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Suffering chronic pain? Declare war on your ailment!

Updated: 11:48 a.m. ET April 1, 2005

Almost 45 million Americans endure some form of chronic pain every day. Armed with the latest medical research and the personal stories of his own patients, Dr. Scott Fishman examines the ways in which the body experiences and registers pain. His unique approach integrates traditional and alternative techniques, including pharmacology, neuroscience, experimental procedures and mind-body medicine. Dr. Fishman was invited on the “Today” show to discuss his book “The War on Pain.” Read an excerpt:

Why Pain Hurts
The Anatomy of Ouch
Illness is the doctor to whom we pay most heed. To kindness, to knowledge, we make promises only. Pain we obey. —Marcel Proust

You know what acute pain feels like. The stubbed toe, the burned finger, the scraped knee. It's an inevitable and universal part of the human experience, an unpleasant sensation that seizes your attention and demands treatment. As Proust astutely observed, pain is a tyrant whose commands everyone is impelled to obey. Yet much of what pain commands is for your own good. While pain may seem like your adversary, it's also your protector and ally of health. Most people know from experience that you ignore pain at your own peril. You must pay attention to it or risk further physical harm.

When I talk to patients about pain, I frequently compare it to a sophisticated alarm system designed to protect you from impending damage, as essential to your survival as eating and sleeping. Ordinary pain, what doctors call acute pain, is a barometer of tissue health. Like a warning system around the edge of a house, it raises an alarm when it has been breached and you have been injured, alerting you to potential danger and the need for help.

Pain is a daily reminder that we are little more than a fragile collection of cells and fluids that can be easily pierced, burned, torn, or broken. Unlike many of nature's other creatures, we have no armor, no rough scales or thick hides to protect us from assault. All we have is our skin, a surface area of about twenty-one square feet composed of microscopically thin layers of cells that not only protect us from invasion by microorganisms but, more importantly, contain millions of sensory nerves specially designed to detect all sorts of sensations, including pain.

Paradoxically, this delicate epidermal perimeter is your body armor; your ability to feel pain enables you to avoid or survive life-threatening incursions on your body. Without pain, you would be in constant danger of fatally harming yourself and would not be aware of when you need medical attention. Acute pain is the reason most people seek out a doctor — after a sports injury, a car accident, a mishap in the home, a change in our health, after suffering fractures, sprains, strains, lacerations, wounds, contusions, and burns. According to government experts, Americans experience about sixty-four million such injuries a year. Most people experience acute pain about four times a year, usually lasting between one and five days.

If you have any doubts about pain's role as your protector and ally, consider what happens to people who don't feel pain. People suffering from a rare syndrome called congenital analgesia are born without innate pain sensors, leaving them senseless to any kind of physical assault. The story of Edward Gibson, who called himself "the Human Pincushion," is portrayed in the fascinating book "The Culture of Pain." Gibson performed in vaudeville shows in the 1920s where twice a day he invited audiences to stick needles into him. Each day, they pushed in fifty or sixty pins up to their heads, yet Gibson felt nothing.

People like Gibson can tear tendons, twist ligaments, even break bones and feel close to nothing. They are constantly hurting themselves without knowing it. They burn their skin, suffer damage to internal organs, and live with dangerous infections completely unaware of the danger they are in. Not surprisingly, most of these people usually die by the time they reach their thirties, often from unfelt injuries. Unlike most of us, they don't have knee pain that says "lay off" or chest pain that might warn of a heart attack.

Decoding the Anatomy of "Ouch!"
When I'm treating a patient, I often begin with the question "Where does it hurt?" But understanding a patient's pain really begins with another question: "What is pain?" There are many answers — true, and all incomplete. Pain has many definitions because it's an intensely subjective experience that we filter through our emotions as well as our bodies. It's any sensation amplified to an uncomfortable level, and it's a constellation of negative emotions called "suffering." When you feel pain, there is much more going on than just nerves signaling the message "Ouch!" If you've lived with any sort of chronic pain, you know that "Ouch!" is a complicated phenomenon that quickly can turn a constant, unpleasant sensation into a life in pain.

Because pain is an intangible sensation, it challenges doctors and patients alike to describe and fathom it. It's usually a symptom, not a disease. I can't see it under a microscope or in a blood test. It's not an event, like a heart attack, that concentrates on a single organ or system in the body. And it's not solely an emotional or cognitive phenomenon, like a mental illness.

Yet, pain is all these things, and more.

Compounding the riddle is the subjective nature of pain. There is no single accepted pain experience — no one feels it the same. Like the perception of beauty, it's very real, but only in the eye of the beholder. What hurts me may not hurt you. "Pain is what the patient says it is" is one of the few definitive, universal statements about pain. What is the difference between a patient who complains of the pain from losing a leg or the pain from losing a loved one? I hold emotional distress and physical torment to be equally painful experiences. I often see patients who claim a physical cause for their pain yet also tell me about great psychic pain, such as deep depression. Pain comprises a wide spectrum of feelings and is as individual as our fingerprint. Pain's inherently emotional quality is what makes it so difficult to define. Emotions like sadness, fear, anxiety, and anger, as well as childhood memories, all contribute to the landscape of pain.

The foregoing is excerpted from "The War on Pain," by Scott Fishman and Lisa Berger. All rights reserved. No part of this book may be used or reproduced without written permission from HarperCollins Publishers, 10 East 53rd Street, New York, NY 10022

URL: http://www.msnbc.msn.com/id/7335629/

Weighing the Difference Between Treating Pain and Dealing Drugs

By TINA ROSENBERG

Published: March 26, 2005
NY Times

Federal prosecutors in Virginia want Dr. William Hurwitz, recently convicted on 50 counts of distributing narcotics, to go to prison for life without parole when he is sentenced in mid-April.

For the 50 million or so Americans who suffer from chronic pain, the fate of Dr. Hurwitz should be of some interest. He is a prominent doctor committed to aggressive treatment of pain. His behavior in some cases was inexcusable. Patients for whom he freely provided large prescriptions should, at the very minimum, have been given more close supervision. But malpractice should be cause for loss of license.

Instead, Dr. Hurwitz has been prosecuted as a drug kingpin because some patients sold their pills, although prosecutors never claimed he made a penny from it. That sends a chilling message to doctors who treat people with extreme pain.

Dr. Hurwitz's case involved prescriptions for opioids like OxyContin or Vicodin. Abuse of those drugs can be a lethal problem, but the new consensus among pain doctors is that very high doses are appropriate in some chronic pain cases. The Drug Enforcement Administration apparently disagrees. The Hurwitz case shows that increasingly it is the D.E.A., not doctors, that decides what is appropriate therapy.

Last August the D.E.A. published policies to guide doctors in treating pain. The document said the amount or duration of pain medicine prescribed was a physician's decision and would not by itself spark a criminal investigation. Dr. Hurwitz's lawyers filed to introduce it as evidence. Mysteriously, it suddenly disappeared from the D.E.A. Web site. The agency then announced it contained "misstatements." In November, the agency published new guidelines that said doctors who prescribe high dosages of opioids for long stretches are subject to investigation.

Pain is already undertreated in America. Although pain experts estimate that perhaps one in 10 people who suffer from chronic pain could benefit from opioids, the vast majority will never find this out. Many doctors won't prescribe opioids, especially in high doses. Opioids are safe and nonaddictive if used correctly, but addictive and deadly if crushed and injected or snorted, which defeats their time-release mechanism.

Abuse of narcotics like OxyContin is a serious problem and has devastated many communities. But a huge amount of OxyContin on the street is stolen from pharmacies - 1.5 million tablets from 2001 to 2003, according to the D.E.A.

Diversion of prescriptions may account for only a small part of the abuse, but it has brought a sadly disproportionate response from authorities. For example, Richard Paey, who has used a wheelchair since a car accident in 1985 and also developed multiple sclerosis, is serving a 25-year prison sentence in Florida for fraudulently obtaining prescriptions for Percocet even though prosecutors acknowledged he consumed all the pills himself.

Dozens of doctors have been charged with drug trafficking because the D.E.A. felt they were prescribing too many pills. The Association of American Physicians and Surgeons warns doctors to think twice before treating pain. "Discuss the risks with your family," it says.

One California doctor who prescribed opioids, Frank Fisher, was charged with five counts of murder - including that of a patient who died as a passenger in a car accident. All charges were dropped. A doctor in Florida, James Graves, is serving 63 years for four counts of manslaughter involving overdoses by people who either abused their prescriptions or mixed their prescribed medicines with other drugs.

Dr. Hurwitz, a crusader for aggressive pain treatment, had a controversial practice. More than 90 percent of his patients were genuine, and many say he was the only doctor who quieted their chronic pain. But his willingness to treat patients other doctors shunned, including drug addicts, also attracted scammers. It is legal to prescribe to addicts who are in pain, and many respected pain doctors believe that in some cases, addiction is caused by untreated pain and ends when the pain is controlled.

Dr. Hurwitz, who was disciplined by medical boards several times, testified that he did dismiss 17 patients he concluded were abusing their prescriptions and was tapering down the dosage for others. But he also said he felt that cutting off patients was tantamount to torture, and he did not do so without strong evidence of bad behavior.

Many of Dr. Hurwitz's colleagues believe that he was far too slow to accept such evidence and that he should not have been practicing medicine. But while he was blind to his patients' deceptions, there has never been any evidence that he was part of their conspiracy. In the prosecutors' post-trial motions, they argue that the conviction should stand even if Dr. Hurwitz believed he was prescribing for a legitimate medical purpose.

His prosecution seems inexplicable except as a signal to other doctors that they can go to prison for life for being duped by their patients. That signal is being heard - the exodus from aggressive treatment of pain is increasing. This might marginally reduce the amount of opioids on the street, but in the process it will sentence hundreds of thousands of people to suffer needlessly.