Unlocking Pain's Secrets

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common reason for seeing a doctor. It is the No. 1 reason people take medication. And yet for a variety of reasons, medical science is ill equipped to deal with pain. While the 20th century has brought remarkable advances in the treatment and in some cases the elimination of disease, doctors' understanding of pain is just beginning to emerge from the dark ages. "Pain is the weak link in modern medicine," says Dr. Josef Wang, director of the pain center at the Mayo Clinic. To begin with, medical students receive only the scantest introduction to the subject. A 1983 survey by Bonica of 17 standard textbooks on surgery, medicine and cancer found that only 54 pages out of a total of 22,000 provided information about pain; half of the books did not discuss it at all. Part of the problem is that there are relatively few known facts to discuss. Pain research is an orphan field that neither anesthesiology, neurology nor psychiatry can entirely claim as its own. As a result, research has been neglected and underfunded. The National Cancer Institute, for instance, spends little more than one-fifth of 1% of its $1.08 billion budget on pain research, even though the dread of terminal-cancer pain has become a national phobia.

The little that is known about pain and how to treat it is often misunderstood or ignored by physicians. A 1973 study by Psychiatrists Richard Marks and Edward Sachar of New York City's Montefiore Hospital found that nearly 75% of hospitalized patients receiving narcotics for moderate to severe pain failed to be relieved by the drugs. A review of their charts showed why. The dosages prescribed by their doctors were 25% to 50% less than what was needed to relieve severe pain. Records showed that nurses had further reduced these dosages substantially. The result: some patients were receiving less than a quarter of the pain medication they needed. According to the study, the problem was largely due to ignorance: most staff physicians simply overestimated the efficacy and duration of painkillers. They also overestimated the risks of narcotics, worrying excessively about the possibility of respiratory problems and addiction. "We've become a nation obsessed with drug addiction," says Bonica, "and this has led to a serious problem with underdosing." Congress is considering legislation to legalize the use of heroin to ease suffering by terminal-cancer patients (see box).

The twelve-year-old boy's sweet smile makes a poignant contrast to his otherwise pitiful appearance. His arms and legs are deformed and bent, as though he had suffered from rickets. Several fingers are missing. A large open wound covers one knee, and the smiling lips are bitten raw. He looks for all the world like a battered child, but only nature is to blame for his condition. He was born with an extremely rare genetic defect that makes him insensitive to pain. His fingers were either crushed or burned because he did not pull his hand away from things that were hot or dangerous. His bones and joints are misshapen because he pounded them too hard when he walked or ran. His knee had ulcerated from crawling over sharp objects that he could not feel. Should he break a bone or dislocate a hip, he would not feel enough to cry out for help.

Pain is the body's alarm system. It alerts us to the fact that something is harming us. It compels us to seek help