“When we treat pain, the first thing we do is try to eliminate the source of pain, say, by relieving compression on a nerve,” says professor of anesthesiology Carol A. Warfield. “When this cannot be done, we treat the perception of pain, i.e., with drugs that block the pain message in the brain. Or we may block the pathway that brings the perception of pain to the brain, say with a nerve block. However, there is a whole gamut of treatments. For example, if a patient has a cancer that’s growing into or around a nerve, first we would try to get rid of the tumor either by surgery, radiation, or chemotherapy. We may inject steroids to try to decrease the irritation and swelling around the nerve. If that doesn’t work, we try to treat the pain itself with morphine or medications aimed at nerve pain, or we might inject something into the nerve that relays pain from the cancerous area to the brain, or electrically stimulate those areas to interfere with the electrical transmission of pain along the nerves to the brain.”
Here are some of the major modalities of pain treatment.
Physicians may prescribe narcotics such as morphine and OxyContin for severe pain. Doctors give narcotics by mouth or, in some cases (particularly with patients suffering from cancer), they may inject them into the spinal area.
These drugs are derivatives of opium and work on the natural narcotic receptors in the brain and spinal cord. Common side effects include constipation and drowsiness. Contrary to earlier beliefs, patients who take narcotics for medicinal purposes rarely become addicted to them. “When I started doing this 25 years ago, it was absolutely taboo to give narcotics to a patient you expected to have pain for the next 10 years,” says Carol Warfield. “Now the pendulum has swung.” Some patients actually do better on these drugs than on other painkillers, she says. “It’s a matter of whether the narcotics can really restore their function.”
Nonsteroidal anti-inflammatory drugs (NSAIDs), including over-the-counter medications such as aspirin, Advil, and Aleve, are less potent than narcotics. They reduce inflammation by blocking the action of certain enzymes called cyclooxygenase (Cox) 1 and 2, thus helping to treat the source of pain when a person has a condition like a toothache or sprain. But they can also cause stomach ulcers and bleeding. Vioxx and Bextra, newer types of NSAIDs, were pulled off the market after studies showed that they increase the risk of heart attack and stroke.
Steroids are powerful anti-inflammatory medications that doctors may inject directly into the area that is the source of pain. For example, in the case of sciatica, where one of the nerves in the back is inflamed, doctors often inject steroids into the epidural space, the sac that surrounds nerve roots and contains cerebrospinal fluid. If taken over long periods, steroids can make bones brittle and can suppress the body’s own production of cortisone. Other possible side effects include thinning of tissues and elevation of blood sugar.
Doctors frequently prescribe antidepressants for people in pain because they increase the supply of a neurotransmitter, serotonin, that helps activate the body’s natural pain-relief system. For instance, doctors often use antidepressants as the first line of treatment for shingles. In addition to dizziness and sleepiness, antidepressants can produce dry mouth, abnormalities of the heartbeat, and inability to urinate.
Anticonvulsant or antiepileptic drugs can also be effective for nerve pain. If you have a seizure, your brain has a spontaneous discharge of electricity, which these drugs soothe, notes Warfield. The drugs act in the same way against pain when a peripheral nerve suddenly sparks and sends an electrical message, she says. But anticonvulsants often cause drowsiness and dizziness.
Stimulating the touch and pressure nerves, for instance by rubbing a banged knee, can help to relieve pain (see “The Gates of Pain,” page 48), so people have developed many ways to accomplish this electrically. “The Egyptians [took] electric catfish out of the Nile and, unbeknownst to them, what they were probably doing was electrically stimulating the tissues to stimulate those touch and pressure fibers,” says Warfield. Now, there is transcutaneous electrical nerve stimulation (TENS), a method of applying low-voltage electricity within tissue using a beeper-sized, battery-powered device with leads connected to electrodes attached to the skin. Acupuncture is another type of stimulation-induced analgesia.
Cognitive behavioral therapy can help patients view their pain as manageable rather than overwhelming, and become actively involved in their own treatment and rehabilitation, according to Robert Jamison, a clinical psychologist who “coaches” pain patients at Brigham and Women’s Hospital. This type of therapy teaches patients to substitute positive thoughts for the negative ones that perpetuate feelings of hopelessness. Relaxation strategies such as diaphragmatic breathing and guided imagery can help lessen pain by relaxing tense muscle groups, reducing anxiety, and increasing the patient’s sense of control over physiological responses, notes Jamison.
Doctors generally recommend surgery only after more conservative approaches have failed to relieve pain. For instance, in some cases of unrelenting sciatica due to a herniated intervertebral disk, surgeons may remove a portion of the patient’s damaged disk through an incision in the back.
Regular exercise improves muscle tone, strength, and flexibility, and may increase levels of endorphins, which are endogenous opiates (natural painkillers). Physical therapy may improve movement and function after a painful injury. Massage can reduce stress and tension and improve blood flow to tissues.
Recently, doctors at the Arnold Pain Center began using nucleoplasty for disk disease. In this procedure, they insert a needle into an intervertebral disk, then place a special radiofrequency probe through the needle to vaporize the disk’s gelatinous core. “It kind of cooks the disk material so it doesn’t leak anymore and cause pain,” says Warfield.
Soon, they will use vertebroplasty for some patients who have compression fractures due to osteoporosis. In this minimally invasive procedure, doctors insert a hollow needle into the vertebral bone and inject a cement mixture, which acts as a glue to stabilize the vertebrae and treat the pain of the compression fracture.