Academic journal article Policy Review

The Contradictions of Pain Therapy

Academic journal article Policy Review

The Contradictions of Pain Therapy

Article excerpt

SEVERAL YEARS AGO I asked a leader in the Maryland pain community what percentage of Marylanders had enough chronic pain to deserve medical therapy. He replied matter-of-factly, "One hundred percent." I thought he was joking, but e quickly explained to me that everyone has chronic pain at some point, meaning pain lasting for more than three months. Because medical therapy is available, such pain is needless, he argued; therefore all Marylanders were candidates for chronic pain therapy.

Although extreme, his position exemplifies the new and aggressive stance toward chronic pain in the country at large. The medical profession now estimates that 116 million Americans suffer from chronic pain and merit some kind of treatment -- more than a third of the entire population. This number doesn't even include sufferers of acute pain, or children. Already eight million Americans use drugs to manage this pain, representing a tenfold increase in the last fifteen years. Pain that a generation ago would have been overlooked as a natural part of everyday life now has the attention of physicians, leading to an enormous increase in both narcotic and nonnarcotic prescriptions, with narcotics now representing the most widely prescribed class of medications in the U.S. Indeed, $600 billion is spent annually on the chronic pain problem.

As an anesthesiologist, I have observed a corresponding change in popular attitudes toward acute pain. All surgical patients hate pain, yet even as late as the 1970s, anesthesiologists typically ignored mild to moderate postoperative pain, not out of cruelty but because they were unconscious of the complaint. Had the public pressured anesthesiologists to change their ways, they might have done so. But the public did not. Some anesthesiologists saw postoperative pain as a useful respiratory stimulant to counteract the depressant effects of their anesthetic. Others worried (wrongly) that aggressively treating pain in the recovery room might lead to drug addiction. But most of the indifference toward pain was convention, among both doctors and patients, and the weight of a reigning convention is like the weight of the atmosphere--it is so universal that no one feels it. Today, such indifference would be considered poor practice if not malpractice.

Pediatric anesthesia exhibits the clearest trend. As late as the mid-1980s, anesthesiologists rarely anesthetized infants for surgery, in part because they worried about the effect of potent anesthetics on sick babies, but mostly because they assumed infants didn't feel pain, a concept that grew out of 194os research that showed newborns failed to pull their limbs away when pricked with a pin. Anesthesiologists simply paralyzed infants with muscle relaxants to keep them from moving while the surgeon cut. During my training in the mid-198os, some of my professors would jam breathing tubes into awake and struggling infants, then, during surgery, administer a little nitrous oxide, a weak anesthetic. They were almost humane for their times. Today, this practice seems barbaric. Although the infant's pain experience remains a mystery, since infants can't talk, the empathic sensibilities of both anesthesiologists and laypeople have been so aroused that letting a surgeon operate on an awake infant today would be inconceivable.

Obstetrical anesthesia reveals the same trend. As late as the 1970s, many anesthesiologists and patients saw epidurals for pain relief during labor as a luxury. Although the labor epidural technique was established in 1942, and the equipment for continuous labor epidurals came into being in 1949, even as late as 1961 prominent anesthesiologists assumed the old, substandard method of pain relief during labor, including narcotics and nitrous oxide, would suffice for most women, and that only ten to twenty percent of laboring women would need epidurals. Today, American women expect epidurals. Sixty to 70 percent of American women get them; the rate approaches 90 percent in some hospitals. …

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