Feature

Pain Killers

One variation on that theme is the specialty of Dr. Emile Hiesiger, a neurologist and pain specialist at New York University Medical Center. Using a hollow needle, he threads a fine electrode into the spine, briefly wrapping it around specific offending nerves and heating it to nearly 180 degrees using radio waves. "In some cases it destroys the nerves; in others it partially destroys them," says Hiesiger. "We don't fix the problem that's causing the pain, we just find the telephone lines that connect the pain impulses to the brain and cut them."

For Stephen Jones, a 39-year-old Floridian who designs roof and floor trusses for houses and commercial buildings, that was more than sufficient. His sciatica pain had gotten so bad, "the only way I could be comfortable was to lie on my stomach on the floor," he recalls. "That's all I could do. It affected everything." Hiesiger's procedure dulled his pain. "I'm smiling again," says Jones, albeit cautiously. "I had a lot of letdowns before."

"Say you have a patient with low-back pain spreading down their leg," says Dr. Steven Richeimer, medical director of the Richeimer Pain Institute at St. John's Health Center in Santa Monica, California. "If you look for the seed of the problem, you may find a disk in the lower back that's bulging and irritating a nerve. But that may have triggered a lot of reactive muscle spasms, and that will be the next layer. And then that person may be under a lot of stress, and stress will increase muscle tension, and that will make their awareness of pain more sensitive, which will in turn lower their pain threshold," he says. "And if these problems aren't addressed, the patient is going to get depressed as well, which can also magnify the pain experience."

The search for anti-pain drugs has led to Ecuadoran frogs and poisonous Philippine sea snails.

"Pain is a sensory experience -- but it can be magnified by something like depression, or panic attacks, or stress, or a combination of all of these," agrees Fishman, a colleague of Richeimer's. "You really can't treat patients without considering their mind and body. It doesn't mean that every patient has to be psychoanalyzed, but it does mean you have to take a kind of holistic approach."

Which is why pain doctors have the unusual distinction of being among the few medical specialists who actually embrace alternative therapies such as biofeedback, hypnosis, and meditation. Most patients treated by pain specialists these days are encouraged to use whatever mind-body approach seems to help them relieve their pain.

Glimmers of change in the system are also evident in legal innovations to patients' pain-related rights. California, for example, just passed legislation making pain the fifth vital sign -- after pulse, blood pressure, temperature, and respiratory rate -- and requiring that doctors get pain-management education before they can get their licenses renewed. A third component of the legislation mandates more such education in the state's medical schools. Many other states are considering similar laws, and making pain the fifth vital sign will soon be routine in Veterans Administration hospitals.

What's more, the Joint Commission on Accreditation of Healthcare Organizations, a nonprofit group that rates hospitals, drew up new standards for pain care, effective January 1, 2000, explicitly recognizing a patient's right to accurate assessment of pain and follow-up on treatment for it. In order to remain competitive, most hospitals will be forced to comply by creating their own pain departments and centers.

Individual doctors, too, may feel increasing pressure. In a recent precedent-setting Oregon case, a doctor was censured by the state medical board for underprescribing pain medication for cancer patients. In states where medical boards can't be induced to censure, there are a growing number of lawsuits against doctors, often filed with the help of patient-advocate groups.

Needless to say, the health-care profession as a whole has still not entirely embraced the goal of overcoming what pain specialists like to call "barriers to care." Those barriers were built into the system long ago: In 1914, the federal government enacted the Harrison Narcotics Act, having been spurred by the number of people addicted to inexpensive, over-the-counter potions like Hooker's Wigwam Tonic, which were liberally spiked with potent narcotics. The act separated opium-derived pain killers -- morphine, codeine, and heroin -- from common analgesics; thus were born "controlled substances." Doctors who prescribed them were to be (and still are) closely monitored, and those whose patients became addicted or died prematurely risked losing their medical licenses.

As a result, narcotics were, and often still are, routinely underprescribed for both dying patients and those with chronic pain, although they are often the most effective means of helping both. Research has shown that while pain patients may become physically dependent on narcotics to relieve pain, they do not tend to develop aberrant, compulsive, drug-seeking behavior -- the hallmarks of the largely behavioral and psychiatric disorder known as addiction.

"With addicts, their quality of life goes down as they use drugs," says Fishman. "With pain patients, it improves. They're entirely different phenomena."

But try telling that to most doctors. Even those who understand the differences are still afraid, and with good reason. Every state enforces the Harrison Act with its own tracking system, and copies of all narcotics prescriptions are filed with the Drug Enforcement Agency.

"Half the neurologists I know don't even bother to carry the narcotics prescription pad," says Hiesiger. In fact, in a 1998 survey of all licensed physicians in New York commissioned by the New York commissioner of health on barriers to good pain care, 70 percent of respondents said they were unlikely to prescribe a controlled substance because of fear of being scrutinized by the authorities.

The pain docs call for more education in medical schools, for starters, as well as continuing education for those long out of school. Insurance companies need to make new reimbursement categories for pain. The government -- not just pharmaceutical companies -- needs to recognize the specialty and sponsor more research. And patients, say experts, need to be educated as well.

"Patients want to be perceived as good patients," says Portenoy. "There's this stoicism in the American character, so they don't talk about pain as much as they should." He cites a recent survey by the American Pain Society that found that only 25 percent of patients with moderate or worse chronic pain ever get referred to a pain specialist.

"I'm optimistic that we will have a much more clearly defined niche in the future," says Portenoy. "But pain management as a specialty is also in a very uncertain time right now, as we face questions about the health-care system and reimbursement and how it fits into the managed-care world. How much precedence will be given to general care versus specialists, for example, and what specialists will be considered essential, and how will people get to them?

"My sense," Portenoy predicts, "is that the next five years, when a lot of these decisions get made, will be a critical period."