SPECIAL REPORT

THE PAIN BARRIER

MANY EFFECTIVE THERAPIES EXIST, BUT MILLIONS STILL SUFFER NEEDLESSLY

CHRIS WOOD February 27 1989
SPECIAL REPORT

THE PAIN BARRIER

MANY EFFECTIVE THERAPIES EXIST, BUT MILLIONS STILL SUFFER NEEDLESSLY

CHRIS WOOD February 27 1989

Last November, 700 scientists gathered in a glittering ballroom of a posh Toronto hotel to acknowledge a 24-year-old breakthrough. The occasion was the inaugural award of a $59,000 prize offered by a drug company for research into how and why people suffer from pain. The first Bristol-Myers Award was given to a bearded, balding British physiologist, Patrick Wall. In 1965, with Canadian psychologist Ronald Melzack, Wall had presented a new vision of how human beings sense pain. Their theory set off an unprecedented burst of further discovery—much of it by Canadians—that led in turn to impressive new techniques capable of reducing the misery of everything from cancer to backache. But last fall’s splashy award banquet obscured a much more recent and more unsettling discovery: although science is constantly expanding its understanding of pain and how to alleviate it, millions of Canadians continue to suffer needlessly.

Even as Wall acknowledged the applause in Toronto, evidence was being gathered at five Montreal hospitals that would amount to a scathing indictment of the medical profession’s attitude toward pain relief. Headed by Mary Ellen Jeans, director of the McGill University School of Nursing, researchers questioned 2,500 patients between June, 1987, and December, 1988. Most were in pain, for reasons ranging from childbirth to advanced cancer. And most were left to suffer. “Half of the people with moderate to severe pain had received no pain medication in the previous 24 hours,” Jeans told Maclean’s last month. “Of the other half, most got less medication than they needed.”

The situation is similar in other Canadian cities and hospitals, according to Melzack (page 40). He added, “We have a great many effective therapies but we are not using them.” And Melzack, like most pain-relief specialists, claims that Canadian doctors systematically ignore an armory of pain-killing techniques.

Potency: The range and potency of those methods have expanded greatly in the quarter century since Melzack and Wall first explained the brain’s influence over pain. Last year alone, clinical trials in Toronto and Hamilton showed that an electronic device that mimics the effect of acupuncture could ease pain in three-quarters of the people who tested it. A Vancouver researcher has established that children’s fantasies can help alleviate their pain. Other psychological techniques—including the use of hypnosis and biofeedback—can reduce or eliminate the discomfort of about 60 per cent of adults who suffer chronic or recurrent pain, say specialists at the country’s several overburdened pain clinics (page 42).

In France, researchers are experimenting with enzymes that may enhance the body’s own pain-killing chemicals, while in England, Wall, 63, is exploring the pain-relieving potential of growth hormones. In Alberta, clinicians have perfected a device that dramatically cuts the cost of administering morphine to cancer patients.

About four million Canadians are in pain in any given week. Nearly one-third—victims of illness or a recent accident, or patients just out of surgery—are suffering acute pain. And for them, research by Jeans and others indicates, untreated pain can hinder recovery and may threaten life. Chronic discomfort—migraines as well as back, muscle and pelvic pains—afflicts as many as three million adults. There are no figures for the number of children who are pain sufferers, but some child-health researchers estimate that 10 per cent of Canadian children are affected. Some of those face the agony of cancer or serious burns, while many of the rest endure poorly understood recurrent abdominal pain.

Victims: Many pain victims say that multiple encounters with doctors have led not to relief but to even more suffering. Arvelle Lévy, 32, for one, a wryly humorous Montreal student, visited half a dozen specialists after a back injury four years ago. Her pain, she says, “was excruciating—dull, throbbing, constant.” But a succession of doctors dismissed her discomfort while attempting treatments that only left her more disabled and increasingly bitter. Declared Lévy: “I have met a lot of doctors who don’t give a damn.”

Many other sufferers echo the charge of medical indifference toward pain. And some of the country’s specialists in pain control support that view. Others say that physicians are often frustrated and puzzled about how to treat a phenomenon that they do not understand. Says Dr. Eldon Tunks, director of a pain clinic at Hamilton’s Chedoke-McMaster Hospital: “The tradition is that pain is a symptom of something else, so doctors look for the something else. They don’t treat the pain.”

At the same time, there is an ever-growing number of therapies available for alleviating suffering. One of the more dramatic is a small bundle of wires, sticky electrodes and miniature computer parts invented by University of Toronto neurobiologist Dr. Bruce Pomeranz. In 1976, Pomeranz was one of two researchers who first found a biological basis for the painkilling effects claimed for the 3,000-year-old oriental practice of acupuncture. He demonstrated that inserting acupuncture needles in identified trigger points on the body stimulates the brain to produce endorphins—natural pain-blocking compounds whose chemical action is similar to morphine, heroin and other opium derivatives. In 1982, Pomeranz began the search for a way of producing a similar effect without needles. The resulting machine—trade named the Codetron—sends weak electrical pulses through seven adhesive electrodes into the same trigger points employed by acupuncture. According to Pomeranz, the technique has relieved pain in more than three-quarters of the 3,000 people who have used it so far—for some, the relief has lasted as long as eight months.

That would represent a major advance on a similar technique pioneered by Wall in the early 1970s. Transcutaneous Electrical Nerve Stimulation (TENS) acted on the discovery that pain sensations can be masked by a second stimulus—an effect most people are familiar with when they rub their foot to dispel the pain of a stubbed toe. TENS machines, like the Codetron, use electric current to stimulate selected nerves in order to reduce the severity of painful sensations. Lévy, for one, was able to reduce her agonizing back pain by up to one-half while using a TENS device. But the technique has numerous drawbacks: its effect wears off after repeated uses; and, at best, it works with 40 to 60 per cent of sufferers.

Still, related methods of nerve stimulation have subdued other forms of extreme pain. In one instance, a 45-year-old man whose ribs were broken in a car accident suffered burning chest pains that were not relieved even by “elephantine doses of morphine,” recalls Dr. Angela Mailis of Toronto Western Hospital’s Pain Investigation Unit. But when a miniature electrical stimulator was implanted permanently in a pain centre in the man’s brain in mid-1988, his chest stopped hurting. Similar effects have been recorded from stimulator electrodes implanted close to the spinal cord. Less drastic, but often equally effective, Mailis notes, are injections of local anesthetics into specific nerves to block pain signals.

Controversial: A marriage of modern pharmacology and ancient acupuncture underlies another, more controversial, approach: the injection of local anesthetics into some of the same spots on the skin activated by acupuncture and Pomeranz’s Codetron. Czechoslovak-trained Toronto doctor Jan Kryspin, for one, uses procaine—a substitute for cocaine—for the injections. “The effect is instantaneous,” he claims. “I would think 70 per cent [of his 600 patients a year] are getting better.” Washington, D.C., doctor Janet Traveil—who treated U.S. president John F. Kennedy’s chronic back pain—also practised a form of nerve stimulation. Her technique was to insert needles into trigger points and apply a cold spray of fluoromethane to them.

Until very recently, children were among the most neglected victims of pain. Noted Patricia McGrath, director of the Child Health Research Institute in London, Ont.: “There was a myth that kids did not feel pain as much as adults do.” As a result, said McGrath, in many centres infants underwent major surgery under sedation but without anesthetic. Older children, too, often faced painful medical procedures with inadequate drug support. In fact, one 1977 study conducted in Boston found that more than 50 per cent of children who underwent surgery—including limb amputations and heart operations—received no analgesics to suppress their pain afterward. A decade later, another study by Dutch researchers showed that few doctors had changed their ways. “Unnecessary suffering is the first consequence,” observed Patrick McGrath, a pediatric pain specialist at Children’s Hospital of Eastern Ontario in Ottawa. He added, “The second consequence is inhibited recovery.” McGrath, for one, advocates freer use of pain-killers when young patients hurt.

Triggers: Research now under way in Ontario and British Columbia, however, shows that psychology, along with such treatments as acupuncture, could offer an alternative to drugs. Observes London’s Patricia McGrath: “There are internal systems to modify pain. We are beginning to learn about the triggers for those systems.” In fact, McGrath allows young patients undergoing cancer treatment to prick their own fingers for blood samples, help prepare their own hypodermic needles and choose the site for injections. Says McGrath: “Giving a child control reduces the pain.” At Vancouver’s Children’s Hospital, another researcher has found that blowing bubbles and imagining themselves in flight can help ease a child’s hurt. During their fantasy flights, says Dr. Leora Kuttner, children are able to dissociate themselves from their pain.

Psychology also offers new hope for Canadians’ intractable pain. Toronto’s Behavioural Health Inc., a private clinic, teaches a battery of techniques to 700 clients a year—many referred by Mailis or the Ontario Workers’ Compensation Board. Said clinic director David Corey: “We’re trying to reprogram your body’s response to pain.” The techniques Corey and his colleagues impart range from self-hypnosis and deep relaxation abetted by biofeedback to behavior modification. It works for some, but not all. “Twelve to 15 per cent of people can eliminate their pain entirely,” Corey says. “The majority have about 50-percent pain relief.” For Valerie DeYonge, 28, even partial relief was welcome. DeYonge was forced to leave her Toronto insurance company job on a disability pension in 1986 after torn muscles in her neck and shoulders left her in what she describes as “excruciating” pain. Corey’s clinic, she says, “taught me how to control the pain.” Her hurt now registers at between one and two on a 10-point scale.

Powerful antidotes are also available for the agony of terminal cancer, which wracks 50,800 victims in Canada each year. In one contentious development, Parliament in 1985 approved the use of heroin for terminal and intractable pain (page 41). But a more significant advance has been the changing of attitudes toward an old drug. Morphine has long been known to be a powerful pain-killer. Among many physicians—and patients—it has an equally well-entrenched reputation for addiction. As a result, many doctors remain reluctant to prescribe the drug and some patients refuse to accept it, says Dr. Elizabeth Latimer, a palliative-care specialist in Hamilton. But British research in 1978 and U.S. studies in 1983 showed that morphine is rarely addictive when prescribed for pain to people without past addictions. Notes Latimer: “We have learned these drugs are safe and can be used in high amounts.”

Control: Indeed, some cancer sufferers are being allowed direct control over their morphine supply. Studies have found that patients who regulate their own dosage tend to use less of the narcotic than most doctors prescribe. Significantly, however, they take the drug more frequently and control their pain better than other patients. The trend toward self-administered morphine is likely to continue with the advent of an inexpensive Canadian technology. The Edmonton Injector—developed at the University of Alberta in Edmonton—allows even weak patients to inject limited doses of morphine through a needle implanted under the skin. For many sufferers, the $30 device replaced a Swedish-designed morphine pump that cost $4,000 and required a nurse to operate it. “It is a Jeep versus a Porsche,” quipped Dr. Eduardo Bruera, who designed the Injector, “but it can do the job.”

Encouraging: At the cutting edge of research, the prospects are also encouraging. In London, Wall has discovered that a compound called nerve growth factor—a hormone responsible for triggering nerve development in fetuses—stops severed nerves in rats from passing on chemical pain signals to the animals’ brains. That finding, Wall says, may eventually help victims of chronic intractable pain—agony that even narcotics do not suppress completely. At the National Health and Medical Research Institute in Paris, meanwhile, scientists are testing kelatorphan, a substance that seems to extend the life of endorphins, prolonging their analgesic effect.

Residue: At the same time, Toronto’s Corey has been teaching techniques to help accident victims whose injuries have healed but left behind a residue of persistent pain. Teaching such skills as deep relaxation within six months of an injury, he finds, doubles their effect. And in Vancouver, University of British Columbia clinical psychologist Kenneth Craig is trying to measure the severity of hurt felt by infants by studying their faces. Says Craig: “The face tells you whether the discomfort reflects physical pain or other forms of distress—like needing the diaper changed.”

As the frontiers of knowledge advance, some persistent myths are crumbling. Perhaps the most entrenched is the inaccurate belief that many people who complain of pain in the absence of an obvious injury are either malingerers or highly imaginative hypochondriacs. “We have overestimated the effect of the mind,” acknowledges London, Ont., psychiatrist Harold Merskey, president of the Canadian Pain Society. “The vast majority of people who go for treatment for pain,” he adds, “do not have hysteria.”

Still, Vancouver’s Craig, like many other experts, says that he doubts the new understanding of pain has resulted in significantly less suffering. “Very frequently,” he observes, “acute and chronic pain are not sufficiently well managed.” That, certainly, is the verdict of many victims. James Donnelly, 34, has suffered almost constantly from severe headaches, double vision and leg pains since a technician stood him up for X-rays after a spinal tap, following a 1985 injury at a Dartmouth, N.S., factory. Now, he says: “I am bitter about the attitude of doctors who have probably never experienced pain. It is almost like they have been taught to combat patients asking for pain medication. They try to ignore you.” Adds Patricia Boychuk, 47, a former crisis counsellor in Hamilton who contracted a deeply painful degenerative muscle disease in 1979: “It doesn’t take long for a doctor to say ‘Sorry, we can’t help you.’ ”

Indeed, in Halifax, Montreal and Toronto, operators of pain clinics told Maclean’s that most of the patients they see have already sought relief from as many as half a dozen medical specialists—without success. Some physicians turn pain sufferers away when they find no disease or injury. Others offer therapies that may be ineffective, or worse. Noted Toronto surgeon Dr. Ronald Tasker, who carries out electrical stimulator implants: “The average neurosurgeon, sent Joe Blow who got knocked down in a car accident and who is feeling pain, will still go in and cut a nerve and expect it to cure the pain. It won’t.”

Truth: Accident victims are not the only pain sufferers who can attest to the truth of that statement. The severing of nerves is still a common treatment for the pain terminal-cancer patients feel. Indeed, relief for such sufferers is all too often inadequate, although the means are at hand. A typical example is the experience of James Rae, 64, publisher and editor of the rural Clifford, Ont., weekly newspaper The Cliffhanger, last November when cancer spread to the brain of his 63-year-old wife and former assistant editor, Doris Rae, during her final days. Recalls Rae: “Every few seconds, she was in spasm, vibrating and screaming.” Still, the dosage given the dying woman was inadequate. “If I had let a dog die this way, my neighbors would have wanted me hanged,” says Rae. “Yet your wife goes like this, and nobody does anything about it.”

Expense: At the same time, with costs rising alarmingly, Montreal’s Mary Ellen Jeans, for one, says that allowing patients to control their intake of pain-killing drugs can reduce the expense. During 1988, she oversaw a study of 40 women undergoing hysterectomies in a group where half were allowed to administer their own pain-killer and the other half received traditional doses. The women receiving the conventional dosage not only hurt more than the others, she said, they also experienced four times as many complications and required on average one extra day in hospital. “Obviously,” says Jeans, “if you don’t control pain, the person won’t get well as quickly.” By contrast, she adds, “people with less pain go home faster. You’re saving money.”

Few physicians, however, appear to have kept pace with the rapid course of developments in pain control. Declared Melzack: “There is not a single medical school doing an adequate job teaching its students about pain.” Indeed, a model curriculum on the subject drafted last year by the International Association for the Study of Pain—a group of 4,000 scientists worldwide—has yet to be matched by any Canadian medical school. Instead, most programs provide a few hours of instruction on the structure of nerves but little training in the treatment of pain. Adds Corey: “Physicians are trained to treat disease and injury. They tend to downplay pain.” That attitude is resistant to change. Reflects Jeans: “Doctors and nurses learn their practice in a mentorship system. We have a lot of work to do to stop behavior from being passed from one generation to another.” Canada’s suffering millions can only hope that the efforts of Jeans and others to break that cycle will soon prove successful.

THE GATE-CONTROL THEORY OF PAIN

In their revolutionary Gate-Control Theory of pain, Wall and Melzack argued that the spinal column acts like a vertical stack of what they called “paingates.” Impulses—provoked by injury or disease—enter the gates at the level of each vertebra and are passed to the brain if they exceed a certain intensity. Other impulses—prompted by individual expectations or other factors—also enter the gates and influence whether pain signals are passed on or blocked. In the case of injured soldiers, relief at being still alive could be enough to close the paingate.