Doctors work on ways to bring comfort for sufferers of chronic, severe pain

By: BRADLEY J. FIKES - Staff Writer | Saturday, September 2, 2006 5:16 PM PDT ∞

Pain is the most mysterious, common malady known to medicine. It doesn't show up on an imaging scanner or in a lab test. Pain is a purely subjective sensation, experienced only by the patient.

But to those suffering from it, pain's reality is inescapable. Chronic, severe pain degrades quality of life, and can totally incapacitate the victim. In extreme cases, unrelenting pain can drive the sufferer to suicide.

Baffling as the causes can be, chronic pain is one of the most widespread disorders in the United States, with an estimated 75 million Americans suffering from it. The cost, in lost workdays and insurance, is $100 billion a year, according to the American Pain Society.

"It's debilitating, emotionally, physically, in every way. It limits your life," said pain patient Ginny Dowling.

"Ten years ago, I had neck surgery as a result of a car accident," said Dowling, an Encinitas resident. "A semi-truck ran me down on the freeway. I had a three-level fusion in my neck, and I have two bolts in my hip. And in January, a guy ran a red light and hit me."

With no relief from the pain in sight, Dowling was referred to the pain clinic at Scripps Memorial Hospital. She was interviewed during her fourth visit to the clinic, on Aug 23.

"I can't exercise as I normally would. I have a shorter temper than I normally would. It's depressing to not feel well, constantly, and to be in pain," she said. "And I can't work full time. I had my own little bookkeeping business and I had to close it. So every aspect of my life has been affected. ... I have severe headaches. Often I can't get out of bed because of it."

Treatment gap


In the last generation, the medical profession has become aware of not only how widespread chronic pain is, but of how much is lacking in pain treatment. Pain is now considered the "fifth vital sign" to be monitored, and hospitals routinely record pain along with other indicators.

Doctors are also enlisting patients in the fight against pain. Instead of passively taking pills or injections, patients are encouraged to learn how to actively prevent or control pain. Body posture, diet, acupuncture, biofeedback and emotional attitude control are being taught to patients. This, added to greater understanding of the physical causes of pain, give patients the ability to endure, and even enjoy life again.

But many people with chronic pain aren't even seeking help, according to an article in the February issue of Mayo Clinic Proceedings. The study found that of 2,211 people who have had pain for more than three months, 22 percent had not sought help from a doctor.

And there's not enough study of pain among the growing population of the elderly, according to a article in the January issue of the journal Pain Medicine, available through Blackwell Publishing. About 4,000 studies of pain are published every year, and only 1 percent of those look at the effect of aging on pain, wrote Debra K. Weiner, M.D.., a longtime researcher into pain and aging.

Pain is considered a normal part of aging, Weiner wrote, so people live with pain that might be treatable.

Tough cases


The most difficult kind of pain to treat is that which doesn't correspond to any diagnosis or physical evidence, said Dr. Jose G. Veliz. A board certified pain management specialist, Veliz is founder of the Palomar Pain Management Center, with offices in Escondido and Poway

To treat these patients, the pain management center provides an array of treatments, some conventional that try to directly treat the pain, others that are aimed at the patient's general well being and sense of comfort.

"We offer a multimodal approach to chronic pain, ranging from physical therapy to medication management, to diagnostic and therapeutic injections of the central and peripheral nervous system," Veliz said. "We have relationships with psychologists in the area, in fact we have a group of psychologists that come to our office on a weekly basis."

The first step for Veliz's patients is an extensive examination, including a detailed questionnaire patients fill out.

"You also want to review any laboratory study that may have been performed, any imaging study," he said. "And if you feel the appropriate diagnostic studies have not been performed, you order those studies."

After those studies have been done, Veliz decides if another specialist needs to be called in. For example, if the pain might be related to the digestive system, a gastroenterologist might be called in.

That team approach is also used at the pain management clinic at Scripps Memorial Hospital in La Jolla. Patients who need opiates see an addictionologist at the start of their treatment, said Dr. Joseph Shurman, chairman of pain management at the hospital. A psychologist or psychiatrist is also called in. The patient is tested for driving skills, and mind/body treatments such as acupuncture, biofeedback or yoga may be offered through the Scripps Center for Integrative Medicine,

Much of Eastern medicine is viewed with skepticism because of a lack of evidence that it works. But pain management is an exception. Although the theory behind these treatments needs much work, doctors and patients are willing to take the results now, and look for explanations later.

Patients with cancer pain, knee pain and chronic headache get relief from acupuncture, according to a review article co-authored by Robert Bonakdar, director of pain management at the integrative medicine center. The article appeared in the September 2004 issue of the journal Patient Care.

The Patient Care article said acupuncture can release naturally produced analgesics called endorphins into the brain, as well as chemicals called neuropeptides into the spinal fluid. These block or overrride the pain.

In a similar fashion to acupuncture, pain can be controlled by electrical stimulation of nerves, the article stated. One of these devices is called a TENS unit, for Transcutaneus Electrical Nerve Stimulation. Dowling, the Encinitas pain patient, was given a TENS unit to apply where it hurts. Electrodes from the device are attached to the skin and the device turned on for no more than an hour at a time, said Joe Otto, a sales representative for Empi, a company that makes a TENS unit being used by Dowling, the Encinitas pain patient.

Treatment dangers


Pain specialists such as Shurman say the risk of addiction is low for patients who are taking medication as prescribed. That message comforted pain patient Dowling, who received an injection during her visit to the Scripps pain clinic.

"I think you can become addicted and it's very frightening to me," Dowling said. "But from what I've learned, it's not as likely (to become addicted) when you're in pain, because you're taking it for a reason, not to get high."

However, Shurman admits that part of his model is defensive medicine ---- defensive against drug authorities, which he said have unfairly targeted pain management specialists.

"Seventeen percent of pain physicians have been investigated," Shurman said. "It has led to this tremendous chilling effect on pain care."

Opiates, the target of the investigations, are "the last resort after you've tried everything else," Shurman said.

"Doctors are in a very tough position," he said. Under-medicated patients will continue to suffer from pain, and there is a heightened risk of suicide. But if the federal government thinks doctors are too lenient in prescribing drugs, they risk going to prison for the rest of their lives.

The case of William Hurwitz, a pain doctor sent to federal prison for 25 years for drug dealing, outrages Shurman and other pain doctors. Hurwitz, who was convicted in 2004, was recently granted a new trial. Hurwitz said the jury should have been told not to convict if they determined he acted in good faith.

Less dangerous for the doctor, but perhaps more dangerous for the patient, is unnecessary back surgery. This is a common abuse, said Dr. Erik Westerlund, an orthopedic surgeon at CORE Orthopaedic Medical Center in Encinitas. Westerlund, who specializes in spinal disorders, said back surgery is done too often, and can lead to irreversible damage.

Westerlund said that unless there is an obvious need for surgery, such as from trauma or a ruptured disc, back operations should not take place until the patient has had chronic pain for at least six months. During that time, less invasive treatments should be tried.

Spinal discs act as shock absorbers between the vertebrae, Westerlund said, providing flexibility. But the interior, a jelly-like cartilage, is "highly inflammatory" to the nerves. So when that interior leaks out, intense pain results.

"It's like putting a syringe full of bleach in your back," Westerlund said.

Spinal fusion, the usual treatment, solves the immediate problem. However, it lessens flexibility and may put more pressure on the adjacent remaining discs.

Pain-free lifestyle


Staying free of pain is something you need to work at, said Sarka Southern, who said she is happy to be out of pain following treatment earlier this year at Scripps Center for Integrative Medicine.

Southern, owner of Carmel Valley-based Gaia Medical Institute, visited the center in May to get rid of pain in her left arm. As a scientist, Southern spends long hours at her computer, and admits she didn't pay much attention to ergonomics in setting up her office.

"I had severe pain from my left had to the neck area," Southern said. "It clearly was not an easy thing to live with, and even interfered with doing housework."

Southern received a four-pronged therapy approach, consisting of acupuncture, trigger-point injections of painkillers, manual therapy massage and physical therapy. It worked. Southern is back at her job, out of pain.

Ergonomics has become part of Southern's pain-prevention vocabulary, along with posture. In a larger sense, Southern has adopted an active approach to avoiding pain.

"They taught me to focus on my health and work with them, rather than take a pill," she said. "That changed my point of view on how I should take care of my health and reminded me I should be much more proactive. Pain in the arm is linked to overall health in terms of what it can affect."

Lifting spirits


Just the possibility of being able to master her pain gives Dowling new hope. So even while the pain persists, Dowling's spirits have lifted a bit.

"It doesn't make the pain easier, (but it gives me) a little less depression, a little more positive thoughts about life in general ahead of you. Because the thought of being in pain like this all the time, for the remainder of my life ---- I'm in my early 50s ---- that's really devastating."

"I think that chronic pain has been undertreated in the past, and this is something I didn't know about previously," Dowling said of the pain clinic. "I think this is really going to be a life saver, or life enhancement, for a lot of people."

Contact staff writer Bradley J. Fikes at (760) 739-6641 or bfikes@nctimes.com.

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