Living with Pain

Up until eight months ago, Catherine Grant would have told you she knew everything there was to know about pain, and considering her line of work you would have believed her. A nurse in the intensive care unit of a local hospital, Catherine was part of a team that struggled to keep patients in unbearable pain alive. When she held their hands, or talked to them, she felt she understood what it was they were going through.

Catherine now has another name for that insight: She calls it sympathy. A hip injury, three operations, and months of living in pain without a day of relief have made her realize what all people battling with ongoing pain know: No healthy person can understand just how bad it is.

Most people have never experienced the sort of pain Catherine is describing. As she did, we assume that the relatively straight-forward sensation we’re all familiar with encompasses all pain: You cut your hand, you feel pain, you seek treatment, the pain goes away. This description does apply to what is known as acute pain, a warning signal that protects the body from further damage by communicating injury.

Chronic pain is something else entirely. It has no apparent purpose, and it doesn’t go away. While it may originate in injury or illness, it may also appear without warning. And whatever the cause, it often doesn’t respond to conventional treatment.

The distinction between acute and chronic pain is, of course, most profoundly felt by the patient living with it. Catherine, for example, initially viewed her hip injury as a temporary, treatable, curable condition. Yet eight months and three operations later she was still in pain, and at least one doctor had told her that she might have to live with it for the rest of her life. The effect was devastating. “The hard part,” she says, “is no longer belonging to something. You have a deep feeling of loss at not being a part of the routine you’re accustomed to. You can’t make plans because you never know how well you’re going to feel. You might be out having lunch with a friend and suddenly you start thinking, ’If I could just put my feet up, I’d feel better.’ You can’t get away from it. You always think tomorrow will be better, and sometimes it is, but the day after that you could be flat on your back again.”



Until recently, the medical profession made no clear distinction between acute and chronic pain. The traditional approach was to view all pain as purposeful – that is, signalling a localized problem – because logic dictated that the only biological justification for pain was its protective function. When a patient complained of pain, doctors went looking for a clinical cause and treated it, as best they could, through surgery and medication.

Because Catherine’s pain originated in a visible injury, surgery was the right choice. Her problems came later, when the pain continued despite the fact that the injury had been treated. Fifteen years ago, doctors would probably have gone on treating the pain as acute. Catherine would have been operated on again and again, and because repeated surgery causes the formation of scar tissue, the results would probably have been poor: continued or increased pain, continued frustration for patient and doctors alike. Between operations, she would have been prescribed large doses of medication, and would likely have developed a drug dependancy.

With conventional treatments producing as many failures as successes, doctors began realizing that chronic pain wasn’t a symptom but a disease. And, pioneered by Dr. J.J. Bonica of the University of Washington, the pain clinic came into being. The idea is that unlike acute pain – which is localized to the site of injury – chronic pain is a general condition, involving the function of the entire nervous system as well as a host of psychological factors. Because the pain often can’t be pinned down, the chances of treating it through surgery aren’t good; in fact, surgery can make matters worse. Says Dr. James Montgomery, an anaesthesiologist at Parkland Hospital who heads a pain clinic at Southwestern Medical School, “I’ve seen very disappointing results in patients who have had surgery for pain itself. If a problem is visible, that’s one thing. If, however, the surgeon says, ’There’s probably some scar tissue here – let’s go in and have a look,’ you may end up with more problems than you started with.”

What a pain clinic can do is deal with non-specific pain through a range of conservative treatments, among them nerve blocks, which interrupt the transmission of pain impulses to the brain; acupuncture, Which operates on diverse nerve centers in the body; biofeedback, which promotes relief from tension through self-relaxation; and various forms of psychiatric therapy, which, by helping the patient to live with the pain, can also alleviate it.

Dr. Raymond Courtin resigned as chief of the anaesthesiology department at Medical City Hospital in 1977 to open a private pain clinic in East Dallas. Courtin specializes in nerve blocks, a time-proven treatment for chronic pain that involves injecting anaesthetic or steroids into the spine.

Nerve blocks act between nerve fibers in the spinal column to keep nerve impulses from firing. Specific ailments correspond to specific locations on the spine. Courtin treats back pain, for example, with a nerve block into the epidural space, the more or less empty area surrounding the spinal fluid; lower body pain is treated with a caudal block, entering the epidural space near the base of the spine. The business of nerve blocks is more complicated than the idea suggests, and patients are given the injections in a small surgery equipped with emergency apparatus. The patient must remain motionless during the injection; even a small reflex motion could dislodge the needle from its intended position, perhaps spilling anaesthetic into the spinal fluid, which, although not harmful, numbs the body from head to toe for hours.

The key to the nerve block is absolute accuracy in locating the desired area. From his years of experience, Dr. Courtin can insert a six-inch needle at the correct spot in about 15 seconds. Attaching a syringe full of liquid, he aspirates to check for punctured blood vessels, then slowly makes the injection. The entire procedure takes about five minutes.

On any given day, patients complaining of chronic back, shoulder, and leg pain can be found in Courtin’s waiting room. Elderly men, to whom pain in the joints has become something of a conversation piece, exchange news of where the pain has spread to this week; women with lower back pain – Courtin estimates that cortisone blocks for back pain make up 45 percent of his practice. Other patients have more obscure pain manifestations – a Vietnam veteran, for example, who feels severe phantom pain in an amputated limb. When Courtin First saw this man, he was taking large doses of medication and suffering from depression, a causal relationship common to chronic pain patients. Courtin took him off the medication and put him on anti-depressants. He then began treatment with lumbar sympathetic nerve blocks, injecting a mixture of short- and long-term anaesthetic into the nerve fibers running along the underside of the vertebrae. The first injection brought only a day or two of relief. Successive nerve blocks have brought longer-lasting relief and in time the man may lose the pain completely.

Phantom pain can probably be explained by the presence of super-sensitive nerve fibers in the stump that continue relaying nerve impulses to the brain after amputation of the limb. Since the pain is generalized, surgery on these nerves is only margin-ally successful. Nerve blocks may succeed by acting on what is known as pain memory, an actual imprint of a pain pattern on the nervous system. Supporting this notion is the fact that patients who have had a limb amputated after drawn-out salvage attempts have failed are more likely to suffer from phantom pain than those who lost the limb suddenly. The idea is that in the former cases a distinct pain pattern has been established, a pattern capable of perpetuating itself after the “reason” for the pain has been removed. While the anaesthetic in a nerve block deadens sensation only temporarily, longer-lasting relief results from having interrupted the pattern.

Dr. Montgomery defines pain as a three-step process: stimulus, or the cause of the pain; interpretation, or the manner in which the pain is perceived; and reaction, or the response produced by the pain. The separation of pain factors is not new. Dr. H.K. Beecher, a physician treating soldiers during World War II, found that when badly wounded men arrived at combat stations, two out of three turned down offers of morphine, saying that they were in minimal pain or no pain at all. Beecher noted that the men were neither in shock nor in-sensitive to pain, since they complained of careless vein punctures. Instead, he attributed the absence of pain to their enormous relief at having come through combat alive; the pain was, in effect, being blocked at the interpretation level.

Interestingly, when Beecher returned to Massachusetts General Hospital after the war, he found that four out of five civilians with injuries similar to those of the soldiers asked for morphine. From his observations, he wrote that “. . . there is no simple direct relationship between the wound per se and the pain experienced. The pain is in very large part determined by other factors, and of great importance here is the significance of the wound.”

Beecher’s findings confound all our commonly held beliefs. We seldom think of injury without pain, or of pain without injury, yet Beecher’s GI’s – and chronic pain patients – make it clear that both are possible.

Not surprisingly, many patients in chronic pain hold on to the idea that their condition is acute, not wanting to face the fact that there’s no visible clinical cause for the pain. When, after her third operation, tests showed no further evidence of injury, Catherine remained sure that something, somewhere, had been overlooked. “You ask yourself, if there’s nothing wrong with my hip then what’s causing the pain?”

It’s not easy to convince a chronic pain patient that at least part of the pain is psychologically induced. But a pain doctor’s first task is to explain to the patient – for what may be the first time – that psychological pain is a fact of the chronic condition; that acute pain is a reasonable, accountable phenomenon; that chronic pain is not and that, as such, it is difficult to accept.

Catherine naturally expected to recover from her injury and return to work in a matter of weeks. As time went on, she became increasingly frustrated at her lack of progress. By the time she first saw Dr. Montgomery, the conflict between her image of herself as a healthy, active person and the reality of the pain had gotten the better of her. She felt guilty at not being able to accomplish simple household chores, “mentally stale” from a concentration span so short that even following the plot of a television show had become an ordeal. And more than anything, she felt defeated by having an injury no one could locate, much less treat. Montgomery may well be able to treat Catherine’s pain, but before anything else, he has to get her to accept it. As he says, “If you start in on treatment before solving the psychological problems, you may waste the patient’s cure at a time when he can’t appreciate it.”

It is a common prejudice that pain which is “merely psychological” is imaginary and somehow ignoble. Since the clinic opened in 1972 Montgomery has fought against the notion, held by both doctors and patients, that psychologically induced pain is nothing but hypochondria. “The most dangerous diagnosis a doctor can make is to say that the pain is ’mental.’ Because of prevailing beliefs about the nature of pain, saying that ensures that no one will pay attention to the patient’s complaint in the future.

“When a patient comes to me and says he’s in pain, I have no choice but to believe him. And although there’s a good chance that psychological factors are contributing to the pain, that doesn’t make it any less real. It’s vitally important to get through to the patient that you understand the pain exists. So, if I say the pain is in your head, I have to clarify by saying that all pain is in your head – if you didn’t have a psyche you wouldn’t have pain.”

In determining the extent of physical versus psychological pain in a patient’s condition, Montgomery relies mainly on his experience with pain patients. There are cases in which psychological factors are wholly responsible for the pain, and pain doctors can identify some of them right off: the “home tyrant,” who uses his pain as an excuse to have his family wait on him; the “confounder,” who challenges doctor after doctor to cure his pain, then awaits failure with complete confidence and even pride. Equally familiar is the drug addict, who “uses” his pain to obtain medication. “Narcotics,” says Montgomery, “are appropriate in the treatment of acute pain, but it is absolutely wrong for a chronic pain patient to be taking them.” The reasoning is simple: Prolonged use of narcotics decreases their effectiveness and promotes depression.

Montgomery cites as an extreme example the case of a man in acute pain as the result of an injury. His doctor started him on aspirin, then escalated to Darvon, codeine, and finally Demerol. While the injury healed, the man was well on his way to becoming a chronic pain patient, his pain actually fueled by drug dependency; by the time the injury had mended, psychologically induced pain was going strong. Eventually, he sought psychiatric counseling and stopped taking the drugs. The pain disappeared. Although the man could be accused of exploiting his pain to obtain drugs, he was completely unaware of having moved from acute into chronic pain – it had felt the same from start to finish. Similarly, patients who at one time had acute pain from an injury that then healed completely sometimes find that the pain returns suddenly after an emotionally wrenching experience, say, the death of a family member. While this recurring pain is clearly psychologically induced, it feels identical to the original pain.

Montgomery sometimes treats chronic pain with biofeedback, which helps patients to reduce and control stress. The biofeedback machine is basically a nerve impulse monitor: Electrodes taped to the patient’s wrists transmit the impulses to the machine, which translates them into a beeping sound that diminishes as he relaxes. Then the volume on the machine is turned up , and the process is repeated until the body is completely relaxed.

The pain clinic treats some patients with nerve blocks. Still another possibility is acupuncture, Montgomery’s specialty. Although not much is known about how acupuncture works, the fact is that in many cases it does.

Eleanor Harris, a piano teacher, first noticed a stiffening in her left hand four years ago. A short while later, she developed back pain and a limp. Then one day, as she was standing on a stage preparing to start a recital, her legs gave out from under her and she collapsed.

She didn’t walk again for months. Tests on her nerves and muscles showed nothing, and it wasn’t until Eleanor saw a specialist that she found out what was wrong with her: osteomalacia and osteoporosis, related diseases of the bones. Eleanor’s body can’t metabolize calcium or phosphorus; her blood literally pulls these elements from her bones. The result: an increasingly brittle skeleton and what Eleanor describes as “a constant aching in every bone of the body.”

There is no known cure for Eleanor’s disease, and it’s unlikely that the pain will ever go away. Facing that fact wasn’t easy. “For a long time I thought it would all somehow go away, because it had to. I felt like a burden to my husband and family; I crocheted myself into oblivion; I was lonely and very angry. My best friend would stop by on her way someplace, dressed up and looking beautiful, and I would look at her and think, how can she do this to me, doesn’t she know how terrible I feel?”

When Eleanor first heard of Dr. Montgomery’s pain clinic, she was afraid he wouldn’t take her case since it was hopeless. What she didn’t know is that even when a cure is out of the question, the clinic can often manage the pain. She’s been going for acupuncture treatments once a week for three years now, and a 15-minute session brings partial relief for several days.

Partial relief is the best she can hope for, but while her pain is constant, the clinic has completely changed her attitude toward it. “When I first went to the clinic I was at the point where I couldn’t handle the pain – physical, psychological, the whole thing. I was really in trouble. Dr. Montgomery said to me, ’You know you’re going to hurt no matter what you do, but do what you can.’ And finally I said I’ve got this disease and I’m just going to have to deal with it.”

These days, Eleanor’s home is cluttered with bundles of imported silk flowers, ribbons, and baskets, all a part of her new business of designing custom flower arrangements. She is good at what she does, and working at home allows her to stop and rest when, as happens frequently, the pain begins to increase. She cares about looking and acting like a person in good health, and in fact many of her acquaintances have no idea she is a chronic pain patient. She takes a lot of chances in trying to lead a normal life – “I even wear high heels sometimes, no matter what” – since her bones could easily break if she pushed herself too hard, but activity helps to keep her mind off the pain. “It took me a long time to realize that just because I’m ill I can’t let my world come to a standstill, or expect other people to alter their way of life. What you have to realize is that your life has changed and that you may never be the same again. And then, you have to not let that bother you.”