The Right (and Wrong) Way to Treat Pain
February 28, 2005 issue
Time Magazine Article.

Chronic pain is a thief. It breaks into your body and robs you blind. With lightning fingers, it can take away your livelihood, your marriage, your friends, your favorite pastimes and big chunks of your personality. Left unapprehended, it will steal your days and your nights until the world has collapsed into a cramped cell of suffering.

Penny Rickhoff's world began to shrink suddenly in 1990, after a very tall and very heavy file cabinet toppled over onto her back. The freak accident damaged her spinal cord, leaving her with a constant, gnawing pressure in her lower back. "If I sit for very long, I'm in excruciating pain," she says. Once an avid tennis player, world traveler and amateur pilot, Rickhoff, who is in her 50s, was not only grounded, but she also became almost a prisoner in her home, unable to drive more than a short distance, unable to go anywhere without toting special "tush cush" pillows.

After seeing a dozen doctors, Rickhoff finally realized she wasn't going to be cured and started looking for ways to live with the pain. She took up Tai Chi and learned how to breathe deeply using her abdominal muscles. These pain- management skills enabled her to lower her dosage of morphine. But Rickhoff is the first to admit she can't make it through the day without her meds, and her powerhouse weapon was Vioxx. It helped destroy any pain, any time. Last September, when she learned that Vioxx was being pulled from the market by its manufacturer because of side effects, Rickhoff began to fret. "I knew from past experience that when I'd run out of a prescription, I would start to ache all over. I was so very distressed." She got a letter from her pharmacist urging her to return her supply of the drug, but she felt tempted--"very, very tempted"--to hang on to her hoard. "I'd taken it for five years with no problems at all," she says. In the end she figured it wasn't worth the risk. "So I returned it to the pharmacy and started suffering."............

.........This is true even for patients in extreme agony. After knee-replacement surgery, Donna Jaeger, 56, of Auburn, Calif., developed a neurological condition that caused excruciating pain that she rated a "17 on a 1-to-10 scale." Pain-management experts at U.C. Davis prescribed a multifaceted treatment that included powerful opioid drugs and a spinal implant--all of which helped. But Jaeger regards psychologist Symreng as "my saving angel." Breathing techniques and soothing relaxation tapes help Jaeger reduce her pain level from 17 to 4 or 5 on a good day. "But really," she says, "it is just the talking to her that helps, because the more you hurt the more anxious you get, and the more anxious you get the more you hurt."

Imaging techniques, which build on biofeedback principles, are another psychological option used at pain centers. At Stanford, Mackey has taught patients to literally watch "their brain on pain," using functional magnetic resonance imaging. By relaxing, they can watch lighted areas change color as pain fades. "It's tremendously empowering," he says, "all without medication."

Psychologists often play a critical role in persuading pain-hobbled patients to get moving again despite the blaring siren that tells them to keep still. "By educating them, by saying 'You've healed as much as you're going to heal,'" says Symreng, "we can deal with the No. 1 issue from a psychological perspective: the fear of reinjuring something." Getting the patient to move--or, better yet, exercise--not only restores function and raises spirits, it also prevents the cascade of health problems that stem from paralyzing pain. "If you're lying in bed all day," explains UCSF's Palmer, "you're going to have more problems from a cardiac standpoint, a pulmonary standpoint and a mental-health standpoint."


If comprehensive pain-management centers are so good at providing relief, why aren't more doctors following their lead? The sad fact is that virtually every trend in medicine--from the training doctors get to the treat-'em-fast pressures of managed care to the way insurance companies cover or fail to cover alternative therapies--works against this. "We don't teach medical students enough about pain, even though it's the most common reason people go to doctors," complains Fishman of U.C. Davis. "We've really wandered from a basic philosophy in medicine, where you cure what you can but always treat suffering, to being focused only on curing."

Fishman, who is president of the American Academy of Pain Medicine, laments the way insurance plans favor quick pharmaceutical fixes over the kinds of physical and psychological therapies that chronic-pain patients need. The bias toward drug treatment is not only bad medicine but is also expensive. "When somebody comes in with 25 years of chronic pain," says Fishman, "I might sit with them for 90 minutes to get the beginning of the story, to really understand what's happening. The insurers would rather pay me $1,000 to do a 20-minute injection than pay me a fraction of that to spend an hour or two talking with a patient."

Inevitably, many patients who find their way to pain-management centers wind up paying out of pocket for some of the nontraditional parts of their treatment. Still, demand for these services is soaring. Six years ago, the center at U.C. Davis received 50 to 60 patient referrals a month; now it receives 500. With fewer than 200 multidisciplinary centers across the U.S., the need simply cannot be met. "The bottom line is that there will never be enough specialists to deal with the problem," says Fishman. "So we have to train primary-care physicians at the front lines to be able to do this as part of the basic care that we give patients." For that to happen, more doctors and patients will have to heed the lessons of Vioxx and Celebrex and refuse to settle for prescription-pad medicine. --With reporting by Dan Cray/ Los Angeles, Chris Daniels/ Toronto, Alice Park/ New York and Maggie Sieger/ Chicago

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