Ouch: Patients Suffering From Docs' Poor Pain Management

Study finds many treatments either ineffective or underused.

June 24, 2011— -- Cindy Steinberg will never forget the day in March 1995 when chronic pain entered her life.

An accident at work left her crushed under a large file cabinet, resulting in torn ligaments and nerve damage in her back.

"I went from doctor to doctor," Steinberg said. "I tried nerve blocks, various injections, physical therapy and acupuncture."

Still, she couldn't get relief from the terrible pain. After long days of work as a manager of educational media and technology development, she often went home crying.

"I was lying on the floor during meetings," said Steinberg, who lives in Lexington, Mass. "Finally, after about years years, I found an osteopath who told me I had to give up my career."

Steinberg is one of 40 million Americans suffering from chronic pain, and new research has found that the overwhelming majority of people like her are suffering from poor pain management. In fact, a series of new studies found that the medical community isn't doing enough to manage different types of pain, including chronic, post-surgical and cancer-related pain.

Each of the three studies, published in The Lancet medical journal, reviewed treatment options currently available for each kind of pain.

The authors of the study on post-surgical pain said that pain management is improving thanks to regional pain relief, such as epidural analgesias and peripheral nerve catheters. For reasons that are unclear, however, patients are still suffering.

"Despite the introduction of new standards, guidelines, and educational efforts, data from around the world suggest that postoperative pain continues to be managed inadequately," wrote Drs. Christopher Wu and Srinivasa Raja of the Johns Hopkins School of Medicine in Baltimore, the study's authors.

They believe there could be a number of reasons, including a lack of pain assessment after surgery and doctors who simply don't use every available method.

Dr. Patricia Baumann, assistant professor of anesthesiology at the Emory University School of Medicine, said epidurals and other types of regional anesthesia -- or anesthesia administered to a certain part of the body -- are very effective with many of the patients she sees, providing pain relief and preventing the need for opioids such as OxyContin.

"It blows my mind that it's not better utilized," she said. "Sometimes, patients are afraid of epidurals, or the surgeons can't stop long enough to have the epidural placed."

Wu and Raja added that using multiple pain relief techniques at the same time "may lead to substantial gains in the treatment of acute postoperative pain and potential reduction in the development of [chronic pain]."

For Cancer Pain, Need a Holistic Approach

As many as 75 percent of patients with solid tumors suffer from severe chronic pain, and more than 40 percent of cancer patients aren't getting the pain management they need. Research has suggested that one reason is the emphasis on treating only the pain.

In a study reviewing methods for managing cancer-related pain in cancer patients, Dr. Russell Portenoy of Beth Israel Medical Center in New York believes the best treatment involves a whole-body approach that is specific to each individual that will alleviate pain and suffering.

Opioid painkillers should be a main component of the regimen, which should start at the time of diagnosis and continue throughout the course of the disease. In addition to pain relief, treatment should include radiation therapy or other cancer treatment if appropriate and "non-pharmacological treatments can be used to improve pain control, coping, adaptation, and self-efficacy," Portenoy wrote.

Another barrier to pain relief among cancer patients may be the belief that pain is part of the disease process.

"Part of the problem is that the pain may be underreported," said Baumann. "Patients may believe it's part of the cancer and are unaware of the treatments available."

"A lot of times, patients' focus is on treating cancer and saving their life, and pain control may take a back seat," she added.

Chronic Pain Difficult to Treat

Steinberg, who lives with chronic pain, is now on the Board of Directors of the American Pain Foundation, a non-profit organization that helps educate people about pain. She also runs support groups throughout New England.

"The most common thing people say to me is that they spend years trying to find something to help them," she said. "Research shows that people see about four or five doctors."

Chronic pain, usually defined as pain lasting longer than three months or as pain that persists beyond what is expected for a certain condition, is difficult to treat. The annual cost of chronic pain is about $210 billion, according to the National Research Council.

Researchers from the University of Washington in Seattle reviewed some of the most common treatments for this pervasive condition, such as nerve blocks, surgeries, physical therapy and implantable devices that deliver pain medications.

They concluded that "currently available treatments provide modest improvements in pain and minimum improvements in physical and emotional functioning." As a result, they believe the focus should be on combining therapies and talking to patients about how to manage pain without expecting total relief.

One of the biggest problems is the complex nature of chronic pain.

"We can't point to one anatomical structure and say, 'Ah, that's the cause,'" said Dr. Richard Deyo, professor of evidence-based medicine at Oregon Health Sciences University in Portland. "There are many anatomical structures involved, and it's a mind-body issue as well. We need to understand how the brain handles chronic pain."

Opioids have long been a mainstay of chronic pain treatment, but Deyo says a growing body of evidence suggests they are not very effective. There is also some reluctance to use opioids among doctors and patients because of their notoriously addictive nature.

But Baumann, who is also a physician at the Emory Center for Pain Management in Atlanta, strongly disagrees.

"We have all sorts of things for chronic pain that are very effective," she said. She also recommends that people living with chronic pain see a pain specialist.

Physicians should not rely solely on opioids, and patients should never approach a doctor asking for them by name. Patients and doctors should know there are alternatives to narcotics, Baumann added.

As with treatment for cancer pain, the authors of the chronic pain study say pain management should integrate multiple types of therapies since none of the currently available treatments work very well.

One of the most important elements of pain management, experts say, is for patients to abandon unrealistic expectations for treatment.

"In many cases, we can't cure chronic pain," said Deyo.

Steinberg gets relief by combining aqua exercise, land exercise and limiting the time she's upright.

She wants people to know that despite the frustration and misery of chronic pain, life can go on.

"Pain can be managed, and you can go on to have a quality of life that you didn't have when you first got diagnosed," she said.