I have been asked several times in the past week about the origins of my interest in pain and pain research. It’s a complex question and it fits in with my past experience: I tend to be interested in issue which both intrigue me intellectually, and that I have, in some way, experienced.
We have all experienced acute pain unless we’re one of those few unlucky people who are born with congenital insensitivity to pain. Since acute pain is in part adaptive–a warning–it makes sense that acute pain is common. Moreover, acute pain is, in most cases, easy to treat, though there still appears to be undertreatment of acute pain in hospitals, but not as much as 30 years ago. As colleague and co-author John Loeser, MD (Neurosurgery, U Washington) puts it, no other group of medications are as effective as opioids in the context of acute pain.
Chronic pain–pain that lasts more than 3 months or past the point of tissue healing–is far more difficult to both understand and to treat. And that is one of the things that has drawn me in.
Back to the central question, though. How did my interest develop? There aren’t many pain epidemiologists, so the niche is relatively unoccupied, which is fortuitous.
Two things happened almost at once. I was asked to join a team of researchers at Washington who wanted to investigate small area variations in lumbar spinal surgery. It was a project that drew me in. We documented the fact that even after adjusting for demographic and epidemiological variables, there was an 11-fold difference between counties in Washington State in the frequency with which a set of low back procedures were performed. And this was interesting. John Loeser, who is one of the founders of pain medicine as a field of study and of treatment, pulled me in a way that intrigued me, enticed me, and stimulated me. And John is one of the most well rounded people intellectually whom I have ever met, as well as being passionate and enthusiastic about understanding and treating pain. And so history went…..the topic, and John, both attracted me.
There was a personal dimension, too. I became the team guinea pig for acute pain and for low back procedures. At the time, I experienced significant pain from nerve root pressure from a herniated disc. And, after about 8 months of this, conservative care was not working, and the condition was impacting my life and my activities in a negative way. Thus, I decided to explore surgical options, and, after talking to a few spine surgeons, I decided to proceed with one of the earliest minimally invasive decompression procedures. This turned into a nightmare. Within a few hours after the procedure, I was in the most severe agony that I could imagine–the classical 10/10 patient on the “what’s your pain level from 0 to 10?” And that is where the trouble began.
It was a week of nightmares and unbearable pain. I was discharged home within a couple of hours. And the pain got worse and worse and worse. And I lost sensation in part of my foot. It was obvious to me that the surgery itself had done some damage.
This damage, however, was not the most disconcerting part. The truly disconcerting part was the insensitivity of the medical staff to my acute pain. I could not turn over in bed without going into severe spasm, and without the hottest rod that you can imagine penetrating deeply into my sciatic nerve. I contacted resident after resident, and all that they could say was that it would probably go away, and just take some acetaminophen with codeine–one of the so called “weak opioids.” And I lived like this for a week until I could no longer go to the bathroom without crawling for an hour and shrieking in real agony. It was hell.
Finally, I called a neurosurgeon colleague who served with me on the Ethics Consult Service (I headed it) at one of the community hospitals in Seattle. And he told me to come right into the ER, by medic unit, if necessary, and he would admit me to his service. And if it is possible to think of a hospital stay as a healing experience, you can understand the essence of what post op week number 2 was like. I was admitted for pain control and for neurologic assessment. I had patient controlled analgesia with either morphine or hydromorphone (Dilaudid). I cannot remember which. And within a few hours, I felt relief. Not total, and I could control how much–I went for enough so that it was very uncomfortable but was nonetheless quite conscious of my surroundings. The CEO of the hospital even sent me a champagne brunch while I was in-house. I thought that mixing champagne with morphine and diazepam (Valium) would probably not be the best idea, but my visitors enjoyed the champagne. And imaging showed that there was damage to my L-5 nerve root because of my procedure at The Other Hospital. Living the experience was interesting, in a way, because I got to feel what I was writing intellectually about.
The whole experience was deeply disturbing, and existentially threatening. I went home 8 days after I was admitted, and cried when I got home, since the experience changed me, and angered me. What made me angry was not the adverse surgical outcome. That is what informed consent is all about, and there is always the risk of damage. I could accept that. What shook me profoundly, though–I think that it caused a pseudo, loosely defined PTSD–was the indifference to pain by the service at the hospital in which I had the surgery. The attitude was the classical “it’s only pain. You can live with it. Nobody dies from pain (which is not true).” I experienced what I hope nobody experiences again: uncontrolled post-surgical pain from inadequate treatment due to indifference. The attending and the residents were more interested in operating than in treating the pain of a post op patient. And, once word got out that I was admitted to The Other Hospital, I began getting cover your ass phone calls. Apologies from the chief of service. Deep regrets from several attendings at The Original Hospital.
So, it was in memory of this experience, and to honor the enthusiasm that I had developed for a new and intriguing health issue catalyzed by a brilliant, charismatic, and productive founder of interdisciplinary pain medicine that I vowed I would become deeply involved in pain research. The wonder about pain–its causes, context, treatment, understanding–is still there. It’s mysterious. And mysteries draw me in almost inevitably.