The Institute of Medicine reports that more than 100 million people suffer from chronic pain. Sadly, conventional pain relief treatments often don’t improve the condition. In Holistic Pain Relief (New World Library, 2013), Heather Tick, M.D. seeks to help patients get through the ins and outs of pain treatment and management. In this excerpt from “Pain, Nature’s Wake-Up Call,” Tick discusses how chronic pain has become an epidemic of its own and the cost it has on society.
Everyone knows what pain is. Most of us have known pain in our own bodies and have seen it in others. But when we really try to describe what pain is, we are often at a loss for words.
Pain itself does not have an emotional component. If you pinch yourself until it hurts, you are unlikely to react with happiness, anger, fear, or sadness. An emotional reaction usually occurs only when your pain seems to be incomprehensible or out of control, when you do not know how or when it will end.
There are words for pain in every language. There is no nation or culture that is spared the experience. Yet the experience of pain is a solitary one. Those who are living with pain pay in immediate suffering and by not being able to live their lives fully. Those in pain feel alone, isolated in their agony, and separated from their former lives and the lives of those around them. Pain sufferers may also feel the separation that comes with the judgments of others.
People in pain often do not “look” as though they are in pain. If they focus on their pain in conversation, or reveal their discomfort by their actions, they risk being labeled as “complainers” or “symptom magnifiers.” Animals in pain instinctively seek privacy to lick their wounds. Similarly, there may be a natural instinct in people to seek comfort in withdrawal.
Pain is always a subjective experience. We have no ways to measure pain “objectively.” There are charts, scales, body diagrams, and ratings, but none of them measure pain the way a thermometer measures a fever. In the end, the person in pain tells us about his pain. Patients with lingering pain almost universally have their experience of pain questioned, challenged, and disbelieved by health care practitioners and by friends and family. Most of these patients also say that the vocabulary available and the scorecards used in pain clinics do not help them convey the true experience of their pain.
Pain is complex. The issues involved spread out like the ripples from a pebble tossed into a pond. When these ripples become intermingled with the wave patterns of countless other pebbles, it becomes impossible to distinguish one pattern from the next. Chronic pain is like a fifty-thousand-piece jigsaw puzzle for which we have placed about five hundred pieces. We are not even sure what the big picture is. This is small comfort for those in pain. The good news is that, despite the lack of clarity in our vision, we have many useful interventions.
Acute pain is pain lasting a relatively short time and is usually injury related. Chronic pain is pain lasting longer than three months—or six months, depending on whose definition is used. But these are simplistic definitions of complex problems. In some cases, acute pain lasts more than six months because there has been neither an accurate diagnosis nor an appropriate treatment. In other cases, we are in the first month of a process which is already evolving into a chronic state. Nothing magical happens during the third or sixth month that makes the process different. Sometimes the pain is chronic pain from the beginning; we just didn’t know. Other times, something does change in the way the body processes pain, but that may happen on day one, or day one hundred, or day three hundred. No expert can impose a timeline on Mother Nature.
The number of people who suffer from pain is staggering. That is why, in late 2000, the United States Congress passed a provision into law, signed by President Clinton, that declared the ten-year period beginning January 1, 2001, the Decade of Pain Control and Research. Countless studies have been undertaken to try to measure the effects of pain and the number of people affected. The definitions used and the variables measured are not identical from study to study, and so drawing information from them can be a little confusing. However, a decade later, the 2011 report of the Institute of Medicine, an organization in the United States that provides national advice on health issues, estimated that there were over 100 million Americans in pain. This figure did not include children in pain or any individuals in acute pain. There are a lot of people in pain. And this is not just an American problem. The International Association for the Study of Pain estimates that 20 percent of adults have moderate to severe chronic pain. Professor Harald Breivik, coeditor of Clinical Pain Management, has called chronic pain “one of the most underestimated health care problems in the world today, causing major consequences for the quality of life of the sufferer and a major burden on the health care system in the Western world.”
Let us look at some of these statistics relating to costs. To begin with, pain has a cost to society, starting with costs for health care services, medication, surgery, and the complications that arise as a result of all those things. Then, there is the cost in lost productivity and absence from the workplace, which has impacts on industry but also on social service budgets and even tax revenues. The 2011 report by the Institute of Medicine estimated the annual cost of chronic pain in the United States at between $560 and $635 billion. The report called for a “culture change” in the medical system that treats pain.
In 2004 Americans spent $16.6 billion to relieve pain, most of it to purchase over-the-counter or prescription drugs. Pain is a problem for insurance companies too. The costs of high-tech procedures and surgeries like epidural injections, spinal cord stimulators and pumps, and spinal surgeries are rising each year. And what is worse is that we seem to be setting people up for other problems down the line. We are spending more and more and not getting people better.
When we look at the workplace, some costs of pain are easier to quantify than others. We can get the annual statistics for Workers’ Compensation costs and lost workdays. What are harder to assess are the costs associated with people in pain who come to work but are unable to work at their full capacity, a phenomenon called “presenteeism.”
A survey done by Gallup in 2011 found that nearly 47 percent of adults reported having a condition affecting the neck, the back, a lower limb, or another part of the body that caused recurring pain in the previous twelve months. Low-income Americans are even more likely to have chronic pain. Nearly 50 percent of all Americans seek care for pain each year.
No matter how you measure it, pain is a big problem: for the person in pain, for those providing treatment, for the insurer who is paying for treatment and time off work, for the employer waiting for an employee to return to work, for the kids who want their parent to play catch, and for other family members living with the person in pain. Unfortunately, conventional approaches to the treatment of pain often do not improve the situation.
Though most physicians would prefer to treat each patient as a unique case, many now adhere to practice guidelines—established signposts intended to shape the problem-solving path followed by physicians. Practice guidelines were originally designed as a sound basis for the minimum care a physician should offer but are now used as welcome assistance to the rushed physician who can spend only a few minutes with each patient.
Recent studies of patient-physician visits show that primary-care physicians in North America spend an average of 10.7 minutes with each patient. The doctors studied allowed the patient to speak for only eighteen seconds before they interrupted. This leaves very little time for nuanced communication and attention to the complexities that characterize most human conditions. There is barely time to decide which drug to prescribe before drawing the meeting to a close.
Physicians may also feel pressure to follow the standard-of-care practices—to do what most others in the community are doing. For example, prescribing the anti-inflammatory drug Vioxx was the standard of care for many years, even though evidence, little known to most doctors, indicated that it increased the risk of heart attack. Few doctors read the studies to learn about the drug’s risk; instead, they simply looked at the information the drug reps handed them. When I presented information about this risk to a group of colleagues two years before Vioxx was pulled from the market, I was called an alarmist. Most of my colleagues continued prescribing the drug until it was no longer available.
I have written Holistic Pain Relief as a patients’ guide to understanding and managing chronic pain. Chronic pain is a growing problem, one that affects more people than before, with increasing severity; and now there are new types of pain that are unresponsive to conventional therapies. There is a growing body of scientific literature explaining the mechanisms of pain and how we experience it. But despite more research and knowledge, there are still patients with confusing collections of symptoms that defy explanation. For these people, chronic pain is just one piece of a complex puzzle that is the healthy human body.
The fact is, we pain physicians don’t have all the answers, and we know it. Being a pain doctor takes courage—the courage to travel the path with our patients, to be present as they present us with their vulnerabilities and look to us for answers that we may not have. It takes courage to tell patients when we don’t have the answers, and it is our responsibility to tell them with kindness, without blaming them for defeating our knowledge, and without making them feel abandoned. Cor, Latin for “heart,” is the root word for courage. Most pain physicians practice because they care. There are two vulnerable people in the room during a pain visit: the patient and the doctor.
My goal is always to treat people with compassion, to ease their suffering, and to reassure them that their voices are heard.
Heather Tick, M.D. is the author of Holistic Pain Relief: Dr Tick's Breakthrough Strategies to Manage and Eliminate Pain and has been an integrative medical practitioner for more than 20 years. A sought-after speaker, she lives in Seattle and works at the University of Washington, where she is the first Gunn-Loke Endowed Professor for Integrative Pain Medicine.