(http://www.chron.com/content/story.html/health/317302)

RELIEVING THE AGONY

Aggressive Treatments Help Provide Comfort For Chronic Sufferers

The new medication resembles a lozenge on a stick. But for Inez Woods,
who is battling debilitating pain from lung cancer, it's more like a
lifesaver.

The medication Woods takes, which looks like a lollipop, is called
Actiq and it's 100 times more powerful than morphine. Fast-acting
because it's absorbed through the lining of the cheek directly into
the bloodstream, Actiq is one of the latest tools doctors have for
improving quality of life for patients with serious illnesses.

But access to such medication is not always easy. A recent study shows
that four of 10 Americans with moderate to severe chronic pain have
been unable to find relief.

Two major reasons: the difficulty in finding a doctor who will
aggressively treat the pain and overcoming the fear of addiction.

"Treatment for pain in the medical society is divided and mostly based
on biases and prejudices. If you're dying, the attitude is that it's
OK to treat it aggressively," said Dr. C. Stratton Hill Jr., professor
emeritus of medicine and founder of the Pain and Symptom Management
Section at the University of Texas M.D. Anderson Cancer Center. "But
there's a hard time out there for people in chronic pain. If you're
not going to die, God help you."

The manufacturer of Actiq (oral transmucosal fentanyl citrate)
emphasizes that the medication is indicated only for breakthrough
cancer pain, a flare of severe pain which "breaks through" medication
already being administered round-the-clock. Woods, whose cancer is
advanced, knows only too well that extreme pain means spending time in
what she calls "zula kula" land, a state of pain so severe that she
asks doctors to let her die.

Last November, she was referred by another pain specialist to Dr.
Richard Patt of the Patt Center for Cancer Pain and Wellness. He
prescribed Actiq, Ritalin, and oral morphine, and he deadened the
nerves going to her ribs with injections of ethyl alcohol.

Soon, Woods was able to return to her much-loved job at a
pharmacy.

Patt has made a career of alleviating pain, and has written several
books on the subject. Before he opened his own pain center in the
medical center area, he was an associate professor of anesthesiology
and neuro-oncology and deputy chief, under Hill, of the Pain and
Symptom Management Section at M.D. Anderson.

Patt is now transferring what he learned from treating cancer pain
into relieving other types of chronic pain.

According to Patt, there are two kinds of pain: acute pain, which acts
as a warning signal (to tell a person, for example, to take their hand
off a hot pot); and chronic pain, which has "no redeeming value" and
becomes an illness of its own.

"The problem with chronic pain is that you can't see it," Patt said.
"If pain were a rash, we wouldn't have any problem at all."

P.J. Heinrich said she wishes she "had this huge sore that people
could see." Suffering from fibromyalgia, an illness that causes
chronic pain in muscles and soft tissue surrounding joints, she was
down to 88 pounds at one point. Her hair was falling out and she
couldn't get out of bed.

Heinrich described her chronic pain as a "searing pain in my back
between my shoulder blades and a hurting in all of my muscles like my
whole body is one tremendous aching pain." She estimated she saw 20
different doctors before Patt. Many, she said, told her there was
nothing wrong.

"Physicians were telling me that I was going to have to live with it
and other people were telling me to try magnets," she said. "I mean,
we don't do this to our animals."

One of his frustrations, Patt said, is that people with chronic pain
are made to feel like "criminals" if they ask for medication too frequently.

Much of the fear of opioid pain-killers, which are narcotics, comes
from a lack of information, Hill said. There are two kinds of drug
dependence: physical and psychological. Physiological dependence means
that the medication has to be reduced in increments to avoid physical
withdrawal problems. Psychological dependence, on the other hand, is a
behavioral disorder.

"It's a compulsion and a craving to take drugs regardless of the harm
to your body," Hill said. "If someone is in pain and taking an opiate
for pain, it is not a mood-altering event. People think it causes
euphoria. Mostly it causes dysphoria."

Heinrich said the medication makes her feel normal. "I'm not walking
around slobbering and I'm not feeling any euphoria," Heinrich said.
"I'm starting to feel like my old self." Heinrich has been treated
with a combination of medications, including the Duragesic patch; a
pain-killer / anti-depressant called Elavil; and if needed, another
type of pain killer called Oxycodone. After eight months of treatment
with Patt, she said, her appetite is returning and she is hoping to
work again.

In addition to treating the physical symptoms of pain, experts
emphasize that the mental aspect must not be overlooked.

Patients at the Patt Center are encouraged to call when running low on
medication to avoid the fear of being out of drugs, which can heighten
pain and anxiety. "Many times, they wait too long to take medication
and then they have the anticipation and enhanced memory of pain," Patt
said.

Patricia L. Starck, the John P. McGovern distinguished
professor and dean of the University of Texas-Houston School
of Nursing, and co-author of The Hidden Dimension of
Illness: Human Suffering, has devoted much of her work to
the emotional toll pain takes on patients.

"The most troubling aspect of severe pain is a loss of the spiritual
dimension," said Starck. "Pain takes away their ability to be useful
and the needs of the human spirit are not addressed. Those people just
go downhill."

Pain-treatment specialists are encouraged that mainstream medical
groups and lawmakers in a number of states, including Texas, are
supporting laws that make pain treatment easier. In 1989, the Texas
Legislature passed the Texas Intractable Pain Act, which lends a
measure of legal protection to doctors who prescribe painkillers to
treat pain caused by medical disorders.

Technological breakthroughs are also promoting better pain
management.

Patt, who participated in studies on Actiq when he was at M.D.
Anderson, is now working with a company to make a small, implanted
pump for opioid drugs that would be much more comfortable for the patient.

In addition to opioid drugs, treatment for pain may include behavioral
modification, biofeedback, guided imagery and self-hypnosis. But, Hill
said, when such techniques fail, it's important that patients not take
the blame. "The theory often is the patient didn't do something
right," he said.

Linda Wynne went through physical therapy, biofeedback, exercise and
acupuncture to treat temporomandibular joint disorder. She was told by
several doctors that they couldn't do any more for her.

"I could live with the pain, but I couldn't have any kind of life. I
would tell my husband that I would rather live one year, and really be
able to live, than live five years sitting around in that pain. At
times, I almost wish it was cancer because people can understand
that," said Wynne, who stumbled across Hill on television one day. "I
saw Dr. Hill with these people who were talking about having their
lives back, and I knew I had to find him."

Hill, who no longer sees patients, directed her to Patt. After three
months of treatment, she said she is more active than she has been in
years: doing the laundry, making the bed, going out of town, cooking
dinner -- things people take for granted.