A modest fountain is tucked away near the northwest corner of the Boston Public Garden. Swarms of tourists seek out the garden's Swan Boats, the statue of George Washington on horseback and the bronze sculptures honoring the children's book, Make Way for Ducklings. But most stumble upon the Ether Monument only by chance. It quietly commemorates the first use of the surgical anesthetic in a historic operation at the Massachusetts General Hospital in 1846. Its main inscription reads, in part, "In gratitude for the relief of human suffering by the inhaling of ether..."
Yes, we're grateful. Ever since medicine first figured out how to relieve the horrific pain of surgery with something more effective than a swig of whiskey, we have been on a quest to further prevent and treat all manner of human pain.
Pain has come to be known in medicine as the fifth vital sign, alongside body temperature, blood pressure and pulse and respiratory rates. In 2001, the Joint Commission, which visits some 19,000 hospitals and other health care organizations and certifies that they meet certain performance standards, added pain management to its requirements. Since then, it's been incumbent upon hospitals, other institutions and physicians to take reports of pain seriously. We must ask about it, assess it and manage it. That sometimes means looking beyond the lifelong stoicism of and elderly patient who doesn't want to complain; it can mean uncovering the groundless fear of addiction of a cancer patient; and it can mean careful observation skills to determine pain levels in young children or people with profound disabilities who cannot tell us where it hurts.
The new health care law gives medicine more tools for improving pain management by requiring more research to understand the mechanisms of pain and through improved patient and physician education on pain control.
Myriad Types of Pain and Treatment
It's not an easy task. Pain is a subjective experience with both physical and emotional components. Pain can be acute — usually temporary and resulting from something specific, like a fall or a traffic accident. It can be chronic, or continuing, like the pain associated with cancer, arthritis, headaches or backaches. Ask a patient to describe the pain and you might hear about aching, burning, dull, sharp, shooting or throbbing. It might be constant. It might come and go. It might be difficult for a person to even pinpoint exactly where the pain is centered.
As one measure of how complicated the components of pain are, the National Institutes of Health has a pain index page with 65 alphabetized entries, ranging from arthritis and back pain to whiplash and wisdom tooth removal.
To begin to tackle pain, medicine has in its arsenal over-the-counter drugs including aspirin, ibuprofen and acetaminophen. It has stronger drugs like morphine and oxycodone, drugs regulated not only by the Food and Drug Administration, but also overseen by the Drug Enforcement Agency. And some drugs that effectively treat pain were developed for other purposes, such as some antidepressants.
In addition, alternative methods have proven successful in treating some forms of pain: acupuncture, electrical nerve stimulation, massage, heat, cold, exercise, relaxation, biofeedback or visualization.
It's quite an impressive toolkit available to tackle pain. And yet people still suffer, and the personal and financial costs are high. The American Academy of Pain Medicine estimates that up to 100 million people suffer pain, at a cost in health care dollars and lost productivity of $560 billion to $635 billion.
Some 20 percent of Americans say they've lost sleep a few nights a week because of pain or discomfort. And more than half of hospitalized patients experience pain during the last days of their lives. For cancer patients, it's worse, with estimates as high as 75 percent of them in moderate to severe pain as they died. In fact, one of the major fears expressed by patients facing a terminal illness is that during their last few days, weeks, or months, they will be in misery from intolerable pain.
Why the Continued Suffering?
There are almost as many reasons that people continue to endure pain as there are methods to try to control it. One is the patient's own stoicism. It seems to be a deeply held belief that one must just live with chronic pain. Older patients are often reluctant to tell doctors or nurses that they're hurting. They may fear being seen as nuisances or of being admitted to a hospital or nursing home or of high treatment costs. So many cringe and bear it.
Another problem is the conflicting messages about prescription drugs, their use and abuse. Morphine, for example, can help control pain in cancer patients. It's largely seen as a myth that treatment with opioids, such as morphine, uniformly leads to addiction. Cancer patients tend not to get "high" or euphoric from morphine. They benefit from a drug that blocks pain messages from reaching the brain. But sedation can be a common, and unwanted, side effect.
Where the Drug Enforcement Agency comes in is that prescription drug addiction is a growing problem in the United States. In 2009, nearly 30,000 people died from unintentional poisoning, the most common culprit being prescription painkillers such as oxycodone. That's just deaths. In that same year, seven million Americans aged 12 and older abused prescription drugs for nonmedical purposes. For every hospital and physician in America, the statistics on prescription drug abuse create the need for a careful balancing act between necessary pain treatment and recognizing potential drug abuse.
Different Pain Thresholds
Who can forget Kerri Strug, the 1996 U.S. Olympic gymnast, who flew through the air and stuck her landing — with two torn ligaments in her left ankle? Any Sunday football game provides anecdotal evidence that athletes can suffer through a lot more hard knocks than most of the rest of us could bear. It's been proven true. A review of 15 studies comparing the pain threshold of 568 athletes to that of 331 normally active people found that those who played sports professionally consistently had a higher tolerance for pain. That doesn't mean we all need to become professional athletes but it provides a basis for exploring the use of exercise as a means of preventing or relieving pain.
Men and women experience pain differently, and, despite the cultural acceptance of the notion that men couldn't even begin to deal with the pain of labor and delivery, it turns out that women report more pain and are more likely to be treated for pain than men. In laboratory experiments, women seem to have lower thresholds of pain than do men, but science still hasn't sorted out whether there are true biologic differences or whether men and women are responding to different sets of social rules for responding to pain. Young boys are still often told to man up and not cry, while young girls may get more sympathy for their tears. And women recover more quickly from episodes of pain, and are more likely to marshal resources — friends and family — to help them through the pain.
It's a good thing that the new health care law calls for more research and education on the mechanisms of pain and on its prevention and control. We've come a long way since surgeons took scalpels to patients without benefit of anesthesia. But we still have a long way to go. Researchers across the country are looking deep into human brains to further understand pain pathways and potential ways to block pain signals. It could be that the body's natural painkillers, including serotonin, norepinephrine and opioid-like chemicals, may offer promise as pharmaceutical solutions to pain. Scientists are working to develop better pain control drugs with fewer side effects.
That's the future. But even today, you have a right to have your pain taken seriously by those who take care of you medically. If you say it hurts, no one should doubt or dismiss you. And you should expect help. We all look to the day when pain and suffering as a part of medical care are appropriately managed in such excellent fashion they're recalled only in museums or in statues.