Since pain is so detrimental, why are the treatments of pain so poor? The drugs we use to treat pain cause an enormous number of problems. The different classes of drugs all have unique problems. The narcotics induce addiction, make you sleepy and nauseated, decrease your energy and depress your mood. The anti-inflammatory medications (NSAIDS, Toradol and aspirin) create ulcers, bleeding and bruising. Tylenol works well but its toxicity profile is much lower than previously thought. (Never take more than 4 grams a day.) Pain patches work pretty well, until they irritate the skin after a few days of use. Ice is extremely effective but must be used carefully in order not to burn the skin.
Many patients prefer nonpharmacological treatments. Some of these treatments work better than others. Some have more of a placebo effect, but who cares if the pain goes down? Acupuncture leads the list of those that are widely used but poorly documented. Fake needles have been shown to be just as effective as sharp, real needles in controlled studies, although many people do get significant pain relief.
For muscle and nerve stimulation, transcutaneous electrical nerve stimulation units, work for some people by overwhelming the pain fiber conduction. They produce variable results, but when they work, patients love them. Soft-tissue massage reduces swelling and pain, but takes a trained therapist to get the best results.
So why are we so poor at pain control in the 21st century? Can’t we have a pain-relieving drug without side effects? How can this be so hard? The problem is that pain and the psyche are so deeply intertwined that stopping one mechanism of pain sensation leaves open multiple other pathways in the brain. Our psyche chooses to recognize the feeling and so the pain continues.
Thus in our hands, the treatment of pain must always start with prevention, so that the brain never gets a chance to build these pathways to pain. For a surgical patient, for example, we will first counsel them about what to expect and how to avoid pain or how to respond to it with the least stress. We remind them of the Buddhist idea that you can have pain but not suffer from it. Before coming to surgery medications that reduce the perception of the pain induced by surgery include a long acting nonsteroidal drug and for some patients an anxiety reducer such as Valium or Xanax.
Just before surgery, we talk to the patient about the Zen of entering the event with complete confidence and relaxation. We reassure them that our team has been together for the last 4,000 cases, with the same anesthesia team and the same nurse surgical assistant. At surgery, our nurse holds the patient’s hand during the induction of anesthesia. We then inject local anesthetics to block the pain fibers before any incision is made, preventing the brain from ever receiving the pain stimuli. Minimal incisions and exposures are utilized and the tissues are handled extremely carefully to reduce extraneous trauma. Before the end of the procedure, additional long acting, local anesthetics are injected usually providing 24 to 48 hours of near-complete pain relief.
The least number of drugs and a number of varied nonpharmacologic methods are used to overwhelm the person with healthy pain reducing stimuli. Essentially, ice, massage, stimulation, exercise and meditation are paired with local anesthetics first, and an elevating pyramid from anti-inflammatories to eventually a narcotic as a last choice if necessary. The taper off starts first with the narcotic and ends with a lifetime prescription for fitness exercises.
It is not just pre-emptive anesthesia where pain can be prevented but in many areas of life where pain is expected. Preparing for and preventing pain is much more possible than has been practiced.
The future of pain relief lies in a much more intricate combination of precise pain-relieving medications that have far fewer side effects and a wide range of psychological interventions that both prevent the onset of pain and prepare the patient for acceptance of a degree of discomfort that is not debilitating. The more skilled we become with the tools we have today, the less we will ever need to inflict pain upon those we so deeply want to help.
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments. For more info, visit www.stoneclinic.com.