2011-06-25 / Columnists

Maintaining Your Health on Mackinac

Dealing with Pain, Stress
By Yvan Silva, M.D.

Pain is one of the most common reasons that patients seek medical care. Most often they do after trying one or more remedies and the pain continues to diminish the quality of life. Pain is indeed an important and serious symptom, and it is most understood and appreciated singularly by the patient. As we grow older, as we succumb to acute and chronic illnesses, pain can become a daily component of our lives. Chronic pain is difficult to live with. It alters our lives and affects the people around us. It is difficult for the doctor to quantify the pain experienced by a patient because it is so subjective. And therein lays the problem – doctors for so long have under-treated pain.

It has been much too easy to dismiss the complaints as exaggeration, malingering, or even an expression of drug addiction. Physicians have found it easy to hold a high moral ground and avoid promoting an addictive regimen while ignoring the reality of pain and the need for effective treatment. And on the other hand, physicians who aggressively prescribe controlled substances to help patients with severe pain have often run afoul of the authorities and faced potential threats to their licenses.

Sudden and severe pain can result from fractures and other injuries, while other conditions can cause chronic and disabling pain – ranging from advanced arthritis to advanced cancer. A recent survey found that four in 10 dying patients were in severe pain most of the time. A New York study found that 71% of doctors said they had under-medicated pain, for fear of potential problems with the authorities. Our society continues to look upon chronic use of drugs as addiction, and that is looked down upon as weakness. The fact that pain can satisfactorily be controlled is gratifying, and that newer and highly effective techniques are now available is good to know.

Ten years ago, federal legislation promulgated the Pain Relief Promotion Act, a measure which recognizes that “the dispensing or distribution of certain controlled substances for the purpose of relieving pain and discomfort and is permissible under the Controlled Substances Act.” This measure gave physicians added legal protection and was supported by the American Medical Association. It recognizes the legitimacy of prescribing drugs to patients to relieve pain and suffering and not primarily to hasten death. There is the prohibition against using controlled substances in assisted suicides, of course.

The question of treatment with painkillers and drug abuse has been long-standing. A recent article in a leading medical journal, reported on the use of opioidbased analgesics (morphine and analogous drugs) to treat severe pain and its relationship to drug abuse (improper use or overuse or for a purpose other than its original purpose, for instance to “get high”). This study found that even though the use of these painkillers for medical purposes has increased, the rate of abuse of these prescription drugs by patients themselves remains relatively low.

Common types of pain include a broad spectrum of headaches that can range from mild, such as a tension headache, to a severe and incapacitating pain from a migraine. Arthritis pain refers to pain involving the joints; the pain results from wear and tear on the joints – osteo-arthritis, or swelling and thickening of the soft tissues around the joints – rheumatoid arthritis. Low back pain may be related to abnormalities of the spine or muscle strain; poor posture and lack of exercise can contribute to low back pain. Cancer pain can be relentless and result from a number of conditions, including pressure caused by a growing tumor or invasion by spreading tumor growths in other areas of the body.

There are several classes of drugs used in pain control. Acetominophen is a non-aspirin pain reliever. Anti-inflammatory drugs such as aspirin, ibuprofen, and naproxen work to reduce pain and inflammation. Narcotics, such as the opioid-based drugs, are used to treat more severe pain, such as occurs after surgery. Acute attacks of pain are usually well treated with over-the-counter, or when needed, prescription painkillers. It is long term, chronic pain that remains the scourge of many. Here, the cause of the pain cannot be eradicated, such as in arthritis and pain management may remain a lifetime pursuit.

Physical therapy – the use of specific exercises and activities to help control pain and improve physical functioning, is one of several therapies available for treating pain. Psychological therapy – individual or group counseling with a trained health care professional - can help by offering support and by providing techniques to cope with pain. Relaxation techniques deal with stress and tension that can make pain worse.

It is a good bet these days, that if you’re experiencing pain, your doctor will help you determine the underlying pathology for the pain and work with you to find effective options for pain management. There has been a nationwide shift in attitude and pain management is emerging as an important specialty. Indeed, most medical centers now operate pain clinics or “centers for pain management.” New medications are being discovered rapidly and delivery systems are improving. In addition to the usual methods, recently, dermal patches are becoming popular for slow and around-the-clock delivery. There is a rise in empathy for people in pain, and the professions are responding favorably so that people living with pain can find proper relief and maintain, under the circumstances, a good quality of life.

The objective evaluation of pain is necessary to enable adequate treatment. Termed the new “vital sign,” it is now taking its place along with blood pressure, pulse rate, respiratory rate, and temperature in documentation in all medical records. Rated on a scale of 10, patients are asked to rate the amount of pain, such as 0/10 the least through 10/10 the most, initially to establish and then correlate with improvement after pain medication is administered.

Stress. It seems to lurk in the background of our lives, coloring or complicating our accomplishments and our failures, influencing our mentalities, anxieties, and dream patterns. Just what is stress?

The term was first coined by the famous scientist Professor Hans Selye, who described it as the “fight or flight” phenomenon. He found that when threatened, animals would survive their predators by one of these two mechanisms, and at the time of attack the output of adrenaline into their bloodstreams would increase over forty-fold, providing huge amounts of energy for the required physical response.

In the 1980s the term “stress” emerged as a buzzword in our everyday conversations, replacing common terms such as worry, impatience, fear, anger, leading to stressed-out, stress-related bases for poor performance, adverse events in daily living and indeed, speculation as a factor in a variety of illnesses.

Stress, these days, is now getting recognized as how people respond to demands. A practical definition: When the problems presented by everyday life exceed your resources for coping with them, you feel stressed. Recent psychological studies of people who respond to demanding situations with losing their sense of well-being are helping to define the so-called “stress-resistant” person.

For example, in a comparison of coping styles of students with the most and the fewest episodes of illness during a given period, one study showed that those who reported little illness tended to maintain reasonable personal control in their lives. If a problem came up, they would look for resources or try out potential solutions. People who approached problems passively tended to be ill more frequently. Goal- oriented individuals did better, such as completing a career, participating in community activity, engaging in a hobby; setting goals in physical fitness and maintaining a disciplined regimen of exercising was an excellent incentive.

Certain choices in lifestyle clearly enhance the ability to cope with stress. Minimum use of “substances” regarded as drugs or drug-like, such as nicotine and caffeine, reflects the “take charge” attitude associated with coping. People who are most vulnerable to stress are most likely to complain they don’t have time to relax and tend to be more socially isolated. People who deal well with stress tend to seek out other people who are active and have positive attitudes.

In a study of a large group of individuals, 80% of a low-illness group engaged in regular aerobic exercise, whereas only 20% of the vulnerable group did so. There are several ways that exercise can ease stress. According to the American Council on Exercise, anxiety is diminished following exercise and the electrical impulses measured in muscles decrease; one exercise session generates as much as 90 to 120 minutes of relaxation response, often described as a post-exercise high. Exercise makes you feel better about yourself, and selfworth contributes to stress relief.

Surely, certain jobs are associated with higher degrees of stress than others, and certain lifestyles predispose to compromise of good health. It is now becoming clear, that stress-resistance can be pursued successfully by problemsolving approaches to unpleasant situations, healthy social bonding, dedicated time for relaxation and maintenance of a regular physical exercise regimen.

There has to be a conscious decision, to accept that although one may not be able to change or eradicate the causative factors for the stress, accepting that there is stress is the first step. Combating stress is the next. Relaxation and the pursuit of simple pleasures is one way - to smell the roses, to take a walk, to see a movie, to get away from it all. The other may be to face it head on - “Get with it, get a life!”

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.

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