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The Infinite Mind: Pain
Week of June 25, 2003
If you live with chronic physical pain, you are not alone. At any given time, one out of four of us has a headache. In fact, in a study of fifteen hundred people in Michigan, 1 out of 5 reported that they experience chronic pain. Of those people, 2 out of 5 say that pain affects their relationships and their work. Nearly half have experienced depression as a result of their pain, and about 1 in 10 say they have actually contemplated suicide to escape it. What is the top selling category of drug? Pain killers. Although pain is such a common part of the human experience, it is still quite mysterious.
Guests include, Lisa Birnbach, author of The Preppy Handbook; Dr. Allan Basbuam, professor and chairman of the department of anatomy at the University of California at San Francisco; Dr. Louann Brizendine, professor of psychiatry at UCSF; poet Linda Martinson; and Dr. Jeanette Liska, a pastoral psychologist.
Host Dr. Fred Goodwin begins with an essay. He says the number of people in physical pain is frightening. He says this is a national problem. What's fascinating about pain is that while it's a common experience it's an enigma. We learn from a young age not to put our hands in fire, and at the same time, people who are unable to feel any pain at all live in great danger. Pain is also subjective; it is impossible for doctors to measure. Pain is what you feel it is.
Best-selling author Lisa Birnbach, humorist and author of The Preppy Handbook, has experienced crippling back pain. One episode, which began while she was pregnant, and unable to take pain medication, lasted seven months. Birnbach's most recent book, 1003 Great Things About Kids, is published by Andrews McMeel Publishing.
Next, Dr. Goodwin speaks with Dr. Allan Basbaum, professor and chairman of the department of Anatomy at the University of Califonia at San Francisco, and Dr. Louann Brizendine, professor of psychiatry also at UCSF. Dr. Basbuam starts off by explaining that pain is subjective. The difficulty with treating pain, Dr. Basbuam says is that doctors have no way of knowing the extent of someone's pain. . Perhaps this is a reason why pain is under treated.
Women experience pain more than men. Their thresholds for pain are lower. Dr. Brizendine says this fact coincides with the male female ratio -- the ratio of depression of women over men is 2 to 1. Patients who have depression report a much higher incidence of pain. In fact 40 to 50 percent of patients with depression complain of some form of chronic pain, so women with depression will often experience pain as well. Anxiety also increases the perception of pain. Treating the anxiety will often reduce the pain. Valium and cognitive therapy both work to decrease the patient's perception of pain.
There are two major classes of pain: nociceptive and neuropathic. Nociceptive pain is associated with tissue injury, and responds to anti-inflammatory drugs and opiates. Neuropathic pain, caused by injury to the nervous system itself, can be associated with diabetes, shingles, or chemotherapy. It is usually much more difficult to treat.
Dr. Babuam explains what it means when we say pain is a perception. He cites Lamaze as an example, it distracts women from pain. There are also cases of athlete who brake a limb and don't realize it until after the game. And placebos work in a similar way. People who train themselves to walk on hot coals is another case of pain being a perception. Dr. Basbuam says he's tried it (and he burned himself). Sweet scents and sucrose work as well. These examples show that the perception of pain can be altered.
Antidepressants are often used to treat pain. Dr. Brizendine says that serotonin and norepinephrine reuptake inhibitors are often used for treatment -- Elavil for example seems to work well. But doctors have a problem when it comes to treating pain, because while there are drugs that can help, many patients tell their doctors only about physical pain. Often what they don't tell their doctor is that they feel depressed. In fact, 40 to 50 percent of patients with depression suffer from chronic pain as well. This contributes to the under diagnosis of depression. But there are warning signgs doctors for which doctors should take note. If a patient comes in with 4 or more parts of their body that hurt, that's a signal to look for the possibility of depression. In addition, a person with depression develops neurochemicals that help to amplify the perception of pain. Dr. Brizendine cautions that in these cases, even though there is a link between depression and pain, the patient sill does feel real pain.
Dr. Goodwin then asks Dr. Basbaum about treatment for pain. There are drugs such as anticonvulsants that are used for epilepsy. And neurontin is a good drug too, he says. Oxycontin is also a drug he recommends for pain, even though there is some controversy over people using this drug illegally. But the more exciting developments are in microbiology. There are special genes that are expressed in the pain fiber. They have been identidified and they are now an important target when it comes to treatment. So we have the opportunity to develop a new drug that will target these special molecules and genes, and that will also have a low side effect profile.
Pain isn't taken seriously as a problem, Dr. Basbuam says. It is now required of all physicians in California to take pain management classes. But this isn't enough. For example, very few oncologist's have a good understanding of pain problems, he says. Pain needs to be treated because when you have an injury the nervous system establishes a memory of the pain. If pain goes untreated, the pain can stay because the memory of the injury continues. Dr. Basbaum warns: "You must treat pain aggressively."
To reach Dr. Allan Basbaum and Dr. Louann Brizendine, you can call them at the UCSF pain management center practice at 415-885-7246.
After a short break, Dr. Goodwin speaks with Linda Martinson. She is a writer who has lived with fibromyalgia, a chronic disorder characterized by often severe pain and fatigue, ever since an auto accident in 1987. She has written a book of poetry about the disorder, and how coping with it has compelled her grow personally in unexpected ways. Her book, Poetry of Pain, is available through Simply Books at (800) 431-1579.
Next up, Dr. Jeanette Liska is a pastoral psychologist. In 1990 she regained full consciousness during surgery. She woke up to see and feel the knife cutting into her body. Because her muscles were immobilized, she couldn't tell the doctors to stop. This went on for three hours. Horrible as the operation was, going home was worse. She experienced recurring nightmares of the pain, thinking she was going to die, and smelling her own flesh burning as they cauterized it during the operation. Dr. Liska overcame severe memory and concentration difficulties triggered by the event.
Dr. Liska claims about 250,000 incidents of explicit or implicit awareness during surgery take place each year in the United States. She has counseled thousands both before and after surgery, and organized AWARE (Awareness With Anesthesia Research and Education) to educate about surgical awareness experiences. Liskay woke up because her anesthesiologist made a mistake. No technology can detect the depth of anesthesia, Liska is interested in a new device called a bispectral monitor has been showing hopeful results.
Patients who prepare for surgery experience minimum blood loss, and a dramatically reduced post-operative hospital stay, says Dr. Liska. She urges patients to speak with their surgical team beforehand to familiarize themselves with their procedure, as well as to eat properly and exercise, to practice meditation, prayer or guided visualization, and to listen to an audiotape with positive suggestions about the operation. Dr. Liska's most recent book is "Silenced Screams," published by the American Association of Nurse Anesthetists.
Our weekly commentator John Hockenberry looks back to childhood memories and reflects that the expectation of pain is often worse than the actual experience.
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