Treating Pain Often Involves a Variety of Different Approaches


May 9, 2005 — -- Dr. Paul Rumble, a veterinarian from Milford, Conn., knows first hand the challenges of living with chronic pain. Following abdominal surgery for diverticulitis, a buildup of scar tissue left him in agony.

Laparoscopic treatments, which use a tiny camera to guide surgeons' hands, provided temporary relief, but not enough. When the problem came back, Rumble's physician prescribed morphine. The drug worked, but taking it also meant relying on a narcotic to be free of symptoms.

"I was doing great on the morphine, and [the doctor] said, 'OK, that's the end of the story. You're on morphine. You're doing great. Adios,' " Rumble said. "But I said, 'I really don't want to be on morphine for the rest of my life.' "

Enter the pain specialist, who eventually helped Rumble overcome his intense discomfort. Chances are, if your regular doctor runs out of options to treat you for chronic pain, you will be referred to a pain specialist or pain clinic that offers a variety of services -- from drugs to acupuncture and psychological help -- to reduce your symptoms.

But what exactly do these specialists offer? And why should you visit them?

Before the field of pain medicine was created, doctors "looked at pain management with blinders on, with one focus," said Dr. Carol A. Warfield, who is the chair of the department of anesthesia, critical care and pain medicine at Beth Israel Deaconess Medical Center in Boston and a professor at Harvard Medical School.

"If all you have is a hammer, everything starts looking like a nail," she said.

In the 1960s, people in the medical community began to consider pain as a specialty, with the idea of bringing together such fields as internal medicine, chiropractics, surgery, psychology and acupuncture to provide many options for success, Warfield said. The movement was popularized in the 1970s and advanced throughout the years.

Anesthesiologists were in the equation early on because of their experience with easing pain during surgery and with drugs such as narcotics, pain relievers, nerve blocks and other treatments, she said. The American Board of Anesthesiology first added a certification in pain medicine in 1993.

Warfield opened the pain clinic at Harvard Medical School in 1980. It began with her seeing a few patients after a day of surgeries, but it is now one of the biggest clinics of its type in the country, with 100 employees and between 12,000 and 14,000 patients a year.

In addition to physicians who are pain specialists, the clinic offers a full-time psychologist, a neurologist, physical medicine nurses, physical therapists and others. "We do the whole gamut," she said.

With some of the same goals in mind, Dr. Joel Saper, a neurologist, founded the Michigan Head Pain and Neurological Institute in 1978 combining neurology, psychology, nursing, social work, anesthesiology, internal medicine, physical therapy and other services.

Treating pain is different from other specialties, Saper said, because it lacks an established hierarchy. For instance, for heart problems patients see cardiologists, or for brain surgery a neurosurgeon.

"Pain doesn't belong to one field," he said. "Anesthesiologists how have their own education curriculum, own knowledge base, own tools used to control pain. Physiatrists come from a different perspective of why a joint hurts or head hurts.

"You have six or seven different disciplines treating the same illness in different ways with different potions and notions," he said. "And what does the patient do? They sort of get the treatment for the door they walk into ... it's the only field of medicine like that."

It is important for facilities like his to address patients' many needs, he said, and they ought to be able to provide help through one of the varied methods of treatment.

Sometimes when traditional treatments continue to fail, patients are referred to centers that combine conventional medicine with naturopathic methods.

One such place is the Integrative Medicine Center in Derby, Conn., which in addition to traditional services offers things like energy healing, homeopathy and massage. Founded in 2000 by Dr. David L. Katz, an internist and preventative medicine specialist who is on the faculty at Yale University, the center often helps patients who have been to other pain specialists and also refers patients who need high-tech treatments to other facilities.

Katz said he created the center based on the belief that traditional medicine does not always offer answers to patients with chronic pain, though he has "no particular fascination" with natural treatments.

"I'm a card-carrying member of the evidence-based science club," he said, but added that he couldn't help but notice that medical treatments don't always help patients.

"It doesn't really require that you're a believer," he said. "It requires you're open to trying something."

That something could mean Chinese medicine, meditation or yoga. When Rumble began visiting the Integrative Medicine Center, they changed his diet, which resolved other stomach problems, and used acupuncture to try to wean him off of the morphine. It provided some relief, but he found the most help from a homeopathic remedy.

"As a person who's been trained and educated in traditional medicine, homeopathy fascinates me," he said. "I was skeptical but I was willing to give it a try."

The remedy worked like nothing else had. "I've been pain-free probably two or three years now," Rumble said.

And that, of course, is the ultimate goal, though results can be more elusive. "It's not always that clean or that dramatic, but I think that's a very clear argument for the holistic approach," Katz said. "We don't really understand all the different mechanisms of pain. There are times people are in pain and we can't figure out why."

At the same time, he said, it's important to recognize the help that things such as massage can provide. "Why do we rub a boo-boo?" Katz said. "Doesn't that seem an odd thing to do? You bang your head, you'd think you shouldn't rub it, but you do and it feels better. You stimulate the sensory nerve … send a message to spinal cord."

If pain were simple to treat, there would be no need for the myriad approaches offered by specialists and clinics. Its complexity is precisely why there is no one-size-fits-all answer and also why mental health is important to recovery.

"The same chemicals in the brain associated with pain are associated with depression," Warfield said. "If you're in pain a long time, you deplete these chemicals. If you're depressed … you feel pain."

Saper noted that thinking about chronic pain can also make patients feel worse, which has been shown by advanced imaging on the brain. "When you focus on your pain, you turn off your brain's center for blocking pain," he said. "When you're distracted, that center goes on. So the more you 'poor me' your pain, and the more you complain and talk about and think about and obsess about your pain, the more it is likely to hurt."

Warfield said no one should continue to be frustrated by chronic pain. "I would certainly encourage them to talk to their physicians," she said. "Together with a primary care doctor, it's worth a consultation with a pain clinic."

Saper added that pain specialists must have a lot of intellectual curiosity to face the challenges. "A good pain doctor's got to have a global sense of a person's brain, their mind, behavior, and have compassion, trust," he said, "but he or she also has to know all this other stuff about how the body feels pain. There are thousands of illnesses that cause pain."

Katz said his group will continue to work with patients referred from other pain clinics and to send them there when they need services his center does not provide. "In the holistic approach, as the name implies, there almost is no defined boundary other than what good judgment dictates, so we have many more options. On the other hand, there's no question they can do things we can't.

"When medicine is functioning well, there really shouldn't be any us and them," he said, adding, "Unfortunately, there's enough pain and enough business to go around."

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