What to do when it hurts

New drugs and alternative therapies mean patients don't have to take pain lying down any more

By Wendy Banks

Until recently, 59 year old George Magee was an avid golfer. Then, following a car accident, he started suffering from neck and back strain. In the weeks that followed, he could barely turn his head, let alone swing a golf club. Back pain kept him awake at night; during the day, his concentration suffered. He became tense and irritable. His family grew resentful of his moods, leading to more stress and loss of sleep. Soon, the slightest touch to his back became unbearably painful.

Mr Magee went to see his family doctor. "Everybody starts to feel aches and pains at your age, " he was told. The doctor prescribed Tylenol. Weeks later, still in pain, he went back to the doctor, who ordered x-rays, a CAT scan and blood work to rule out systemic arthropathy. The tests all came back negative. On the recommendation of a friend, he went to a chiropractor. Guess what? The pain's still with him.

According to Dr Steve Blitzer, a family physician with a specialty in pain management in Thornhill, Ontario, Mr Magee's problems getting adequate pain management were once the norm. That's starting to change as doctors take chronic pain more seriously. "Doctors used to assume that if they couldn't find an obvious physical cause for pain, it was all in the patient's head, " explains Dr Blitzer. "Now, there's more of an acceptance that there is physiological basis for pain. "

According to a recent University of Chicago study published in the Archives of Internal Medicine, one in five hospital patients who reported pain said that it was inadequately controlled. The study looked at 5584 hospitalized patients, 59% of whom reported experiencing pain (28% severe, 19% moderate, and 12% mild). Interestingly, 28% of them didn't have high-risk characteristics for pain. Part of the problem lies in assessment -- pain is subjective and tough to quantify.

Dr Mark Frobb, a pain management physician who specializes in orthopedic medicine in Surrey, BC, acknowledges the difficulty. "Wellness is more than the absence of pain; it's a sense of well-being, emotionally, spiritually and physically, and that's difficult to measure. If you're dealing with a broken bone and you want to see how well it's healed, you can scan or do x-rays. But with pain management, it's far more subjective. " Basically, you have to rely on a combination of the patient's testimony and your own experience and observation.

The most common assessment method is to ask the patient to rate his or her pain on a scale of one to 10, compared to the previous visit. Dr Blitzer also relies heavily on observation. "I watch how a patient behaves in my office. Does he turn his head to look at things, or does he move his whole torso? How does he take off his sweater? "

In recent years, available methods for pain management have increased dramatically. Options range from pain-modulating medications and newer controlled-release narcotic medications, to alternative therapies like acupuncture. Which method is used depends on the patient, the problem, and, largely, on the doctor.

Dr Blitzer discusses the appropriate use of medication. "Doctors used to hesitate to prescribe opioids for pain, " he observes. "But in recent years, controlled release/long acting opioid medications have been developed, and there are guidelines supporting their use. " He observes that often, pain medication in hospitals is only prescribed on demand. By the time the patient receives the medication, their level of the neurotransmitter associated with pain is elevated, leading to higher sensitivity to pain and the need for more drugs. "It's better to start with pain medication immediately whenever possible, for example after surgery, and keep it up until the healing process is well underway. That way, patient reports of pain on subsequent days are noticeably lower, " he says.

OPEN OPTIONS
Dr Frobb prefers alternative methods of pain management. "As a professor of mine used to say, if the only tool you have in your bag is a hammer, everything starts looking like a nail. The key to pain management is to have a large skill set. In my field -- orthopedic medicine -- I use manual therapies (increasing the range of motion of joints through manipulation), and neural acupuncture (the injection of anesthetics on acupuncture points). I use medications as well, but they tend to be my last resort. I offer the patient physical modalities first, because there are fewer side effects. "

Both doctors agree that exercise is key in pain management. Not only does it help with the physical causes of pain in many cases, strengthening muscles and correcting posture problems that can lead to pain, but it can help with mental and emotional stresses that accompany pain. "Pain is a complex problem, " Dr Blitzer says. "You have to treat the whole patient. "