Less Pain, More Gain

By SAM ALLIS BOSTON

WHEN RESEARCHERS AT MASsachusetts General Hospital order white rats for medical research, they must fill out detailed forms explaining whether the animal will experience pain, what procedures will be used to minimize its suffering, and who is responsible for pain management. A grandmother who undergoes a hip replacement in a U.S. hospital enjoys no such concern. There are no questionnaires about the suffering she will endure after her operation. And chances are she will hurt.

Experts estimate that up to half of surgical patients suffer moderate to severe postoperative pain. No one knows for sure because while hospitals laboriously monitor every patient's temperature and blood pressure, they keep no charts on pain. It is the rare hospital that employs a comprehensive pain- management team to ease patients' suffering, and a rarer medical school that spends much time teaching the subject. Traditionally, physicians have regarded pain as an ancillary problem. "The focus was on disease. Pain was merely a marker of disease," says Dr. Kathleen M. Foley, pain-service chief at Memorial Sloan-Kettering Cancer Center in New York City. To some degree, this attitude simply reflected the bias of a culture that prizes the stiff upper lip: no pain, no gain.

But among cancer specialists, pediatric surgeons and many other doctors, this tough-it-out attitude has begun to change. Worries about the physical and psychological risks of using large doses of narcotics have largely been proved unfounded. Technological advances have enhanced the efficacy and safety of analgesia. And, perhaps most important in an era of cost cutting, doctors have learned that not only is pain management humane, but it also speeds recovery and saves money. When a patient is in such agony that he cannot move about in his bed, the risk of life-threatening blood clots increases. When he hurts too much to cough after chest surgery, the risk of pneumonia jumps.

A study at Dartmouth-Hitchcock Medical Center in Hanover, New Hampshire, five years ago proved the point. Dr. Mark P. Yeager randomly divided 53 intensive-care patients into two groups. One received morphine by ordinary intravenous catheters, while the other had morphine delivered epidurally, through a catheter placed near the spinal cord. The epidural patients, who were virtually pain-free, spent an average of just 2.5 days in the intensive- care unit and a total of 11.4 days in the hospital, while the other group required 5.7 days in the ICU and 15.8 days of hospitalization. In dollars, the difference was $11,200 per epidural patient, vs. $20,400.

"Pain influences physiology," explains Dr. Daniel B. Carr, director of the pain service at Massachusetts General and co-chairman of a commission that last spring issued the nation's first comprehensive guidelines on acute-pain management. Acute pain directly affects heart rates, respiration, blood pressure and urine production. It can also make cancer progress more rapidly. John Liebeskind and Gayle Page of the University of California, Los Angeles, have studied the effects of surgery-related pain on laboratory rats with lung cancer. They found that tumors metastasized two to three times as fast in rats that received no pain-killers as in those that were given morphine. The stress of pain appeared to inhibit immunological defenses. Concludes Liebeskind: "Pain can kill."

Some of the benefits of relieving pain may be described as psychological. Pain, after all, is depressing (and depression makes pain worse). Because of the complex interplay between emotion and physiology, experts on analgesia have learned that it is useless to make distinctions between mental and physical pain. "We never say, 'It's all in your head,' " explains Dr. Charles B. Berde, director of the pain service at Children's Hospital in Boston.

Many physicians now concede that patients have been undermedicated for decades, suffering needlessly. One reason was concern that big doses of opiates could depress respiration, but a large part stemmed from an exaggerated fear that patients would become addicted. This fear, which continues to hold sway over American medicine, is basically unwarranted. A landmark study, published in 1982, followed almost 12,000 Boston hospital patients who had been given narcotic pain-killers. After eliminating those with a history of addiction, researchers found that only four became addicted to the drugs they received as patients. "You don't see cancer patients running around robbing shopping malls to support their habits," notes Carr.

NO GROUP OF PATIENTS HAS SUFfered more from undermedication than young children. For years, many doctors insisted that babies under six months didn't feel pain and those just above that age didn't experience much discomfort. Both ideas are now discredited. Nonetheless, cautions Bruce J. Masek, head of behavioral medicine at Children's Hospital in Boston, "society is still hysterical about making a four-year-old a heroin addict."

Fortunately, technology, improved drug protocols and changing attitudes toward pain management have come to the rescue of children and adults. Skilled pediatricians now routinely give morphine to children and infants to ease postoperative pain. Oxymeters, which monitor breathing, alert nurses to early signs of respiratory problems. When morphine is inappropriate, large doses of local anesthetic work well. Pediatric-pain specialists use a plastic scale of happy to crying faces to help young children express how they feel. And doctors have learned to recognize certain infant sounds, grimaces and motionlessness as signs of suffering.

Cancer-pain management has also changed dramatically. Physicians today give megadoses of morphine without great risk of depressing a patient's breathing. Sloan-Kettering's Foley estimates that the morphine doses she prescribes for chronic cancer patients, usually as time-released tablets, are at least ten times the amount she gave a decade ago.

Furthermore, doctors have learned that a given dose of morphine packs more punch when combined with local anesthetics like Bupivacaine or with the newest nonsteroidal anti-inflammatory drugs (the category to which Tylenol and aspirin belong). That strategy also helps patients avoid the side effects of opiates, such as nausea, constipation, hallucinations and itching.

While there are few truly new analgesics on the market, pain specialists have been ingenious about expanding the use of existing drugs. Surgeons, for instance, have learned that by putting a local anesthetic directly into the wound during and immediately after an operation, they prevent acute pain from getting established. "You never let the spinal cord see the pain messages," explains Berde. "It mollifies the entire course of postoperative pain."

Drugs originally approved for other purposes have been added to the analgesic arsenal. Tricyclic antidepressants like Elavil, for example, are now recognized as highly effective for the agonizing pain caused by damaged nerves in patients with shingles and diabetes. Methadone, the synthetic heroin substitute, has found new use as a cheap, long-lasting easer of chronic pain. And fentanyl, a highly soluble opiate, is available in a stick-on patch that offers up to three days of relief from the chronic, steady pain endured by many cancer patients.

The growing use of epidural pain relief, once largely confined to the obstetric delivery room to ease labor, has been a tremendous boon to cancer and postoperative patients. A terminal cancer patient who no longer receives adequate relief from huge doses of oral morphine can find relief at a fraction of the dosage with an epidural, and feel a lot less "doped up" as well. Epidurals are commonly used today after knee surgery and are increasingly being incorporated into the home care of acutely ill patients.

The breakthrough idea in acute-pain management today is titration -- the precise tailoring of dosage to the needs of a particular patient. There is, quite simply, no such thing as a standard dose anymore. Doctors have grudgingly come to recognize that the patient is the best judge of how he or she feels. Today people in acute pain can control their own medication with PCAs, or patient-controlled analgesia. These are digital pumps that are connected to a catheter. Physicians set a base amount of drugs that enter the body continuously. When pain increases, the patient can push a button and get more medication, up to a maximum set by the doctor. Gone are the every-four- hours injections of morphine that left a patient in agony for the final hour of each cycle as the drug wore off.

PCAs have been available for a number of years but have only lately gained widespread use. Genevieve Anderson, 64, had part of a cancerous lung removed two years ago at Massachusetts General without benefit of a PCA. More recently, she recovered from additional lung surgery with the device. "There is no comparison," she says. Carr notes that five years ago, a patient who had an aortic bypass would be unable to move the next day. Now, with PCAs, "a lot of them are sitting up doing the crossword puzzle," he says. "The old way was barbaric."

Chronic pain remains the biggest challenge because it is less well understood than acute pain. It may range from mild back discomfort to an amputee's agonizing phantom limb pain. While acute pain is essentially a healthy response to tissue damage, much of chronic pain is considered "neuropathic" -- the result of inappropriate nerve signals. Physicians now rely on physical therapy and behavioral techniques like biofeedback to battle chronic pain. In severe cases, they resort to antidepressants and local nerve-block injections, with varying results.

As doctors have become less fearful and more skilled in using narcotic painkillers, a debate has erupted over whether it is appropriate to supply these drugs to chronic-pain sufferers other than cancer patients. "Any chronic pain might be appropriate -- diabetes, sickle cell, arthritis," contends Dr. Russell Portenoy, director of analgesic studies at Memorial Sloan-Kettering. But, he concedes, "it's a controversial area." And controversial with patients too. Even in the cancer ward, says Foley, "patients say, 'I don't want to take that drug because it's morphine.' " An education program is needed, she says, to explain that suffering is not virtuous, that pain relief can speed healing and that narcotics, if used appropriately, do not lead to addiction. "We need to change the attitudes of both physicians and patients."