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While there are few truly new analgesics on the market, pain specialists have been ingenious about expanding the use of existing drugs. Surgeons, for instance, have learned that by putting a local anesthetic directly into the wound during and immediately after an operation, they prevent acute pain from getting established. "You never let the spinal cord see the pain messages," explains Berde. "It mollifies the entire course of postoperative pain."
Drugs originally approved for other purposes have been added to the analgesic arsenal. Tricyclic antidepressants like Elavil, for example, are now recognized as highly effective for the agonizing pain caused by damaged nerves in patients with shingles and diabetes. Methadone, the synthetic heroin substitute, has found new use as a cheap, long-lasting easer of chronic pain. And fentanyl, a highly soluble opiate, is available in a stick-on patch that offers up to three days of relief from the chronic, steady pain endured by many cancer patients.
The growing use of epidural pain relief, once largely confined to the obstetric delivery room to ease labor, has been a tremendous boon to cancer and postoperative patients. A terminal cancer patient who no longer receives adequate relief from huge doses of oral morphine can find relief at a fraction of the dosage with an epidural, and feel a lot less "doped up" as well. Epidurals are commonly used today after knee surgery and are increasingly being incorporated into the home care of acutely ill patients.
The breakthrough idea in acute-pain management today is titration -- the precise tailoring of dosage to the needs of a particular patient. There is, quite simply, no such thing as a standard dose anymore. Doctors have grudgingly come to recognize that the patient is the best judge of how he or she feels. Today people in acute pain can control their own medication with PCAs, or patient-controlled analgesia. These are digital pumps that are connected to a catheter. Physicians set a base amount of drugs that enter the body continuously. When pain increases, the patient can push a button and get more medication, up to a maximum set by the doctor. Gone are the every-four- hours injections of morphine that left a patient in agony for the final hour of each cycle as the drug wore off.
PCAs have been available for a number of years but have only lately gained widespread use. Genevieve Anderson, 64, had part of a cancerous lung removed two years ago at Massachusetts General without benefit of a PCA. More recently, she recovered from additional lung surgery with the device. "There is no comparison," she says. Carr notes that five years ago, a patient who had an aortic bypass would be unable to move the next day. Now, with PCAs, "a lot of them are sitting up doing the crossword puzzle," he says. "The old way was barbaric."
Chronic pain remains the biggest challenge because it is less well understood than acute pain. It may range from mild back discomfort to an amputee's agonizing phantom limb pain. While acute pain is essentially a healthy response to tissue damage, much of chronic pain is considered "neuropathic" -- the result of inappropriate nerve signals. Physicians now rely on physical therapy and behavioral techniques like biofeedback to battle chronic pain. In severe cases, they resort to antidepressants and local nerve-block injections, with varying results.