WHEN RESEARCHERS AT MASsachusetts General Hospital order white rats for medical research, they must fill out detailed forms explaining whether the animal will experience pain, what procedures will be used to minimize its suffering, and who is responsible for pain management. A grandmother who undergoes a hip replacement in a U.S. hospital enjoys no such concern. There are no questionnaires about the suffering she will endure after her operation. And chances are she will hurt.
Experts estimate that up to half of surgical patients suffer moderate to severe postoperative pain. No one knows for sure because while hospitals laboriously monitor every patient's temperature and blood pressure, they keep no charts on pain. It is the rare hospital that employs a comprehensive pain- management team to ease patients' suffering, and a rarer medical school that spends much time teaching the subject. Traditionally, physicians have regarded pain as an ancillary problem. "The focus was on disease. Pain was merely a marker of disease," says Dr. Kathleen M. Foley, pain-service chief at Memorial Sloan-Kettering Cancer Center in New York City. To some degree, this attitude simply reflected the bias of a culture that prizes the stiff upper lip: no pain, no gain.
But among cancer specialists, pediatric surgeons and many other doctors, this tough-it-out attitude has begun to change. Worries about the physical and psychological risks of using large doses of narcotics have largely been proved unfounded. Technological advances have enhanced the efficacy and safety of analgesia. And, perhaps most important in an era of cost cutting, doctors have learned that not only is pain management humane, but it also speeds recovery and saves money. When a patient is in such agony that he cannot move about in his bed, the risk of life-threatening blood clots increases. When he hurts too much to cough after chest surgery, the risk of pneumonia jumps.
A study at Dartmouth-Hitchcock Medical Center in Hanover, New Hampshire, five years ago proved the point. Dr. Mark P. Yeager randomly divided 53 intensive-care patients into two groups. One received morphine by ordinary intravenous catheters, while the other had morphine delivered epidurally, through a catheter placed near the spinal cord. The epidural patients, who were virtually pain-free, spent an average of just 2.5 days in the intensive- care unit and a total of 11.4 days in the hospital, while the other group required 5.7 days in the ICU and 15.8 days of hospitalization. In dollars, the difference was $11,200 per epidural patient, vs. $20,400.
"Pain influences physiology," explains Dr. Daniel B. Carr, director of the pain service at Massachusetts General and co-chairman of a commission that last spring issued the nation's first comprehensive guidelines on acute-pain management. Acute pain directly affects heart rates, respiration, blood pressure and urine production. It can also make cancer progress more rapidly. John Liebeskind and Gayle Page of the University of California, Los Angeles, have studied the effects of surgery-related pain on laboratory rats with lung cancer. They found that tumors metastasized two to three times as fast in rats that received no pain-killers as in those that were given morphine. The stress of pain appeared to inhibit immunological defenses. Concludes Liebeskind: "Pain can kill."