Sunday, October 01, 2000

The Best Analgesic is Hope

Why We Hurt: The Natural History of Pain

By: Joy Hirsch Ph.D.

As I was seeing patients one Friday afternoon, I foolishly paused to chew a caramel candy and promptly pulled a large filling out of one of my rear molars. With a large portion of the tooth’s nerve now exposed, I found that I could barely breathe without excruciating stabs of jaw pain. I tried to rinse some of the candy away with lukewarm water and nearly passed out. Unable to speak and barely able to swallow, I canceled my patients and headed straight to a dentist’s office. My life as a...[chronic pain] patient lasted less than two hours; Mildred’s has lasted for three years.

Yes, even busy surgeons snap to attention at the blare of what C.S. Lewis called “the megaphone of God.” It is this shared experience of pain that Frank T. Vertosick, M.D., a neurosurgeon and past president of the Pennsylvania Neurological Society, draws on throughout Why We Hurt to illustrate the complexities of pain physiology and showcase the urgency of an emerging medical specialty—treating pain. A seasoned guide, Vertosick steers us through the often-misunderstood, almost universally dreaded world of pain. Doing so, he reveals a refreshingly honest, human side of medicine. The reader is introduced to the man behind the white coat and the armamentarium of procedures and treatments available for dealing with pain, and will gain a new appreciation for the challenges in understanding pain’s complex etiology and finding its solution for each patient.

Unlike acute pain, persistent or chronic pain seems to have no function in the adaptation of people to their environment. Instead for many patients pain itself becomes the primary disease (see for example R.K. Portenoy and R.M. Kanner, Pain Management: Theory and Practice, F.A. Davis Co., 1996). Arising from the emerging view of pain itself as a disease beyond the initial precipitating disorder are new clinics, medical services, and departments that focus exclusively on treating pain. Vertosick opens a window into this new medical specialty and the scientific and technical advances that make it possible. According to Portenoy and Kanner, pain is the most common symptom for which patients seek medical help, and those who enter the health care and disability systems now (a relatively small percentage of those who suffer) represent a “chronic pain and disability epidemic.” 

NATURE’S SURVIVAL SCHOOL

In plain English, and in a conversational and engaging style, Vertosick uses the stories of his patients to give us an informal, educational survey of the landscape surrounding “why we hurt.” 

The book has 13 chapters, each based on a particular kind of pain experienced by a patient. The entry point for our journey is “The Megaphone of God,” an introduction that describes the natural history of pain and its probable role in the survival of an advanced species. The pivotal idea is that “Pain is a teacher, the headmaster of nature’s survival school and like any teacher, it requires pupils with an ability to learn.” This conceptual framework, starting with the co-evolution of pain and intelligence, extends to a possible connection among neurological development, suffering, and even the roots of human consciousness. Thus we start our odyssey with the view that sensations of pain are a key component of human survival, keen intelligence, and creativity. Simultaneously Vertosick prepares us to consider even unanswered questions about our minds, our pain, and our biology. 

This personal account helps the reader understand that pain is a human equalizer that challenges our accomplishments in science and medicine, as well as the human spirit and its will to triumph over debilitating obstacles.

In Chapter 1, Vertosick blurs the boundary between patient and physician with his own story as a long-time migraine headache sufferer. This personal account helps the reader understand that pain is a human equalizer that challenges our accomplishments in science and medicine, as well as the human spirit and its will to triumph over debilitating obstacles. Skillfully woven into the story of his migraine history as a teenager, a medical student, and physician is a tutorial on the causes of migraines and treatment options. Readers who suffer similarly will be inspired by his example and informed by his lucid explanations. Headache is the most common recurrent pain complaint, affecting about 80 percent of the population every year, according to Portenoy and Kanner. Like many chronic pain syndromes headaches are rarely cured; they are managed. Thus the author sets an example of success with this debilitating pain syndrome where the goal is learning to adjust. 

Chapter 2 focuses on a patient who is also an adventurous, handsome, and successful young doctor. While speeding to the hospital on his motorcycle one cold, wet autumn night, he crossed that line between physician and patient when he became the victim of an accident that left him with a serious back injury. This was the beginning of a long, costly, downhill spiral from the chronic pain of a phantom limb, to depression and a change of medical specialty. Ultimately, the turning point was a risky operation on the cervical spinal cord that slew the dragon of pain and gave “Rich” new direction. The reader benefits from the human side of the case, and the background it takes to appreciate the medical conditions. This is enhanced by a poetic glimpse of surgery from the neurosurgeon who finally silenced the pain: 

When I open someone up and peer at an injury that is months or years old, I feel like an oceanographer seeing a lost shipwreck for the first time. I can’t help but imagine how the ruined organ appeared in its pristine state; I also instinctively see in my mind’s eye the events that rendered this marvelous machinery useless and decrepit. I’m certain that shipwreck explorers are likewise haunted by visions of water pouring through damaged hulls and the death howls of sailors long gone. For me, seeing a withered, lifeless nerve torn apart by trauma is like seeing a child’s doll lying at the bottom of the sea. It gives me a hollow feeling, a feeling of something wonderful that has been lost, never to be regained. 

“MY LIFE AS A TN PATIENT...”

“Mildred” illustrates pain of the head and face. Her case, diagnosed as tic douloureux, is a trigeminal neuralgia (TN to those who know the lingo). Vertosick takes the reader through Mildred’s medical background to appreciate the condition, then through various pharmaceutical interventions and finally to a happy ending with a curative surgery. The pathophysiology of trigeminal neuralgia often is unknown and is an active focus of research intended to improve drugs for medical management and surgical interventions. Vertosick uses his own experience to characterize the pain that Mildred endured. 

Next, the tyranny of back pain is introduced by “Anne” who herniated a lumbar spinal disc while lifting a bag of topsoil for her garden. The vignette has a happy ending following a surgery annotated by Vertosick: 

Anne’s surgery went smoothly. I found her fourth lumbar nerve stretched tautly over a lump of wayward disc material. I pushed the swollen nerve gently away from the disc fragment and pulled the piece of glistening cartilage out of the spine. I then tossed the source of her pain into a silver basin to be whisked away forever. An instant cure. I could almost hear the nerve sighing in relief. I probed about a bit more and located the rip in her disc’s annulus that gave rise to the herniation in the first place. It was large, about the diameter of a ballpoint pen. There’s no easy way to repair these large holes, so surgeons routinely enter the center of the disc and try to scrape away what’s left of the disc’s interior in order to prevent more nucleus pulposus from extruding later on. 

“Anne’s” story includes a fascinating discussion of human evolution from quadrupeds to bipeds and our resultant non-optimal spinal cord design. Thus the reader learns that poor posture is another factor in why we hurt. 

CHOOSING TO EXPERIENCE PAIN

No discussion of pain would be complete without mentioning childbirth. The heroine of this chapter is Vertosick’s wife as she struggles to give birth without the benefit of an epidural block. The story includes a nearly comical account of the (universally understood) plight of the husband, who eventually understands his non-central role in the birth event. The general discussion of birthing practices, risks, and cultural attitudes toward anesthetic relief during childbirth is a delightful read. This chapter stands out among others because the pain of childbirth is acute, of relatively short duration, and is associated with a nonpathological event. Although the intensity of pain is noteworthy, the chapter focuses on attitudes toward pain relief during childbirth in a variety of cultural settings past and present. The underlying theme is that having a choice about whether or not to experience the pain of birth creates a dilemma for expectant mothers, and Vertosick encourages a thoughtful dialogue on the subject. 

A chapter on rheumatoid arthritis pain opens by comparing Vertosick with Sherlock Holmes to illustrate similarities between reaching a diagnosis and solving a crime. He extends the mystery theme to explain inflammatory disease processes: 

There is a foreign invader inside the joints of (rheumatoid arthritis) RA victims, but that invader proves not to be foreign at all. Amazingly, the white cells of RA patients aren’t attacking bacteria inside the joints—they’re attacking the joints themselves! Like a snake eating its own tail, the RA victim slowly consumes her own joints, mistaking them for foreign tissue and rejecting them as she would reject joints transplanted from another body. It’s all a case of mistaken identity. 

The story of “Clara” and the tutorial on rheumatoid arthritis lay a framework for a history of the development of aspirin, modern anti-inflammatory drugs, and cyclo-oxygenase (COX-2) inhibitors. This includes the story of cortisone and the elusive cure for rheumatic conditions that turn out to be a Faustian contract when cortisone causes devastating long-term side effects in patients with rheumatic arthritis. Immunosuppressives and methotrexate are frankly discussed in terms of possible patient benefits and probable risks. The reader leaves this segment of the journey with a global perspective on the delicate balances among the pain of rheumatoid arthritis, the nature of the disease, the physician’s treatment challenges, and a glimpse of the pharmaceutical industry’s role in offering solutions. 

The patient depends on the physician’s talent, skill, and knowledge to do the detective work and solve the problem. Vertosick allows his readers behind the white-coat icon to appreciate the challenges of practicing medicine.

In addition to the rheumatoid arthritis tutorial and Clara’s case, the Sherlock Holmes motif conveys the message that physicians must diagnose the problem before treating it. Patients rarely arrive at a doctor’s office with an instruction book that directs a course of action. Instead, the patient depends on the physician’s talent, skill, and knowledge to do the detective work and solve the problem. Vertosick allows his readers behind the white-coat icon to appreciate the challenges of practicing medicine. 

Carpal tunnel syndrome is another painful affliction arising from the human anatomy. Like the links between childbirth pain and head size, and back pain and upright posture, carpal tunnel syndrome stems from non-optimal muscle-bound human thumbs. Through “Lou,” the milkman, we learn of the intricate surgical and other treatments for this uniquely human condition. 

The pain of angina (intermittent left arm and chest pain) and heart attack are illustrated by the case of Vertosick’s father. This chapter offers a lucid, straightforward explanation of the physiology of heart ischemia and the rationale for various treatment approaches. 

Chapter 10, “A Twilight Between Sleep and Death,” is the history of the development of anesthesia. Nitrous oxide, ether, and chloroform are subjects of a fast-paced story of discovery, competition, failure, and success in the quest to offer analgesia for dental and medical procedures. This is a high point in modern medicine and anesthesiology, and Vertosick reminds us of human elements that are key in the practice of medicine, and in discovery and science. 

WHY DYING OUTLASTS PAIN TREATMENT

One of the biggest challenges for a physician may be the terminally ill patient in devastating pain. “Willa” had advanced-stage bone cancer and relentless pain. Although the cancer was incurable, the medical goal was to reduce her pain and maintain her quality of life as long as possible. Vertosick openly discusses the risks and limited benefits of surgical procedures like spinal blocks, and the pros and cons of narcotics, addictions, alertness, and mental state: 

Like a spendthrift retiree who wastes his money long before he dies and winds up a pauper, the physician who is too liberal with narcotics early in the treatment of cancer pain may be surprised when death doesn’t come quickly enough and the narcotic account runs dry. This was my mistake with Willa. 

The reader feels acute empathy for patient and family, and for the physician who must balance the trade-offs against the patient’s quality of life. Thus Vertosick offers another view of pain—pain that comes from caring for and treating an individual who suffers. 

“CLIMBING THE MOUNTAIN”

In “Climbing the Mountain,” Vertosick concludes with heroic stories of races run and mountains climbed by people whose pain was just one of many obstacles between them and victory. Vertosick uses their examples to leave his readers on a higher plane—mind over body: 

Pain can chain our bodies but can never chain our minds unless we permit it to do so. If we study all the triumphs of the human psyche over great diseases and injury, we will see that the body is indeed the lesser partner in the mind-body dualism. 

“Climbing the Mountain” also characterizes the challenge to medical science that pain syndromes present. As a scientist at Memorial Sloan-Kettering Cancer Center, I target understanding and treating chronic pain as one of the most important problems in medicine and neuroscience. Fortunately, recent developments in brain imaging using functional Magnetic Resonance Imaging (fMRI) let us focus on sensations associated with chronic pain by exposing cortical areas that participate in the syndrome. The guiding hope is that such efforts will lead to improved and novel drug options to supplement more conventional surgical treatments such as described by Vertosick. The rationale is that a clear view of the brain areas associated with persistent and unprovoked sensations of pain such as in allodynia (exaggerated sensitivity to normal touch) and hyperpathia (a painful sensation that persists after the provoking stimulus stops) may lead to the brain as a target to remedy some symptoms of chronic pain. The climb is steep, but our hope must be that linkages between clinical medicine and basic science will lead the way to the summit. 

Although people will continue to ask why we hurt after reading this book, Vertosick illuminates many facets of the universal question. Why We Hurt is a memorable, educational, thoughtful book that carries a message of hope to victims of chronic pain. This may be the best analgesic of all. 

EXCERPT

from Why We Hurt: The Natural History of Pain by Frank T. Vertosick, Jr., M.D. ©2000 by Frank T. Vertosick, Jr., M.D. Reprinted by permission of Harcourt, Inc. 

Medical science didn't acknowledge the heart's role in pumping blood until Harvey’s landmark treatise on circulation appeared in 1628.

Despite their ignorance of physiology, ancient healers began diagnosing and treating chest pain as early as the fifth century. Even in the Dark Ages, physicians recognized the common association of severe chest discomfort, anxiety, and shortness of breath; a few astute clinicians even ascribed these symptoms to the heart itself, although they could deduce little else given their limited knowledge. 

The use of the word angina for recurrent bouts of coronary insufficiency started with renowned London internist William Heerlen in 1768. In an address to the Royal College of Physicians, Heerlen coined the phrase angina pectoris, which we now commonly shorten to angina. Angina was an ancient medical term even in Heerlen’s day. It comes from the nasalized Indo-European root Ang. meaning “to choke” or, alternately, “to suffer.” In Latin, Ang. became angina, a word Roman healers used in its material sense—choking—to describe inflammatory diseases of the throat. In modern English, Ang. spawned a menagerie of similar words, including angst, anguish, anger, anxiety, and ache. Heerlen, like the Romans, used angina in its “choking” context; his phrase angina pectoris loosely translates as a choking in the chest.

Ang. implies much more than the simple physical act of choking. The word also refers to the feelings of panic and doom that accompany strangulation and drowning, which explains the modern conversion of Ang. to emotional words like anguish and anxiety. Heerlen’s choice of angina couldn’t have been more appropriate in this sense. He knew that cardiac pain had both a physical and an emotional side and that these two sides could not be easily separated. A patient suffering severe cardiac strangulation feels not only pain, but a morbid fear of imminent death as well. 

The underlying cause of anginal pain is ischemic, a word formed by the Greek words ischo (to keep back) and haima (blood). Ischemic results when blood flow to a given body part fails to satisfy that part’s requisite oxygen, glucose, and waste disposal needs. In economic terms, ischemic represents a gross imbalance of blood supply—the reduction or cessation of blood flow—but ischemic can also result from excessive demand. Cramping in athletes, for example, is a form of muscle ischemic in which the demand for oxygen in overexercised limbs exceeds the ability of healthy arteries to provide it.



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Carolyn Asbury, Ph.D., consultant

Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Robert Malenka, M.D., Ph.D., Stanford University School of Medicine
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine

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