Everybody has a pain story. "The worst pain I ever had was . . ."
This story is about "chronic" pain, but in a way, it's also about getting through life itself, as painlessly as possible.
Perhaps 40 million people have chronic pain to one extent or another. According to a new pamphlet from the National Institute of Neurological and Communicative Disorders and Stroke, that pain costs about $50 billion annually in medical expenses, lost income, lost productivity, compensation payments and legal charges.
Two psychiatrists in the Maryland suburbs have made pain control their specialty. And because patients--and many doctors--are misinformed about the nature of pain, they have written a book they believe could complement any treatment.
Pain Control, The Bethesda Program, by Dr. Bruce Smoller and Dr. Brian Schulman (Doubleday, $15.95), could be useful for almost anybody. It is an easily absorbed lesson in the newly understood chemistry of the brain as well as a persuasive testament to the so-called "wellness approach," not just to pain control but to healthy living in general.
Schulman and Smoller (an orthopedic surgeon and psychiatrist) each concluded as they finished their medical training that, as Schulman puts it, "The isolation of psychiatry had really devastated the profession--psychiatrists had become preoccupied with the psychoanalytic aspects of patient care," and this coupled with the explosion of discoveries about brain chemistry "led us to seek a more broadly based practice."
Adds Smoller, "We had both been interested in the new medical model, the biological phases of psychiatry . . we think that knowledge of brain chemistry is the future of psychiatry."
One of the first things they noticed, as their practice in pain control began to burgeon, says Schulman, "is that people can have the same degree of disease, whether it's arthritis, back injury, disc disease or whatever, and there can be enormous differences in the amount of functioning between these two individuals.
"One person can function very well, maintain a job, support a family, have a good sex life, a good social life and the other one, with the same degree of disease, is totally incapacitated--depressed, overwhelmed by the whole syndrome."
It was this latter kind of patient that got on what Schulman and Smoller have labeled, "the Pain-Go-Round:" the "circular repetitive process of chronic pain treatment and disappointment, followed by new treatment, new hope, renewed pain and more disappointment."
Smoller and Schulman like to get their patients early, before they are locked into the Pain-Go-Round, before other doctors have given up on them ("nobody wants to treat the chronic pain patient") and before they are labeled "psychiatric" patients. ("No one likes being thought of as nutty," they write, "especially when they have real pain.")
Their program can involve hypnosis, biofeedback, group therapy, pain/behavior modification, psychoanalysis, even an occasional drug treatment, although usually for only short periods.
Many of the patients they see have been victims of what they call "iatrogenic polypharmacy," which means, simply, too many medicines as the result of (probably well-meaning but inappropriate) attentions of the medical profession.
"People," says Schulman, "often lose track of their medications. Many are unaware of what they are taking and sometimes medications exacerbate the problem for many reasons. Perhaps they're not being taken in large enough doses and perhaps in doses too large." And the same dose that may be too much for one person may be not nearly enough for the next. Then there may be reactions between medications, dependencies, even addictions.
They even "minimize the use of analgesics and the new non-steroidal anti-inflammatories because we don't know what natural healing processes we may be suppressing. If you inhibit prostaglandin production as these new drugs do , what else are you blocking? Why are prostaglandins there? It must be because they are involved, somehow, in the healing process . . ."
In their book, Smoller and Schulman discuss at length the effects of pain not only on the victim, but on family and friends. Four types of families, they have found, contribute to the Pain-Go-Round:
* Oh Dad, Poor Dad--Surrounding the pained parent with so much love he or she fails to learn the skills needed to deal with the pain.
* Hidden Resenters--Unexpressed anger can prevent the patient from getting well.
* Helpless Helpmates--The paralysis and eventual abandonment by the dependent mate when the dominant one is the sufferer.
* Good Old Troopers--Rigid and unbending, the family goes on about its business, eventually leaving the sufferer behind (like a wounded soldier).
Because the pain of one member is a family affair, it must be dealt with on a family basis, Smoller and Schulman suggest. The family must interact with the patient without smothering him or her. They should seek help, become involved, work as a unit.
Stress is a big part of chronic pain, and the doctors recognize that traditional hints for stress control may not work for pain. "Teaching a person with pain the art of relaxation," they write, "is like telling someone who is sitting in the dentist's chair, hearing the drill buzzing, to relax . . ."
Nevertheless, relaxation is a critical step for getting off the pain cycle. "Many people do not realize," says Schulman, "that relaxation is not simply sitting down in front of the TV. It is an active state, not an absence of activity."
In the book they write, "Many pain patients have a hard time finding a comfortable spot. Everybody has his own technique for avoiding pain. For most people this means squirming around a lot. But restlessness is one sure obstacle to achieving deep relaxation. Fidgeting about, stretching your legs and arms, squirming from one place to another, all break the spell of relaxation."
Suggestions from the book:
* For a low back problem, try a firm pillow under the small of your back. Move it up and down until you find the comfortable spot. Allow your back to "settle" around the pillow.
* Use a heating pad on the painful area during relaxation. ("Anything that increases the level of personal comfort is fair game.")
Although Smoller and Schulman came out of traditional American medical training, they are not reluctant to apply a cogent (and unprintable) four-letter word to describe the state of American medicine.
"Not to blame anybody," adds Schulman, "but it's that way because there are too many procedures, and doctors are trained to get people 'worked up' with a Cat Scan or this test or that. And suddenly you've cost them a few thousand dollars and done them no good, when the chances are that the patient doesn't need anything more than an hour of the doctor's time . . . but nobody wants to spend that hour."
For a free copy of a new government pamphlet on pain, write "Chronic Pain," National Institute of Neurological and Communicative Disorders and Stroke, Room 8A-06, Building 31, National Institutes of Health, Bethesda, Md. 20205.
For information on Drs. Smoller's and Schulman's one-day seminar on pain management Oct. 2 at the Bethesda Marriott, write "Bethesda Pain Control Program," 4400 East West Hwy.,Suite G, Bethesda, Md. 20814. Or phone 654-5030.
A free seminar for medical professionals on "New Developments in Pain Research as Applied to Clinical Practice," sponsored by the Psychiatric Institute Foundation, will be conducted by the doctors Sept. 10 at the Hannah Harrison Career School, 4470 MacArthur Blvd. NW. To register phone 467-4677. For information call 467-4538.