Medicine Talk

When It Hurts All The Time

By Dr. Terry Maresca
Tribal Connections

Chronic pain is a hot issue among the family practice doctors-in-training where I teach. In fact, it is a hot subject in my own clinic, as well as in our region. So much so that the Portland Area Indian Health Service sponsored an entire conference on how to help doctors better address this issue with patients in 2002. Sadly, two facts stand out for me on this topic. One: chronic pain is under-treated in America. This is evidenced by "doctor shopping" practices by many persons with pain.

Worse yet, some doctors may be reluctant to appropriately take care of pain due to problem number two: drug diversion risk. And, it is illegal, and commonly done in Indian country and beyond. Because of this, it was a workshop topic at the Portland conference. Diversion implies that persons prescribed controlled substances to treat pain may or may not have a legitimate medical diagnosis that would require strong pain medicine. A person who diverts controlled substances either sells these medicines to others, or gives them away to friends and family members to treat their under-treated pain or prescription drug addiction. Now, that is a painful fact.

I seem to have more clients than ever with chronic pain conditions. They range from non-surgical low back pain, to diabetes nerve damage, to fibromyalgia syndrome. The majority are already on a laundry list of drugs, often short-acting pain medicine or other mood-altering substances. Fortunately, many of them also come with the belief that they are the ones who need to control their symptoms. I know that those clients who understand that short-acting pain drugs only feed the acute pain/dependence cycle will probably get better faster. These folks either want to go off most prescription medicine or are willing to sign a pain contract with me.

What is a pain contract? It details the terms of what strong medicines will be used, how they will be used, and how a person will be monitored for abuse or addiction. Most have never signed such an agreement with their doctor before, even though such contracts have long been readily available to clinics. I wish more clients asked their doctors to do this.

I also know that my patients who focus on self-responsibility and remain open-minded to non-drug approaches will likely do well. What is "well", you ask? To me, it means my patient shows improved function in the important realms of life, like family relationships, job or school, sleep, sex life, spirituality, mobility, and social/creative pursuits, to name a few.

American society in recent years seems to have adopted a "biomedical model" of health care. This puts drugs and surgery at center stage in medical interventions. What might be called complementary or alternative medicine is put in the outer circle as an area to explore only when the primary methods fail. James S. Gordon, MD in his book "Manifesto For a New Medicine", has described a model called the "new medicine", which puts self-care as the first-line core practice in health care. Should this fail, the next level involves therapies that require a professional and stimulate a person's capacity for self-healing. Finally, drugs and surgery make up the last level. From my viewpoint, this approach is really quite ancient, and reflects the teachings of many of our Native elders.

So, what should a person living with pain regularly do? Perhaps a personal and honest review of this "new medicine" model is worth doing first. Do you practice any of these self care methods? It can be a better fit for those with chronic pain. As Dr. Gordon defines it, self care consists of eight modalities: self-awareness, relaxation, biofeedback and autogenics, meditation, imagery or self-hypnosis, exercise, nutrition, and prayer. Of course, most of us may not need all of these methods to heal. However, expanding one's choices appears important to increase the odds of doing so. Being ready to step out of your comfort zone to check new methods out definitely takes guts.

Many of us are familiar with exercise, nutrition, and prayer as means of promoting healing. If we are honest, we might admit that we don't use them as often or effectively as we could. Less common approaches such as self-awareness may not be emphasized in the average clinic visit - but they could be. This might involve writing in a personal journal, dance or movement therapy, or drawing/art therapy.

Biofeedback using inexpensive skin temperature meters or temp-a-dots (remember mood rings?) can also reduce pain and stress. This is vital, given the fact that more than 50 percent of those with chronic pain also have mood problems. Yoga and breathing training can be done to bring on the relaxation response. Years ago, I tried breathing techniques for the first time with a library-loaned cassette alone on a long drive to Sells, Arizona. I became convinced when I nearly drove off the road listening to Shirley MacLaine's voice. Right technique, wrong timing.

What if medicines are needed? Consider asking your doctor to review a pain contract with you so you can get your needs met. If your kidneys are normal, consider vitamin or mineral supplements to reduce muscle spasm or inflammation, such as magnesium or higher dose vitamin C (over 2 to 3 grams a day). Those with diabetes should be aware that high dose vitamin C can cause falsely high blood sugar readings. For those with back pain, consider low doses of white willow bark, used by our Eastern tribes for pain and inflammation. There is evidence in medical journals that this can help persons who also take other pain medicines. Those with aspirin allergies or who are on other blood thinners like gingko, coumadin, vitamin E and others should be very cautious about this and check with their doctor. Other herbal medicines can be used that are tailored to the exact condition a person has. For example, the Snoqualmie (Washington) Tribal herb garden has Oregon grape in it, used traditionally for bone and muscle pain. This tailor-made approach is especially important if sleep problems or anxiety/depression are playing into the pain cycle.

We need mutual support and trust - what Dr. Gordon calls "healing partnerships" - to make lasting changes. Always remember the option of seeking help from an experienced healer in the community to take a "whole person" view of your needs.

Those living with chronic pain deserve nothing less.

Terry Maresca, MD (Mohawk) is a board-certified physician in family medicine. She is the former president of the Association of American Indian Physicians, and a clinical assistant professor teaching at the University of Washington School of Medicine in Seattle. Her medical practice with the Snoqualmie Tribe of Washington combines her Western and herbal medicine approaches. She maintains a medicinal herb garden at the clinic, and is a frequent speaker on the subject of combining Western and traditional approaches to health.