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Chronic Pain That Never Goes Away

According to a CBS News Poll out this morning, almost one American in five lives with chronic pain whether diagnosed by a doctor or not.


For Americans over the age of 65 the number is more than one in four. The pain these millions of people feel is very real. But now, with new research and treatments, the hope of easing that pain is becoming very real as well.


Martha Teichner reports on the subject in the CBS Sunday Morning Cover Story.


"It's as if someone were hitting you very, very hard with a fist," says pain sufferer Bob Simon.


Robert Kallman agrees. "It's as though somebody took an ice pick and just drove it into my neck or ear and just tore it around," he says.


There is no fancy machine to assess pain, not even something simple, the equivalent of a thermometer or a blood pressure cuff.


"It's like what it's like in your body to have a toothache throughout your entire body," says Susan Meehan.


Pain has always been measured by metaphor--or not measured at all--except in the faces of its sufferers, the contortions of their bodies, the pleas of their relatives.


Shirley MacLaine's frantic mother in the Academy-award winning Terms of Endearment was no exaggeration, according to studies published in America's most respected medical journals over the last 30 years.


Recognition that pain is often undertreated, even ignored, has forced changes in every hospital, nursing home, and clinic in the United States--and that's just the beginning.


Big Changes to Ease Pain

As of January 1st of this year, medical facilities must use a 0-to-10 scale to assess pain regularly--asking the patient to rate their pain on a scale ranging from "none" to "the worst you can imagine"--just the way they record a patient's vital signs. They then must control that pain to the best of their ability or risk losing their accreditation. The new standards have been described as a Bill of Rights for pain sufferers.


So what is pain? "Pain is whatever the experiencing person says it is," says nurse Sheila Gleeson.


Gleeson oversees the postoperative unit at Moffitt/Long Hospital, which is part of the University of California San Francisco (UCSF). UCSF is one of the world's leading centers for pain management and pain research.


"We're very aggressive with pain medication in surgery so patients have no pain," Gleeson says. "It's a traumatic experience that people do not need to have anymore."


In fact, according to Gleeson, the more pain you're in, the slower your recovery, as she had to tell a patient recently who was refusing pain medication.


"I said, 'Listen, you've just had surgery. You have to be able to take deep breaths and cough so you don't get any infections in your lungs or acquire pneumonia. You need to be able to walk around,'" Gleeson says, recalling her discussion with the patint. "I said, 'Try and take a deep breath,' and he couldn't. I said, 'Well, you know what, you are not accomplishing the goals that we have for you today, and the way you can accomplish your goals is by taking some pain medicine now.'"


But undertreating pain can have much bigger consequences.




Pains Long Memory

The more doctors have learned about the nervous system, the more they've come to realize that if they don't treat acute pain quickly and aggressively, they may actually cause that pain to become permanent.


"Don't be stoic," says Allan Basbaum, who heads the Department of Anatomy at UCSF. "I think the person who says, 'Well, I can handle this, I'll put up with it, I can live with it'--I think that's a mistake. Think of pain as a disease, not a symptom.


"When pain persists, or an injury persists, input continues into the spinal cord and ther are changes that take place in the sensitivity of the spinal cord," he explains. "I like to say there is a memory of the experience."


Doctors now know that the spinal cord literally rewires itself and tells the brain there is pain even after there shouldn't be any. The trick is to eliminate pain messages to the spinal cord before the process has a chance to get started.


"We are a pain management center and not a pain cure center, and so managing your drugs effectively, maximizing pain relief, minimizing side effects--okay, don't expect too much out of it," Dr. Pamela Palmer, director of UCSF's Pain Management Center says during a lecture.


"Our goal is relief of pain, but also increased function. What a lot of patients come in and say is, it's not so much the pain that's bothering them, it's that they can't live their life," Palmer says.


"Last night I fell asleep, I was crying. I'm a big person: I don't cry easily," says Bob Simon.


Simon was a physical education teacher for 30 years, a baseball coach, when his spine began to disintegrate. After the two back surgeries that were supposed to fix it, he was left in agonizing pain 24 hours a day.


"My whole life has been turned upside-down, inside out," Simon says. "I'm married. I have three daughters, I have a granddaughter, and all of our lives have been changed and have been very, very radically maneuvered by the pain that I suffer. I mean it changes every nuance of one's life, from one's relations with one's wife to just getting dressed in the morning."


Before he found his way to Palmer at the pain management center, his doctors had him on dozens of pills a day, heavy-duty morphine based painkillers. He couldn't even drive.


"I was a zombie before. I was taking so much medication," Simon says.


Palmer took him off most of those drugs and substituted a pain pump surgically implanted under his skin. It delivers a preprogrammed level of morphine and other medications directly to where his pain i. Simon remains clear-headed and gets more relief on less morphine.


"Thank God for the morphine pump and for all the other things I've discovered to help manage the pain," says Susan Meehan.




The Stigma of Relief

As Meehan learned, management of excruciating spinal pain involves a whole list of things--spinal nerve blocks, physical therapy, psychotherapy, even acupuncture and biofeedback, treatments outside the realm of conventional medicine. But it was her reliance on morphine, she says, that caused her husband to walk out on what had appeared to be the perfect 26-year marriage.


"I can remember him saying one day, I would never take morphine, and I looked at him and said, 'You have no clue what you would do if your body was on fire 24 hours a day,'" she says. "He viewed using morphine and pain management . . . I was a morally inferior person for using morphine."


"We like to break out the difference between physical dependence and addiction," Palmer says.


Palmer speaks for a substantial proportion of pain specialists who say morphine gets a bad rap--that for most patients, especially those who are terminally ill, addiction is a nonissue. Pain practitioners see themselves as struggling to reeducate the rest of the medical establishment.


"It can be very frustrating when a patient's been referred to me from a primary care physician," Palmer says. "They're happy, they're doing better, and I turn around to return them back to that physician so that I can see new patients and they don't want to take them back."


Palmer says that the patients are often reluctant to return to their old doctor because they are on too strong an opiate for that doctor to feel comfortable: The doctor may be afraid of ending up with a lawsuit, a yanked license, or a jail term.




Latest Research

Shingles is one of many conditions that don't respond well to opiates. Anybody who's had chicken pox can develop the virus. Dr. Michael Rowbotham, a research scientist at UCSF, is studying why some people, like retired oncology professor Robert Kallman, can't get rid of their pain long after their shingles rash has disappeared.


"We now have a whole set of animal models in pain, experimental models of nerve damage: What bridges the gap between that and many of the very complicated chronic pain disorders we see in the pain clinic is shingles. That's a disorder that is perfect for clinical research into what the causes of chronic nerve damage pain are, and what are the best treatments for chronic nerve damage pain," Rowbotham says.


He is following shingles patients like Daniel Miller, observing how they heal. Over a period of 6 months, he will compare nerve function in the affected areas to areas that ar normal and record whether Miller's pain goes away or becomes chronic.


"I think the exciting things are going to be understanding how acute injury unfolds and to find places in that cycle, in that cascade, where we can intervene and stop it and not allow it to restart," Rowbotham says.


Snails--that's right, snails--may provide one answer to the question of precision pain relief. Cone snails from the Philippines inject potent toxins into their prey, paralyzing them. They target the creature's nervous system. Drug companies are adapting the toxins for human use.


"Why do they work in a human or an animal? Because the same receptor that exists in the prey of the snail, it could be a fish, a small fish, exists in my spinal cord and your spinal cord--and the trick is to find the dose," says UCSF scientist Allan Basbaum.


The spinal cord connection is what interested Basbaum in taking part in the snail research, in linking a new clue to the mystery of why the spinal cord develops that memory of pain that won't go away.


"I do believe that by understanding how the spinal cord works, I will get a handle on how the brain gets that information, and that's a therapeutic target," he says. "The good news is that the basic science of pain mechanisms have now identified a slew of new targets, new therapeutic targets. That's exciting."


Especially for the nearly 80 million aging baby boomers.


"Here you've got a group of people all marching down the timeline coming into the age of chronic low back pain, degenerative joint disease: It's going to be a very large market. There's plenty of companies now that are realizing that and really trying to push forward and get some technology out there to help these groups," Palmer says.


So does it seem that baby boomers aren't going to tolerate the same kind of discomforts that their parents of grandparents lived with? "Absolutely," Palmer says. She says the generation's outlook is sure to have an impact on what happens in the field of pain in the future.


According to today's CBS News poll, 65% of Americans suffering from chronic pain take a prescription or other medications daily. Translation: Pain is big business . . . and money talks.


If you wish to be considered for Dr. Michael Rowbotham's shingles study, or for more information, visit the UCSF Pain Clinical Research Center's web site.

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