Unlocking Pain's Secrets

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combining the skills of doctors in many disciplines to deal with pain was pioneered by Bonica at the University of Washington Medical Center's Clinical Pain Service in Seattle (see box). Treatment at a pain clinic begins with a thorough workup, including physical, psychological, neurologic, orthopedic, radiologic and laboratory examinations. If a physical problem is detected—a tumor pressing on a nerve, a slipped disc—surgery or some other appropriate treatment will be recommended.

However, in general, pain clinic patients have less concrete causes for their suffering. For them, the first step often is to be weaned from whatever narcotics they have been taking for relief, substituting methadone if necessary and offering psychological counseling. Doctors tend to frown upon the use of narcotics and muscle relaxants like Valium because they may add to a pain sufferer's debilitation.

The first line of treatment is the "simple analgesics": usually aspirin and acetaminophen. Even cancer patients can sometimes find relief in a bottle of aspirin. A number of other nonnarcotic drugs have proved useful in treating specific kinds of pain. Migraine Sufferer Elaine Anderson, 31, of San Francisco had tried everything from strong doses of codeine to psychic counseling to relieve pain "that felt like someone was tightening my head in a vise." She finally found relief with calcium channel blockers, originally developed for heart patients. Antidepressive drugs like the tricyclics are frequently recommended for shingles and chronic lower-back pain. Antiseizure medications like Dilantin, commonly used to treat epilepsy, can help calm the spasmlike facial pain of trigeminal neuralgia.

Physical therapies are helpful not only in relieving pain, but in helping patients get on with their lives despite it. Such treatments, including exercise, whirlpool and massage, are particularly useful for back pain, which is often compounded by muscular weakness. Before Maureen Brennan, 37, of Helena, Mont., arrived at the Seattle pain clinic for treatment of her back problem, she was confined to a wheelchair and was spending $180 a week on narcotics, sleeping pills and antidepressants. An accident four years earlier had ruptured five discs in her spine. Seven operations had failed to relieve the pain, and her weight had dropped from 160 lbs. to 81. After Seattle's three-week program of intensive physical therapy and psychological counseling (at a cost of about $10,000), Brennan was walking briskly down the hallways. "I have the same pain I came in with,""she says, "but you're busy here. It's like working an eight-hour day." The hard work makes it easier for her to sleep, and Brennan plans to get a job for the first time since her accident. Observes Clinic Psychologist Fordyce: "People who have something better to do don't hurt as much."

Hypnosis, biofeedback and TENS stimulation, once considered "fringe" methods of treatment, have earned respectable places in the pain clinic arsenal. Acupuncture, which tends to give only temporary analgesia, has a smaller following. According to Bonica, TENS provides significant short-term relief for 65% to 80% of patients and long-term relief for 30% to 35%. The electrical stimulating devices are widely available at costs ranging from $60 to $400. Biofeedback, in