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Living with pain Managing hurt that won't go away is medicine's next huge frontier

By Shari Rudavsky

shari.rudavsky@indystar.com

Desperation drove Elaine Morfas to acupuncturist Lei Shaw.

A ski accident nearly 20 years ago left Morfas, a Carmel resident, with persistent headaches that no medicine could ease. For the past five years, she's visited Shaw regularly for the treatments that are her only path to pain relief.

Like millions of Americans, Morfas suffers from chronic pain. Like many, she has struggled to find a detente between the pain and her own desire to live a normal life.

Only recently has the medical establishment started to address this population, many of whom suffer in silence. A growing movement, however, argues that health professionals should bring this issue to the forefront.

"No one needs to be suffering needlessly in pain," says Harriet O'Connor, coordinator for the Indiana Pain Initiative, a statewide effort begun about a year ago. "In this day and age, people shouldn't be told, 'OK, learn to live with it.' That happens far too frequently."

A recent Stanford University survey found one out of two people in the United States grapples with pain. One in four deals with chronic pain.

But chronic pain is not the same for everyone, experts agree. Nor is chronic pain a completely physical phenomenon; mental health has a direct impact on how people experience the pain.

"Pain is an alarm," says Dr. Scott Fishman, chief of the division of pain medicine at the University of California Davis and vice chair of the American Pain Foundation. "Chronic pain is a disorder of that alarm. . . . When that alarm is broken, the symptom of pain becomes the disease of pain."

Pain specialists don't promise to cure everyone; instead, they teach patients how to manage their pain.

"When you go to the doctor, you expect to be fixed," says Jim Ryser, chronic pain rehabilitation program coordinator at Methodist Hospital. "With chronic pain management, you're not going to get that because there's no fixing chronic pain."

Many pain programs focus on how to help patients come to grips with that fact. At the Meridian Health Group in Carmel, psychologist Ari Gleckman encourages patients to understand that they must claim responsibility for their pain and learn how to live with it, no matter what physiological condition has caused it.

"It's not the pain that's critical and it's not the generator of the pain," Gleckman says. "It's the person's pain perception. . . . The psychology of a person with pain is even more important than cause of pain."

Not surprisingly, then, pain programs draw on a variety of tools to address the problem. Painkillers such as opiates and anti-inflammatory medicine are just the start. Individual therapy, group therapy, exercise, physical therapy, water therapy, electrical stimulation, massage and acupuncture are just a sample of the tricks that pain programs may try.

Little black bag of relief

Dr. Palmer MacKie, medical director of the integrative pain center at Wishard Memorial Hospital, which runs a six-week program on pain management, says help can come from a variety of sources. One counselor recommended a patient go outside to collect buckeyes.

"We try to create an individual's little black bag," MacKie says. "You cast a wide net and then you find the things that resonate with the individual. It has to be tailored, but the three elements that you need to attend to is recovery of body function, recovery and maintenance of psychological function and addressing the pain."

Morfas found her little black bag in Shaw's office. Her weekly treatments ease her pain, which she describes as a "12 out of 10" when she began.

For Fishers resident Jeffrey Nance, the answer was Meridian's eight-week program, which included physical therapy, information about diet, posture, relaxation techniques and meditation. A back injury 20 years ago, at the age of 19, eventually proved his undoing.

"Your lifestyle is constantly occupied by the pain, so it kind of consumes your life," he says.

After trying several options, he found his way to Meridian Health Group about a year ago. Since then, Nance, who hopes to start an American Chronic Pain Association support group on the Northside, has managed without medicine.

Others who suffer chronic pain find narcotics are the answer. Jeanne Atkins, a retired teaching assistant, has struggled with pain since she had surgery on a non-malignant brain tumor more than 11 years ago. The operation left her with recurring pain in her left leg. She tried acupuncture and some other medicines, but those did not work.

After fighting the idea of a controlled substance, she has found that opiates allow her to live a relatively normal life without many of the negative side effects she feared.

Choosing how to live

"It's something you have to learn to live with and you can live gloriously with it or just live depressed with it," Atkins says.

Still, narcotics are not always an option. In some areas, says O'Connor, they can be difficult to find as pharmacies are reluctant to stock them for fear of misuse.

Some narcotics patients become addicted and must learn to handle the pain without the drugs. That happened to Ryser, who was on narcotics for about 18 years and underwent more than 50 operations for his spina bifida.

While the Methodist pain program allows participants to use anti-inflammatories and depressants, it does not accept narcotics. For many, says Ryser, the intensive outpatient program is their last resort. More than 60 percent of those who start the program complete it. Many of those continue to attend a weekly pain support group in Plainfield.

Wishard's six-week pain program takes a similar tack. Not everyone, however, has the patience to endure such a class. Of the more than 300 invited to the five or six classes offered a year, only about 70 attend each class, MacKie says.

"It's an alternative thought. It's not that the doctor's going to heal them and not that it's someone else's fault. It's an acceptance and coping and it's transformational," he says. "When people decide that they can take it, that's when they can take it."

Pain and politics

Some pain-treatment advocates argue that Indiana could do more to help those in need. The Pain and Policy Studies Group at the University of Wisconsin recently gave Indiana a C+ for its policies -- or lack thereof -- on pain management.

The state scored poorly because it is one of four whose medical board has no policy that specifically addresses pain management, said Aaron Gilson, the group's associate director for U.S. policy research.

"What Indiana needs to do is focus on having their regulatory boards for health-care professionals adopt policies that promote effective use of controlled substances," Gilson said. "Pain management is a public health issue, and undertreated pain is a public health crisis."

Indiana's Medical Licensing Board has tried to adopt a policy, said Michael Rinebold, its director. Last year, the board proposed a rule stipulating how practitioners should handle patients with pain issues.

But the medical community argued the state had overstepped its bounds and was prescribing practice, so the board dropped the effort. It plans to revisit the issue, Rinebold said.

"Ultimately, it's patient safety and public safety, and that's the board's mission," he said.

-- Shari Rudavsky

Posted 12-29-06