Drumroll, Please

"He was not very good at drawing teeth, and he liked his patient to be deafened, amazed, stupefied by a thundering in his ears [...] the tooth came out--came out at bloody last, piece by piece--to the howling of conchs, the fire of two muskets, and the metallic thunder of several copper pots."  Dr. Stephen Maturin in Treason's Harbor by Patrick O'Brian

In the late eighteenth and early nineteenth centuries, while Napoleon roiled Europe with decades of war and modern chemical anesthesia was still decades away, surgeons relied on alcohol, on laudanum when they had it, but primarily on distraction and sensory competition to minimize suffering in their surgeries. Aboard warships and on the battlefields a deafening drumroll in the patient's ear could raise the pain threshold effectively (by up to forty per cent, as measured today).  For this post, a bit of self-disclosure that pains me, some news, and a book recommendation. Easy part, first.

The New York Times reports this week that the FDA has pulled Darvon, an opioid drug used for pain for over fifty years, from the market entirely.  They had really good reasons--the drug has been controversial for over thirty years and was banned in Britain since '05 for causing life-threatening heart arrhythmias-- but it was this sentence that struck me powerfully:

 "The announcement ended a 32-year dispute over the safety of the 53-year-old drug. The F.D.A. recommended doctors switch patients to other painkillers, notably Extra Strength Tylenol or acetaminophen."

I don't believe I've ever used Darvon, or Darvocet, as it is commonly prescribed in combination with acetaminophen. Perhaps it was prescribed after a surgery, but I can't recall. Some people have been prescribed it for frequent use to treat chronic pain and have become addicted to it because opioids are addicting, period. It's got nothing to do with a person's character; I expect you already know that, Dear Reader, but I mention it because it is an important point. According to the article, propoxyphene (Darvon), for which 17.5 million prescriptions have been written in 2009, has been shown to have very little effect on pain. I promise you there are lots of people out there this week who would beg to differ with that conclusion and who are scared right this minute. I appreciate that.

The uncomfortable disclosure: I suffer from an aggressive, degenerative osteoarthritis in my spine and larger joints, so pain has declared itself my BFF, riding always in my back pocket, so to speak. The integrity of my right hip is suspect now and occasionally I have to use a cane. Hard chairs, long car and plane trips, stairs are instruments of torture masquerading as elements of normal life. I taught dance aerobics in my forties and walked a fast four miles every morning throughout my fifties, but some days now I have trouble making it down my own hall. My rheumatologist pushes challenging daily workouts, anti-inflammatories, and GABA analogues which leave me foggy. I comply, but my post-workout day is often shot, so it's a struggle to accomplish much of anything else.

I wonder why I have system-wide osteoarthritis when neither of my parents did. At eighty-three, my father was baffled to learn that he was ill, since he noted "nothing hurts me." And then I recall my mother's story of my tiny great-grandfather who sat by the potbellied stove at night, smoking a pipe of marijuana for his arthritis. And that's probably another blog post, altogether.

The favorite tools in my pain management toolbelt are three which Patrick O'Brian's Dr. Stephen Maturin would thoroughly approve: the transcutaneous electrical stimulation system or TENs unit, which I wear in a portable version, is my own private drumroll. And there's my precious iPod piping Maddow in podcast, or "This American Life," or Tom Ashbrook's "On Point," or O'Brian's Treason's Harbor, or Stieg Larsson's Millenium Trilogy into my ears. Sometimes it can be a trick to maneuver around all my cordage--especially when I'm wielding hedge trimmers or pruning shears--but that sensory competition stuff works wonderfully to make life better for me. Writing, you may have guessed, is my third power tool against pain.

I understand there's no cure for arthritis--there's only the full-time job of management--so I'm trying to save the big gun opioids until my last years. Besides, even doctors who are most savvy to chronic pain secretly prefer heroes to victims, so I tough out all I can. Should I do that? How much pain should be tolerated and how much is too much, triggering a worsening chronic pain cascade? Chronic pain sufferers want to know.


So my ears pricked up when I heard NPR's "Talk Of The Nation" interview with Melanie Thernstrom, introducing her new book, The Pain Chronicles. I recommend it in analogue form; sometimes, you need actual pages to turn...with a bright yellow highlighter in hand. The science in the book is up to date--brain imaging, stress-induced descending analgesia, hyperalgesias, nociceptors, et alia--but it is the language  employed here that sang to me and made me feel less alone, for Thernstrom is a writer. She quotes Nietzsche,

 "I have given a name to my pain and call it 'dog.' It is just as faithful, just as obtrusive and shameless, just as entertaining, just as clever as any other dog--and I can scold it and vent my bad mood on it, as others do with dogs, servants, and wives."

Sections include Pain As Metaphor, Pain As History, as Disease, as Narrative, and as Perception. Some people who suffer chronic pain merely want it to go away; Melanie Thernstrom and I insist on understanding it, a trait that drives specialists crazy and sometimes causes them to label us Problem Patients. For me, knowledge has always been power and I like my knowledge best when delivered in a literary vein, so The Pain Chronicles might have been written just for me. It was hard to choose an example, so I opened the book to one of my bottom dog-eared, highlighted pages, at random:

Physical pain changes the body in the same way that emotional loss watermarks the soul. The body's pain system is not hardwired, but soft-wired (what neuroscientists call "plastic"), and it can be maladaptively molded by pain to increase its pain sensitivity. Ordinarily we think of neuroplasticity as being a positive trait: as the brain adapts to its circumstances and learns new things, new nervous pathways are laid down and old neural pathways disappear, the way the forest reclaims an untrodden path. But in the case of persistent pain, neuroplasticity is negative.

This is not a cover-to-cover read for me. Instead, I pull it out and read a few chapters as one of the tools in my pain management tool belt when osteoarthritis and secondary fibromyalgia are playing particularly hard on me.

I am always amazed at people my age and much older who do not experience unusual pain--there are more of us who do not than those of us who do--but most of us know someone of some age who struggles with trigeminal neuralgia or rheumatoid arthritis, an aging athlete whose knees must be replaced, or someone like me who never slowed down until they had no choice. They may feel that no one can possibly understand and that no one wants to hear one more time how frustrated and sorry they are that they cannot keep up. If you know someone, I can't think of a kinder gift to that person than Thernstrom's book.

Today is a Stieg Larsson in my ear, TEN's unit cranked up, Thernstrom chapter kind of day for me and there is a fence waiting to be painted. Drumroll, please.