Duke University Alumni Magazine

o the elderly woman, relief comes simply by pressing a small black button clutched firmly in her right hand. Floating up from the enveloping fog of anesthesia, she lies in Duke Hospital's bustling recovery room, leaving her care after cardiac surgery to the attentive nurses. But she controls her own pain, periodically quelling its determined advance with a flick of her thumb, an action that produces a reassuring beep and brings a precisely metered dose of fentanyl from a small beige console at her bedside.

     To the little girl suffering from lupus, relief begins with an "oucher"--a collection of pictures of children's faces showing expressions from happy to grimacing. She points to one to tell the pediatrician how much her joints ache today--critical knowledge that can guide treatment.

     To the young man with sickle cell anemia, relief is a large "menu" of mental strategies. When the disease's needlelike twinges strike, he confidently picks from the menu of cognitive behavioral techniques with which Duke's therapists have equipped him. Today, he uses imagery to "go to the beach," leaving his pain behind by imagining himself walking beside a rolling, frothy surf, on a sunny day, breathing in the salty tang borne on a soft breeze.

     These three patients are among tens of thousands each year who come to Duke Medical Center seeking treatment for their illnesses, of which pain is a major symptom. They find an institution equipped with a surprising array of therapies for the intricate personal demon that is pain--not only a multitude of analgesic drugs and delivery techniques but, just as importantly, new ways to overcome psychological barriers to pain relief. Too often in the past, "it's all in your head" was but a dismissive diagnosis for complaints such as pain. But Duke's therapists are proving that much pain can, indeed, be "in the head," and that they can treat it successfully.

     The medical center has also learned that having the right pain-treating drugs, machines, and techniques is still not enough. Pain treatment can be subtle and complicated, requiring the marshaling of wide-ranging expertise --meaning that efficient organization is a key to relieving patients' pain. So the medical center launched a Pain Management Program to link all the hospital's pain-treatment resources into a coherent whole.

     "For many of the patients we serve, pain is their most important problem and one that deserves far more attention from the medical community. We have come a long way to develop more effective facilities for treating our patients' pain, but we believe we must make them more comprehensive and accessible," says Chancellor for Health Affairs Ralph Snyderman. According to Snyderman, the initiative will include increased pain-management training for primary-care physicians, better patient education, a pain consultation center to link physicians with the hospital's specialized treatment units, and greater emphasis on clinically assessing pain. "For those who are suffering, we'd like to make pain the fifth vital sign," says Snyderman. "Each patient's pain will be evaluated just as regularly and carefully as we measure blood pressure, pulse rate, temperature, and respiratory rate. We believe that such attention and individual consideration will help ensure quicker and more effective treatment of discomfort."

     The medical profession has not always paid such close attention to pain, says anesthesiologist Brian Ginsberg, a co-director of the Pain Management Program. "Up until the early Seventies, pain was an absolute stepchild of modern medicine. You could have had an operation then, and they would have used the same analgesics they used in the Thirties." Since then the medical profession has come to understand the profound benefits of treating patients' pain, he says. "Of course, effective pain control is a humanitarian act, but it's also important therapeutically. Many studies have shown that controlling pain not only reduces the time patients spend in the hospital, but speeds their convalescence."

     Even though pain treatment has progressed enormously, the mysteries of pain remain profound, says psychologist Francis Keefe, also co-director of the medical center's Pain Management Program and an expert in cognitive behavioral treatment of pain.

     "Pain is not just a sensory event, although that's the simple view that has historically dominated," he says. "Rather, pain can be influenced by thoughts and feelings, beliefs, memories, and expectations." Scientists tracing the neural pathways of pain have found them tangled and complex, he says. "Originally, it was thought there was just a single pathway for pain between the site of injury and the brain. But now we know there are multiple pathways. We also know that it's not just a one-way system from the periphery up to the brain. There are also multiple descending pathways as well, from the brain downward to the rest of the central nervous system." This discovery that the mind can influence pain has greatly affected pain treatment, says Keefe. "It really opened the potential for involving a person in regulating his or her own pain."

     Clinicians have emphatically confirmed the startling phenomenon of the brain's ability to control pain, Keefe says. He cites classic studies of pain reported in emergency-room patients in Montreal. "They would ask people who came in with obvious injuries how much pain they were having. And then they would ask the physicians how much pain they expected the people to have, based on their disease or injury. They found that 40 percent of the patients reported no pain at all; another 40 percent reported more pain than the doctors thought they should experience, based on their tissue damage. So, only 20 percent fit the old view of pain being proportional to tissue damage."

     Ironically, the belief that pain arises only from tissue damage can create more pain for the patients who hold it, says Keefe. "People have come to me who had pain whose basis couldn't be shown on an X-ray or a blood test. And they were devastated by that because their belief was, 'If I can't see it on a test, then I must have mental pain. Therefore, my pain must be imaginary. Therefore, I must be making this up. And there's really no hope for me, then.'" Such people are likely to deny their pain, neglect treating it, and end up with enormous suffering, he says.

     Giving surgical patients a sense of control over their own pain is precisely the reason that Duke Medical Center boasts 155 small computerized boxes called Patient-Controlled Analgesia (PCA) machines--among the largest number at any medical center. The PCA operates a large syringe filled with analgesic, which can be triggered by a hand-held button to release a precisely metered amount. Even though the PCA is computer-controlled, programming its dosages is still a careful medical art, overseen by a team of anesthesiologist, pharmacist, and nurse. As with all pain treatment, success depends on the skill of the medical professional, says James McAllister, director of the hospital pharmacy and associate chief operating officer. "Over time, the pharmacists have gotten very good at balancing the trauma of the surgery with the capacity of the various drugs," he says. "The magic is finding that narrow window where you're alleviating the pain but not over-sedating the patient." What's remarkable, notes McAllister,is how widely different that window can be among patients. Two patients undergoing the same surgery can vary many fold in their need for analgesics, he says. "So, it's important that the health-care provider literally be in touch with the patient, and finding the pain-relief solution that is specific to that patient really is an art."

     And as might be expected, psychological factors are also important, says anesthesiologist Ginsberg. "Those people who are highly anxious require more medication than those who aren't. If a patient has a caring spouse at bedside, he or she will use less than a patient lying there alone."

     Patients suffering from acute pain due to surgery or trauma can usually look forward to eventual complete relief. But those with chronic pain must cope with an affliction that could require care their whole lives. Helping such people cope with such a psychological mountain is the mission of the medical center's Pain Clinic, where some 3,000 people come for help each year. Such patients have usually been referred by their physicians after months or years of treatment for their chronic pain, says clinic director Bruno Urban. The clinic offers the full range of pain-management techniques, including medications, nerve blocks, physical therapy, spinal-cord stimulation, and instruction in pain coping strategies such as biofeedback and relaxation techniques. Despite this impressive arsenal, says Urban, he and his colleagues must be realistic with their patients. "We must often tell the patient that he'll have to live with a certain amount of discomfort, like living with any kind of handicap. If he had diabetes, he could have a reasonable lifestyle if he stuck to his diet and took his medications. The same goes for pain."

     Drug treatments may include not only narcotics, but also antiepileptic and antidepressant drugs that have shown value in pain treatment, says Urban. "It's like everything in medicine. There's no black and white. Sometimes pain will respond to a certain medication and sometimes not. So, we use a variety of drugs and try to get some effect from each. Since pain is a symptom, every treatment of pain is by definition symptomatic." For example, Urban has helped many patients with low doses of the narcotic methadone, which doesn't habituate the patient, but offers relief. "I've had patients on methadone for close to twenty years," he says. "They still have some discomfort, and they accept a certain amount of disability, but they are working and managing their lives."

     For "neuropathic" pain caused by the nervous system itself, Urban has found spinal-cord stimulation helpful in many cases. The technique involves an operation in which several tiny electrodes are inserted into the patient's spine, and electrical stimulation applied in various combinations and levels until the patient responds. "It only needs a local anesthesia, and the patient is awake and can tell us when he feels tingling from the stimulator in the area of pain," says Urban. Although the stimulation technique works well, as in so many cases in pain treatment, the underlying reason remains a mystery. "I could give you three hypotheses, but I'm not sure any of them is true. Basically, we don't know how it works, except we know it works in pain which doesn't respond to other treatments."

     And, in fact, the great mystery still remains of why many people suffer chronic pain in the first place. "If you look at back operations, like a simple disc operation, 70 percent of patients recover without any complications," says Urban. "But 30 percent will go on with their back pain and very often with more operations. Only 50 percent of those are cured with a second operation, and the chances go down rapidly with succeeding operations. And we just don't know why some people go downhill. There's no good explanation for it."

     Many times, patients need psychological, and not just physical help to cope with their pain. The Pain Management Program led by Keefe aims to give new coping methods to patients with such problems as arthritis, autoimmune diseases, fibromyalgia, and cancer pain. Patients usually arrive in his clinic with the traditional simplistic view of pain. But once they learn the complexities of their enemy, they are open to new strategies to fight it, says Keefe. "They're very relieved to hear our explanations of how the mind affects pain," he says. "Learning about pain opens them up to a whole array of things that they can do for their pain. They'll say, 'Gee, could I do something to change my thinking? Could I do something to change my feelings when I hurt?'"

     Keefe and his colleagues respond by teaching their menu of coping strategies, which is usually much longer than the patient's. "It's like when McDonald's restaurant first opened, they only had a few things on their menu. You could get fries, a hamburger or cheeseburger, and a Coke--that was it. Well, when a lot of people come in, their menu is very, very short --maybe pain medication and bed rest. And they say, 'Well, neither one of those work very well, but I keep using them.' "

     Through their research and experience, Keefe and his colleagues have developed about a dozen new menu items for pain treatment. They include:

• Progressive relaxation training, which helps people "put their pain into the distance," says Keefe. "When they're relaxed, their pain doesn't get them as depressed, angry, or irritable."
• "Mini-practices," of only twenty seconds, in which the patient "scans" his or her body and relaxes these muscles.
• Activity-rest cycling, in which patients are taught not to push themselves guiltily to high levels of activity to "atone" for their pain. Instead, they are taught to work gradually into a comfortable round of work and relaxation.
• Pleasant activity scheduling, which encourages patients to make room for things they enjoy and not restrict themselves to obligatory chores.
• Distraction techniques such as imagery, which diverts the patient's attention away from his or her pain.
• Cognitive restructuring, in which patients use diaries and discussion to monitor their own thinking to eliminate pain-aggravating negative thoughts and attitudes.
• Problem-solving, in which patients use worksheets and notebooks to analyze pain-causing episodes and how to cope with them.
• Relapse-prevention training, which helps patients stop pain setbacks from becoming full-blown relapses.

     Besides treating patients, the center conducts research on pain management, funded by such supporters as the Arthritis Foundation and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Studies are exploring whether coping-skills training and exercise reduces fibromyalgia pain, how to prevent relapses in patients with rheumatoid arthritis, and how spouses can help patients with osteoarthritis learn coping skills.

     Keefe's colleague geriatrician Debra Weiner has concentrated her research on the complexities of treating pain in the elderly. Aging brings such obvious problems as a higher frequency of chronic pain compared to the young, and the paucity of drugs that their aging bodies can tolerate, says Weiner. "While drugs may produce the same side effects as in younger people, elderly people have less physiological reserves to cope with them."

     But her research, supported by the National Institute on Aging, has revealed many more subtle problems with pain treatment in the elderly. One study of nursing-home residents revealed poor agreement between the residents' reporting of their pain and the staff's assessment. "It's not clear to me whether the problem lies in the residents or the staff. Are some elderly more stoic, not revealing their pain? Or is the staff so distracted by other more pressing issues like incontinence or wandering that they don't notice?" Also, she says, behaviors like screaming may not mean the resident is in pain, but just overreacting to a minor discomfort like having to use the bathroom. "Some demented elders, for example those with Alzheimer's disease, may have forgotten how to modulate their reaction to stimuli, like a child who's cut his finger and thinks he's going to die."

     Weiner cited a study that found that nursing-home staff tended to rank pain treatment low on their list of patient-management priorities. One reason for the low ranking, says Weiner, may be that nursing-home residents usually experience chronic rather than acute pain. "Since the residents have lived with their pain for months or years, they have largely learned to function despite their pain. Perhaps if staff observe a resident to be functioning at his or her baseline, they don't feel the need to probe into whether the resident was hurting that day." Clearly, says Weiner, more research is needed to understand such potentially serious breakdowns in communication about pain. One solution to improving nursing-home pain management, she says, may be better training of residents to report their pain and staff to notice pain-related behaviors.

     Weiner is interviewing residents' family members and nursing-home staff to understand how they observe pain-related behaviors such as crying and limping, or protecting a body part that hurts. She has discovered that nursing-home residents in the middle of a scale of cognitive functioning reported more variation in their chronic pain than those with either high or low cognitive functioning. The finding suggests a possible way to better treatment, she says. "Maybe those residents in the middle would be more amenable to non-pharmacologic distraction-based therapy like music therapy or support groups."

     At the other end of the age spectrum, children have also not had their pain optimally treated, says pediatric rheumatologist Laura Schanberg M.D. '84. "Traditionally, children have been under-treated for pain, both because we didn't know how to ask them about their pain and because we were scared to use drugs. If you give a child, especially a young child, a narcotic, they can't even tell you how weird it makes them feel." Schanberg's studies, funded by the Arthritis Foundation and the Fetzer Foundation, concentrate on enhancing pain coping skills in children with rheumatic diseases such as lupus, arthritis, and fibromyalgia. She's found that children are, indeed, fully capable of using such skills to alleviate their pain. "They may use distraction, calming self-statements, or just making a phone call to a friend, but they can work out ways to cope with their pain," she says. She's also planning a study to directly correlate children's activities and moods, their pain, and the levels of stress hormones in the body. The objective is to determine just how pain coping skills affect the body's chemistry of stress.

     In all these studies, she emphasizes, just measuring children's pain is difficult. Physicians can assess older children's pain with such visual aids as the "oucher" facial scale. But in very young children, even pain symptoms may not be reliable. "Children just have an amazing ability to run around regardless of pain. Often in pediatric wards, even kids who are really at death's door still sort of act like kids."

     While medical treatment aims to relieve pain, unfortunately it also sometimes causes pain--a worrisome issue that is the heart of radiologist Phyllis Kornguth's pain research. She explores the nature and effects of pain caused by mammograms, during which a woman's breast is squeezed between two plates with a pressure equal to the weight of seven bricks. Her studies, supported by the medical center's radiology and psychiatry departments, hint at a possible problem. "Pain has been implicated as being one of the reasons women don't get mammograms," says Kornguth, who is also chief of breast imaging. "At this point, we just don't have a clear picture of whether this is the case. But if 5 to 10 percent of women in the general population failed to return for mammography screening because of fear of pain, it would have enormous health implications."

     Kornguth's studies have included exploring whether a woman experiences less pain if she can control the compression herself. "I remember when I was a child running around barefoot, I'd always get splinters in my feet. When my mother tried to take them out with a needle, it really hurt. But, if she handed me the needle, I could remove that splinter and it never bothered me as much." When Kornguth gave a hundred mammogram patients the opportunity to self-compress one breast, the majority reported no difference in pain compared to the breast that was compressed by the technician. The patients who did report a difference indeed felt less pain in the self-compressed breast.

     Her surveys of pain in mammogram patients have revealed that, while reports of intense pain were relatively low --about 15 percent--an overwhelming 91 percent of women reported low to moderate pain. One possibly important finding was that women with denser breasts, as opposed to fatty breasts, reported more pain. Now Kornguth is exploring in greater detail which women are most likely to experience pain during mammography. "We would like for radiologists and technologists to be able to identify a subset of women coming in who are likely to have painful mammograms. It might be women with denser breasts, or of a certain age or education level. Once we can predict, we can offer coping skills, self-compression, or perhaps a few magic words from the technologist to lessen the anticipated pain."

     As Duke's pain treatment and research has revealed, pain is a complex, insidious nemesis, and not soon to be conquered. But those who face its consequences, such as anesthesiologist Ginsberg, are more optimistic than ever before that remarkable progress lies ahead. "The basic research today on the body's pain receptors and pain mechanisms is absolutely phenomenal," he says. "These insights will lead to medications with far fewer side effects that target pain far more effectively. Each time I go to a scientific meeting, I come back rejuvenated and invigorated and enthralled with what it is leading to." Hearing such optimism from those on the front lines of pain treatment can, itself, offer patients thankful relief. is also chief of breast imaging. "At this point we just don't have a clear picture of whether this is the case. But if 5 to 10 percent of women in the general population failed to return for mammography screening because of fear of pain, it would have enormous health implications."

     Kornguth's studies have included exploring whether a woman experiences less pain if she can control the compression herself. "I remember when I was a child running around barefoot, I'd always get splinters in my feet. When my mother tried to take them out with a needle, it really hurt. But, if she handed me the needle, I could remove that splinter and it never bothered me as much." When Kornguth gave a hundred mammogram patients the opportunity to self-compress one breast, the majority reported no difference in pain compared to the breast that was compressed by the technician. The patients who did report a difference indeed felt less pain in the self-compressed breast.

     Her surveys of pain in mammogram patients have revealed that, while reports of intense pain were relatively low--about 15 percent--an overwhelming 91 percent of women reported low to moderate pain. One possibly important finding was that women with denser breasts, as opposed to fatty breasts, reported more pain. Now Kornguth is exploring in greater detail which women are most likely to experience pain during mammography. "We would like for radiologists and technologists to be able to identify a subset of women coming in who are likely to have painful mammograms. It might be women with denser breasts, or of a certain age or education level. Once we can predict, we can offer coping skills, self-compression, or perhaps a few magic words from the technologist, to lessen the anticipated pain."

     As Duke's pain treatment and research has revealed, pain is a complex, insidious nemesis, and not soon to be conquered. But those who face its consequences, such as anesthesiologist Ginsberg, are more optimistic than ever before that remarkable progress lies ahead. "The basic research today on the body's pain receptors and pain mechanisms is absolutely phenomenal," he says. These insights will lead to medications with far fewer side effects that target pain far more effectively. Each time I go to a scientific meeting I come back rejuvenated and invigorated and enthralled with what it is leading to." Hearing such optimism from those on the front lines of pain treatment can, itself, offer patients thankful relief.