Special of the week; Issue 42-70 "You and Pain"

And E.R. the national educational radio network presents a special hour of the week. You know what pain is when you feel it. But can you define it. Is pain a warning or a disease. And what is the only pain that is easy to bear. According to the French surgeon Ren Natal Rege the only pain that is easy to bear is the pain of others. To explore some of the mysteries of pain we have with us for a man whose work gives them unique insights into pain. A clergyman who is Parish is a hospital a psychologist who helps patients suffering from chronic pain. A physician who specializes in the treatment of arthritis and a federal research administrator. Dr. Edgar Lee who will introduce the other three participants and moderate the discussion. Dr. Lee Payne is a universal human experience. It's something that we all know something about something that we have all experienced group of us here today would like to discuss some of the complexities of this subject. And I think we have a spectrum of experience in our group. Chaplain Kearney

is the chaplain of the. National Institutes of Health Clinical Center in Bethesda Maryland. Dr. Lee is a clinical psychologist who has been involved in many experiments and studies of patients reactions to pain and how one deals with it. Dr. Brown is a professor of medicine in the George Washington University where his particular interest is in arthritis and a crippling condition that we're all quite familiar with. Chaplain Kearney in your experience you. Are in a particularly good person position to be an observer of the the reaction of patients to pain. Can you tell us something about what you have observed. Well I'd like to make one point clear at first namely I think unless you experience pain. It's exceedingly hard to really understand the other person. Really as someone said or only one person can take your own bath. And I think this is involved with pain. Pain

has many different meanings and interpretations. From a whisper to a shout. I think when you get to the shot level there's a tearing burning. Can be excruciating for some people. And one of the things that we can say about it is that there are certain Come analogous when you are talking about a long term severe pain. Not the kind of a pain that is sudden sharp and acute but the long term pain. There are certain things about it. And one of the things that might be worth pointing out here is that it's like a nightmare. And if you look at what makes a bad dream into a nightmare The Terror Dream. It has special components. And I really there are three factors in it. And one is that terrible things are being done to you worse or threatened or perhaps. And second is that you're helpless. Your will is impotent there's nothing you can do. And the third is there's no time limit. And when you put these three together you have a nightmare. Where the patient and long term pain. Is living a nightmare he wakes up to the night there instead of going to sleep. And this has very

particular characteristics that make it much more difficult to be to exist to function. It's something that serves no purpose and was a function in other words we we do know that there is a form of pain which is very useful as a warning of the acute pain. And you draw your hand away from the hot item. But here the Chronic Pain serves no function. Not not only does it serve no function it also makes the person less and less able to deal with it. It pulls us to the center. We're constantly pulled to the point of pain where it hurts. We're pulled back from the future. Towards us in the past. We're constricted. We're brought into ourself really and all our usual defenses are ways of handling things our associations. Our usual approaches to things. I made lists because all our attention on our being is only to the pain. Now this is a principle but of course we know that some people seem to be able to overcome this or they seem to be able to react in a great variety of ways.

Do you find this is true for instance all have pain in the joints. What many people respond in different ways though. Oh yes tremendous individual variation. And I think people who deal with that group and there are lots of them that 18 million are sort of in the country and perhaps many more. On the way to have it who live with pain constantly. But the individual variation is very important not only for themselves to understand it better. But in terms of medications and particularly in terms of. The people that observe it. The family members to understand their type of pain it's a fluctuating pain incidentally quite different from the steady pain of. Some nerve damage. What was the reaction of families at the Clinical Center. Surely there are many very seriously ill patients and in pain there. I think many. Families experience a feeling being helpless. You know we live in a

world which is used to being active and aggressive. If I have a flat tire I don't like it but I get out. I get the jack out I change it. And I stand by the bed of someone having pain is almost intolerable situation for a family. Do you help the family. Do you treat the family as much as a patient in your. You know either the family is just as important as a patient in fact many times I think they're more important because the attitude they share with the patient is important. And predict I think at the point of pain because pain tends to isolate someone described as an island a prisoner. And I think to be nearby almost just being present being with is extremely important and of course the physician also frequently feels somewhat helpless with the RMN Tarion that we have. But. Aren't there certain psychological principles involved and handling pain aren't there ways that I think that really you have to look at two aspects of this.

One is kind of thing we have a lot of experimental work on the short term pain handling this now there's the longer term. In the short term we've learned a lot in some of these we've learned from this. Description of the nightmare that I gave the principals for example. A few years back we began to work in the field of dentistry. Happily dentist avoid pain. And the dental drilling too can be like a nightmare. You have the same qualities of terrible things being done. Your will being helpless in no time limit. Will have been interrupted. And now for example many dentists have a button on the arm of the dental chair. And the patient is told when you press that button the drill goes off it cuts the current. And one of the things that you find that is when people have this control the pain is just as great. But it's not overwhelming. They are still masters of their fate they're still alive. And they interrupt with the book much less than they used to interrupt before by saying sorry if this kind of thing. And that's one of the ways. Another way we've done it is by and by changing the time limit giving at a time when. If the dentist knows he's going to drill say for a maximum 45

seconds. What's up with a sweep second hand. And says we're going to drill for a maximum of 60 seconds no more come what may. Be can bear anything for 60 seconds. You know again you're not being overwhelmed destroyed by being lost in time. What about distractions. Something like music or something the patient isn't or the individual to be interested in does that help. I think the last phrase that you mention is the crucial one something the patient is particularly interested in. Because when we get from the short range into long range his kind of the overlapping area and one of the things we find is that anything that makes the individual more in his own way. Makes him more the person that he is. Can help him to handle the pain. If the person. Enjoys music. This is natural to him then it's wonderful. If they don't it's simply one more stimulus. It's making life harder to handle. It's like using occupational therapy in hospitals if you give the person the person who's a

Democrat a executive basketweaving forget it. Doesn't this come back to the point of noting that knowing the whole patient really. Is I think I think they get to know your person. I think it's been the finding of meaning in one's life. Maybe it may that not take a long time to get that knowledge and then when pain comes you're sort of cared for. Now the words I'm getting to the physician patient relationship and the fact that there is not a matter of I'm just using drugs or just the right psychological principles or not it has been an allegation for us in the first place. I think I think just because the context the meaning of which this person is helpless and he's tremendously depended upon the physician the nurse at the same time he fights because he wants to be independent he wants to control it. And I think to understand this phenomena is extremely important for the whole caring team who takes care of this person and this is perhaps one of the crucial elements that the caring

team and the family must not make the patient lists not make them more dependent. When you make a person more dependent you make them more like a child. And children can cope with stress. Not half as well as adults. But to make them more independent more in their way. They can fully human beings I think that's extremely well the words we're talking about. The reacting saying and something reacting to the thing we talk about in medicine the host parasite relationships but this is almost the same idea of pain and a reaction to it. So in handling it we have to think of the whole thing. Of pain if we talk of sensations and sensitive beings the sensations in themselves. Can be measured can be dealt with. But the important thing is the sense of the person. And pain is determined by the context it's in. You have a football player who plays three quarters with the excitement of the game is all with him up in agony.

It might be a physiologic principle. You know I mean there is have a dress for extra steroids for example which block the reaction. But again I'd like to speak just a little bit a bit. The drug business that we've observed if this is a good time to talk about I should think so but I think that people don't realize that drugs have a useful place but they can be overdone and underdone. And when someone sees a medicine cabinet of arthritic patients and sees all these remedies they say how terrible work. Are many did work for a while the body blocks the reaction sort of rejects the medication but if you leave it alone for a while it begins to work again when you need it again. So that they do and they should switch off. But the brutal trouble is today we're hearing all these things about how wonderful one thing is against another. And that really is doesn't take into account the individual variation some people block a medication completely. And we've seen drugs for pain that actually worsen pain because

they're allergic to it. So you really have to come back to that to understand why don't people realize this. Someone hasn't spent enough time with them explaining it because well I think this is one of the things that's condemned in our society is that we all have a medicine chest full of pills and we well I'm a great promoter of individual physician concept. I believe in doctors being one naturally had that have to do with it. But I think there's more to it than that. I think doctors. Know these things. Their time incidentally is consumed with paperwork these days and I'm a nice if we could get them back to. Communicating more and give them the time to do it. But if they do they would explain these things to patients that it's OK to have many remedies and vest because your neighbor across the street responds to one well you may not. I think this has to be said more often so people won't try to inflict their famous remedy on somebody else.

There's of course many doctors themselves who have to learn better ways of coping with this sort of a problem takes years. As a medical student I didn't understand these things and as the years have gone by these patterns are going to unfold and become very very important. Are there principles that come out of short term experiments that you talk about like in dental pain. Are there or are there generalities that can be applied. For instance the Dr. Brown could use in his practice in coping with chronic pain. I think the first thing is really what you were saying before and that is the tremendous individualization it is this person who has the pain. It's like in an illness where you don't say anymore at least we hope one doesn't say. You know. What is this illness but who is this patient who has this ill just quite a difference. Was the patient was hurting in this way he was in pain in this way. And to find out the total context total meaning of the pain it's tremendously different I remember one woman who

had a tremendously painful era disease. And she went on for years with a cheerful. Vital full life. And when she was asked how she was how she did it. She said when the pain becomes too severe I rise above it and I look at it from another level. Now this woman was not hysterical or anything like this. She retained control of herself. Her master was master of her own fate. And so the pain was very severe but she was running her life. Which is a very remarkable person. This is something that most of us can't do. I mean I think you hit the other kind of person who feels that they have to be stoic a stiff upper lip somebody that you can't give in to pain. Actually the pain the word itself refers back to penalty right punishment right. And sometimes when the one liners i use of patient given to an old friend was. Just because I understand it doesn't mean I have to like it. And there is something in that willed up to a

particular point it isn't. True and I got to a point. I think this is true someway What is the meaning of this experience. To me this is the crucial area that I see from my. Point of view and some way to change that context or meaning. Changes changes the significance of the illness. Would you advocate the old philosophical principle that some people espouse that pain is good for you. That makes you a better person for no having had it. I think good can come out of pain but I don't think pain is good enough in itself and I think the more we can do to avoid it to treat it to help people with it to help them accept good treatment of pain. I think this is crucial. Pain is a disease in itself. Because it is a useless sort of. And as with any disease or any real crisis the individual can grow through it. We could say the individual faces the tremendous crisis of pain. They can become more through the experience. But this doesn't mean you set up the pain of the pain is good because of this.

It's true nature once put it whatever does not kill me makes me stronger. And this is also something that comes out of. Hemingway dealt with the same thing. He spoke of being stronger at the broken places that one sometimes is. Someone remind me of the oyster with the grain of sand which makes the pearl. The friend said what about a whole handful of sand. And I think this is the kind of person we're talking about here who just overwhelmed with pain. Because pain can be so crippling in itself and in arthritic where actually the joint may be able to move but it's just so painful. The patient is really crippled because of the pain itself. I think there's a good deal we know about the mechanisms of the pain and in some fields say the rheumatic arthritic at least from our experience this may be an interpellation. But it's rather interesting to watch these patterns and I think we can learn something because pain really is a complex and it varies enormously. We've already talked about people

individual variation we haven't talked much about disease variation nor environmental variation in our family relationships. But I just want to point out a few things in the arthritic that I've learned. If a person is in a flare and a flare reaction is when the joint becomes acutely inflamed it usually runs through a cycle and comes down on its own. This is one of the characteristics of this type pain. During that period medications of any sort are blocked pretty much. And if you push the medication up the pain reliever to too high a dosage. The body begins to reject the medicine really. And other words the arthritic who can get along on a very little bit of medicine he knows this instinctively does better in the crises he has to up the dose. And lots of times when he does that nothing works or it works for a little while and stuff so if you switch is around or something else where it starts to work again usually he's got to tide himself over that period of inflammation. But it is an interesting thought isn't it that the

inflamed state inflamed tissue blocks the pharmacological action of drugs. We have an example of that say an appendicitis once it gets acutely inflamed. Antibiotics don't work very well. Then you have to remove it. Inflammation interferes with medication. Therefore we've got to do everything to subside the inflammation at that point rest. And that point psychologic things if people are worried intensely about this product the inflammatory reaction that that means and then your medicinal action works better. Another thing we can get into that movie but I just wanted to say there are some things that block the information like. So listen lights. That Happen. That's right helps to pave the way for the body's immune forces to work. So there are many many things that we haven't studied and I'd like you to take up the question of research and not important it is. Well since I'm involved in in the support of medical research it's certainly been obvious to me that most of the research has been carried out on

the relatively easy to study problems. You cute pain neurophysiologists of you know I've been primarily involved in which nerve fibers conduct pain responses where in the brain pain is felt and this sort of thing so that we know a lot about acute pain. But. I'm impressed that we still don't have a good handle on how to study chronic pain. What sort of things do we need to handle pain better. Well we're trying and I'm not saying we know the answers but we're trying to use a computer to collect the data in say the rheumatics subject and study pain that way. Now it's just as good as it is the programming of course and the program is taking us years. But I think it's possible to take about there about 8000 variables that you'd have to capture. And if we do this where the pain is where the action is in the offices of doctors and psychologists and chaplains and

begin to put this together. We could come up with a format that we could all work together with. We all need to work together much more. And I think you're right the laboratory approach is just one approach. It often clarifies details but it's got to be put in OK you got to get back to the whole and maybe maybe if it's properly done the computer would help or some other method. First just plain conversation and then communicating and talking about the different aspects of it the tremendous variations that you speak of. The problem that. The. How the individual regards the pain also influenced strongly how much pain they report and how much they feel. One of the whole problem is when the research is that when the individual has a meaning for his pain he feels much less and so when he doing research on pain killing agents for example on. And other drugs to reduce pain. Even those patients who are part of the experiment but not getting the drugs feel less pain and they do this by simply because now there's a meaning to

what they're doing it will help someone else. It will give them a feeling then there is something valid about this. I remember one woman who had very severe pain and in her case it was related to the healing process. The fact of the. Getting better and when she finally understood this she said you know it's quite different now the pain is just as severe but I can do other things when it comes and I can live with it now because something is coming out of it. She said it's like giving birth to a baby in labor you know something will be produced and it's never as bad as when the pain is going to produce anything. I think another concept which we haven't introduced formally is what I would use the word hope. And I think home is extremely important. I don't mean only the grandeur of the large scene but when a patient is lying in bed and the doctor says I'll be by four o'clock. He has an expectation anticipation I hope and I think just looking forward to something

different. The possibility of cessation of some of the pain is extremely important both along those lines even the distantly. There are times when you treat an arthritic with something that really aggravates it to begin with and later on improves it. And if you know that precisely and you can tell the patient that to expect this pattern. And it happens that way. And your experience should be able to get to dictate the actual likelihood then the patient will take that flared situation perfectly just like a patient of Dr. Chan was right. But if you don't mention that. Then you have a very disturbed individual whose pain is much worse because of the disturbed state and this is what makes it so tough to get a handle on because how do you measure hope. This is why I have the old fashioned doctor who didn't know all these answers but he knew these principles instinctively gave us all a feeling of well-being when he walked in the room with a child just think.

Yes very much so. The child instinctively runs runs to his mother to kiss him. Now how therapeutic is it. Well a parent is. Subsiding a pain. How. Would we go about. Putting some sort of number or evaluating this hope factor. Anybody have any idea I think it's too early to give it any kind of quantitative measurement or even think about it. But we first have to do is to accept its importance in the total picture. I think that the just the hope of the cessation of pain. In itself has an effect on the pain I was once put it. Very often the only thing that's gotten me through a bad night is the knowledge I could commit suicide. That in the last Lassie could stop the pain which enabled him to bear the pain. And here again it's a curious form of hope if you will but at least the knowledge that something can be done somewhere. That's right. It's really to quantify the standard of yes I magine chaplain Turner you see this when people recognize what they're dealing with they handle the problem very much

better. This is amazing isn't it. It's amazing. So communicate more. Knowledgeable people with patterns must must let other people have them whether they are the answers or not. That's right. But now even if we knew all of the principals involved and if all physicians and people dealing with patients and pain could know all the principles we still really don't have all of the tools that we need to deal with doing. We must not make a mistake and presume that we shouldn't go on with measurement. We've got to get better forms of measurement and also treatment. And I mean we've got to through measurement right but we also I think have to admit some of our measurement ideas which we consider perfect or very imperfect. And a very self-limiting. And there must be an area here that we can probe where there are no measurements at all as yet. But it shouldn't stop us from probing those areas particularly in thought. And in concept and so on as a group of people. This is what

we have we need today much more. It seems to me I think what you were saying before of communicating makes a tremendous difference by communicating what we know to the patient. We enable him to take some kind of a hand in his own destiny at least to know what's happening and enable him to remain if you will. Much more on top of his pain. And not necessarily the despairing communications as you know in almost every situation there's something good you can say. For example nature in the cancer patient when they d compensate the turn of events. They don't care. And people ought to know that they don't care and not to try to keep lifting them up at that particular point. Nature has done something nice at that point I think. Shakespeare put it. How often when men are about to die. Have they been. What they keepers call a lightning before death right. This happens very very typically but very very frequently Certainly. But don't you agree that families ought to know this

sort of thing. But I think families have to a tremendous amount. One of the things we have to teach both families and other people working with the patient in pain for example is not to make him less. We have a tendency that because someone is in pain to say they're there to wrap them in cotton batting they say sit very quietly. The less give up your activities your thoughts sort of huddle in bit. But when you do or your attention is pulled to the pain. Your pain expands to fill your entire world because nothing more in it. And at that point you can handle it much less because you're much less coming in. You're much less of an adult of a person very they're the kind of batting idea is a tremendously important. There's Chaplin Kearney's unique contribution really in actual treatment. At this point. I think some way that if you give meaning and purpose to this event I recall a cancer patient number of years ago. Sort of softly complained. If I were at home sewing and taking care of the house

my family would have meaning for me but here I am helpless and hopeless in a bad thing to do. And this brings up the whole question of hospital care these days. The dehumanizing that can happen I hope it gets a little more humanistic thing to say oh it's obviously obvious that we have an extremely complicated subject and one that has not been dealt with in fine detail yet in a way that we hope it will be eventually. I think that any of our audience who might be interested in learning more about the subject might want to write to the National Institute of general medical sciences for a brochure on pain. I think this goes into more detail in some of the things that we've discussed and you can get this by writing to and I g s the National Institutes of Health with as the Maryland 2 0 0 0 1 4. To repeat that address and I g m s the National

Institutes of Health. But Thursday Maryland the zip code 2 0 1 4. Right to the National Institutes of Health for your free copy of the pamphlet pain. This is the national educational radio network.