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                                                                                MEDICINE, Page 61

Less Pain, More Gain


After years of sparing the morphine, doctors see that better
pain relief means a faster, cheaper recovery

By SAM ALLIS/BOSTON


    When researchers at Massachusetts General Hospital order
white rats for medical research, they must fill out detailed
forms explaining whether the animal will experience pain, what
procedures will be used to minimize its suffering, and who is
responsible for pain management. A grandmother who undergoes a
hip replacement in a U.S. hospital enjoys no such concern. There
are no questionnaires about the suffering she will endure after
her operation. And chances are she will hurt.

    Experts estimate that up to half of surgical patients
suffer moderate to severe postoperative pain. No one knows for
sure because while hospitals laboriously monitor every
patient's temperature and blood pressure, they keep no charts
on pain. It is the rare hospital that employs a comprehensive
pain-management team to ease patients' suffering, and a rarer
medical school that spends much time teaching the subject.
Traditionally, physicians have regarded pain as an ancillary
problem. "The focus was on disease. Pain was merely a marker of
disease," says Dr. Kathleen M. Foley, pain-service chief at
Memorial Sloan-Kettering Cancer Center in New York City. To some
degree, this attitude simply reflected the bias of a culture
that prizes the stiff upper lip: no pain, no gain.

    But among cancer specialists, pediatric surgeons and many
other doctors, this tough-it-out attitude has begun to change.
Worries about the physical and psychological risks of using
large doses of narcotics have largely been proved unfounded.
Technological advances have enhanced the efficacy and safety of
analgesia. And, perhaps most important in an era of cost
cutting, doctors have learned that not only is pain management
humane, but it also speeds recovery and saves money. When a
patient is in such agony that he cannot move about in his bed,
the risk of life-threatening blood clots increases. When he
hurts too much to cough after chest surgery, the risk of
pneumonia jumps.

    A study at Dartmouth-Hitchcock Medical Center in Hanover,
New Hampshire, five years ago proved the point. Dr. Mark P.
Yeager randomly divided 53 intensive-care patients into two
groups. One received morphine by ordinary intravenous catheters,
while the other had morphine delivered epidurally, through a
catheter placed near the spinal cord. The epidural patients, who
were virtually pain-free, spent an average of just 2.5 days in
the intensive-care unit and a total of 11.4 days in the
hospital, while the other group required 5.7 days in the ICU and
15.8 days of hospitalization. In dollars, the difference was
$11,200 per epidural patient, vs. $20,400.

    "Pain influences physiology," explains Dr. Daniel B. Carr,
director of the pain service at Massachusetts General and
co-chairman of a commission that last spring issued the nation's
first comprehensive guidelines on acute-pain management. Acute
pain directly affects heart rates, respiration, blood pressure
and urine production. It can also make cancer progress more
rapidly. John Liebeskind and Gayle Page of the University of
California, Los Angeles, have studied the effects of
surgery-related pain on laboratory rats with lung cancer. They
found that tumors metastasized two to three times as fast in
rats that received no pain-killers as in those that were given
morphine. The stress of pain appeared to inhibit immunological
defenses. Concludes Liebeskind: "Pain can kill."

    Some of the benefits of relieving pain may be described as
psychological. Pain, after all, is depressing (and depression
makes pain worse). Because of the complex interplay between
emotion and physiology, experts on analgesia have learned that
it is useless to make distinctions between mental and physical
pain. "We never say, `It's all in your head,' " explains Dr.
Charles B. Berde, director of the pain service at Children's
Hospital in Boston.

    Many physicians now concede that patients have been
undermedicated for decades, suffering needlessly. One reason was
concern that big doses of opiates could depress respiration, but
a large part stemmed from an exaggerated fear that patients
would become addicted. This fear, which continues to hold sway
over American medicine, is basically unwarranted. A landmark
study, published in 1982, followed almost 12,000 Boston hospital
patients who had been given narcotic pain-killers. After
eliminating those with a history of addiction, researchers found
that only four became addicted to the drugs they received as
patients. "You don't see cancer patients running around robbing
shopping malls to support their habits," notes Carr.

    NO GROUP OF PATIENTS HAS SUFfered more from
undermedication than young children. For years, many doctors
insisted that babies under six months didn't feel pain and those
just above that age didn't experience much discomfort. Both
ideas are now discredited. Nonetheless, cautions Bruce J. Masek,
head of behavioral medicine at Children's Hospital in Boston,
"society is still hysterical about making a four-year-old a
heroin addict."

    Fortunately, technology, improved drug protocols and
changing attitudes toward pain management have come to the
rescue of children and adults. Skilled pediatricians now
routinely give morphine to children and infants to ease
postoperative pain. Oxymeters, which monitor breathing, alert
nurses to early signs of respiratory problems. When morphine is
inappropriate, large doses of local anesthetic work well.
Pediatric-pain specialists use a plastic scale of happy to
crying faces to help young children express how they feel. And
doctors have learned to recognize certain infant sounds,
grimaces and motionlessness as signs of suffering.

    Cancer-pain management has also changed dramatically.
Physicians today give megadoses of morphine without great risk
of depressing a patient's breathing. Sloan-Kettering's Foley
estimates that the morphine doses she prescribes for chronic
cancer patients, usually as time-released tablets, are at least
ten times the amount she gave a decade ago.

    Furthermore, doctors have learned that a given dose of
morphine packs more punch when combined with local anesthetics
like Bupivacaine or with the newest nonsteroidal
anti-inflammatory drugs (the category to which Tylenol and
aspirin belong). That strategy also helps patients avoid the
side effects of opiates, such as nausea, constipation,
hallucinations and itching.

    While there are few truly new analgesics on the market,
pain specialists have been ingenious about expanding the use of
existing drugs. Surgeons, for instance, have learned that by
putting a local anesthetic directly into the wound during and
immediately after an operation, they prevent acute pain from
getting established. "You never let the spinal cord see the pain
messages," explains Berde. "It mollifies the entire course of
postoperative pain."

    Drugs originally approved for other purposes have been
added to the analgesic arsenal. Tricyclic antidepressants like
Elavil, for example, are now recognized as highly effective for
the agonizing pain caused by damaged nerves in patients with
shingles and diabetes. Methadone, the synthetic heroin
substitute, has found new use as a cheap, long-lasting easer of
chronic pain. And fentanyl, a highly soluble opiate, is
available in a stick-on patch that offers up to three days of
relief from the chronic, steady pain endured by many cancer
patients.

    The growing use of epidural pain relief, once largely
confined to the obstetric delivery room to ease labor, has been
a tremendous boon to cancer and postoperative patients. A
terminal cancer patient who no longer receives adequate relief
from huge doses of oral morphine can find relief at a fraction
of the dosage with an epidural, and feel a lot less "doped up"
as well. Epidurals are commonly used today after knee surgery
and are increasingly being incorporated into the home care of
acutely ill patients.

    The breakthrough idea in acute-pain management today is
titration -- the precise tailoring of dosage to the needs of a
particular patient. There is, quite simply, no such thing as a
standard dose anymore. Doctors have grudgingly come to recognize
that the patient is the best judge of how he or she feels.
Today people in acute pain can control their own medication with
PCAs, or patient-controlled analgesia. These are digital pumps
that are connected to a catheter. Physicians set a base amount
of drugs that enter the body continuously. When pain increases,
the patient can push a button and get more medication, up to a
maximum set by the doctor. Gone are the every-four-hours
injections of morphine that left a patient in agony for the
final hour of each cycle as the drug wore off.

    PCAs have been available for a number of years but have
only lately gained widespread use. Genevieve Anderson, 64, had
part of a cancerous lung removed two years ago at Massachusetts
General without benefit of a PCA. More recently, she recovered
from additional lung surgery with the device. "There is no
comparison," she says. Carr notes that five years ago, a patient
who had an aortic bypass would be unable to move the next day.
Now, with PCAs, "a lot of them are sitting up doing the
crossword puzzle," he says. "The old way was barbaric."

    Chronic pain remains the biggest challenge because it is
less well understood than acute pain. It may range from mild
back discomfort to an amputee's agonizing phantom limb pain.
While acute pain is essentially a healthy response to tissue
damage, much of chronic pain is considered "neuropathic" -- the
result of inappropriate nerve signals. Physicians now rely on
physical therapy and behavioral techniques like biofeedback to
battle chronic pain. In severe cases, they resort to
antidepressants and local nerve-block injections, with varying
results.

    As doctors have become less fearful and more skilled in
using narcotic painkillers, a debate has erupted over whether
it is appropriate to supply these drugs to chronic-pain
sufferers other than cancer patients. "Any chronic pain might
be appropriate -- diabetes, sickle cell, arthritis," contends
Dr. Russell Portenoy, director of analgesic studies at Memorial
Sloan-Kettering. But, he concedes, "it's a controversial area."
And controversial with patients too. Even in the cancer ward,
says Foley, "patients say, `I don't want to take that drug
because it's morphine.' " An education program is needed, she
says, to explain that suffering is not virtuous, that pain
relief can speed healing and that narcotics, if used
appropriately, do not lead to addiction. "We need to change the
attitudes of both physicians and patients."