The Changing Science of Pain

Among chronic-pain patients, O'Neal is actually one of the lucky ones. He, at least, knows why his pain started; some patients are deniedeven that knowledge. Chronic regional pain syndrome, for instance, is a rare disorder that can begin with something as trivial as a skinned knee. The scrape heals, but the nervous system does not. Within a few years the knee that was skinned feels like it is on fire, even though nothing is outwardly wrong. Similarly, fibromyalgia assails the bones, muscles and joints, but has no obvious bodily causes and doesn't show up on X-rays. Growing evidence now suggests that it is in part a brain disorder that sets the pain pathways afire, responding to imaginary wounds—as if the brain's diary of injuries has suddenly filled up with wild, untrue stories. The pain itself is not imaginary. But because it is hard to pinpoint and even harder to treat, for years many doctors used to write it off as such. Andrea Cooper says that's all doctors did when she first developed fibromyalgia, which afflicts 6 million Americans. "There was a bunch of 'We can't figure out what's wrong with you, therefore there's nothing wrong with you'," she says. "People don't like to hear about symptoms that they can't do anything about."

Some fibromyalgia patients may be helped by standard pain treatments. Others aren't. In that, at least, fibromyalgia patients are just like all other pain patients: relief can come for them, but it is often hard-won. Cooper, who is now on fentanyl and Kadian, compares her current pain to "the roar of the faraway interstate, as opposed to being in traffic." But to get to her current regimen she had to go through nearly everything else—antidepressants, anticonvulsants, muscle relaxers, acupuncture and six operations that probably made the pain worse.

Some of the most promising pain treatments of the past decade have turned out to be disappointments. Studies of some radiofrequency therapies show they work no better than placebos. Spinal-fusion surgery, a recent review found, has "no acceptable evidence" to support it. And if a treatment does work, says Edward Covington, a pain specialist at the Cleveland Clinic, "for most people, the effect is temporary." There is no cure for chronic pain, period.

There's not even any "single drug or technology alone" that can treat all the types of pain, says Eugene Viscusi, director of acute-pain management at Thomas Jefferson University Hospital in Philadelphia. Most people need two or three therapies in combination. Scientists' new understanding of pain's broad effects on many levels of the nervous system explains why: a multipart syndrome requires multipart therapy. Viscusi notes that patients under anesthesia still have elevated levels of the pain enzyme Cox-2 in their spinal fluid following surgery. They may not feel pain, but some parts of their brains still think they're in it. For any treatment to work long term, it will have to address not just the immediate sensation of pain but the other, subtler aspects—and there are surely some of those that scientists don't know about yet.

At the American Pain Society's annual meeting in May, a panel drew attention to what seems like the best option pain medicine currently has to offer: "multidisciplinary pain centers," essentially rehab clinics that employ doctors, nurses and therapists from a variety of fields. They prescribe a tough-love regimen of physical therapy (as well as the psychological kind), and many also make a point of cutting down on drug use. Pain specialists have been singing their praises for the past three decades. Data show why: they help many debilitated patients get back to work. But multidisciplinary clinics are on the wane. There are no statistics, but Covington says he suspects their numbers have dwindled by about 90 percent in the past 30 years. The problem is that a lot of patients just don't like them. "Americans love deep brain stimulation, replacement discs, things that are sexy and magical and frequently hyped," Covington notes. Multidisciplinary clinics are a much harder sell. They're not a quick fix, and their emphasis on exercise strikes fear in some people who are already worried about injuring themselves.

Insurance companies also sometimes balk at multidisciplinary clinics, which are costly. They'll cover them, Covington says, but usually "only enough so they lose just a little bit of money on them every year." Insurers say they sometimes have trouble determining how legitimate the clinics are or how much of a service they'll provide, since there are no national guidelines for what the clinics should encompass.