"Are you in pain?"

Think back to the last time you saw a doctor. Were you asked that question? If so, chances are good that your answer was yes. Half of all people worldwide who are visiting a physician are there for one reason—relief from pain.

If your doctor didn't ask you about pain, she or he probably should have. Pain is gaining new respect as something that should be treated in order to speed recovery and allow patients to resume a normal life, and physicians and patients alike are starting to recognize the importance of adequate pain assessment and control.

One of the most frightening aspects of any disease or injury, pain reaches far beyond the individual suffering from it. Families and loved ones feel its grip, and lost working days and reduced productivity cost industries billions of dollars every year. For some people, pain is a temporary nuisance, or something that is easily treated by their family doctor. For others, it's a more complicated aspect of their lives, one that can be debilitating and psychologically devastating. Persistent pain will drive 45 percent of all Americans to seek medical care at some point in their lives.

Each year, thousands of people seek relief from acute and chronic pain at the UI Pain Clinic. For these people and others, new and better treatments for pain cannot come quickly enough. That's why research into understanding why pain happens and what can be done to treat it is so important. At the University of Iowa, researchers in several departments are asking questions, finding answers, and using the newest treatments available to reduce pain.

"We want to have the very best integrated deducation, research, and clinical pain program in the country," says David Brown, head of the UI Department of Anesthesia. "We're trying to integrate the pain clinic with th research and education being done here, and eventually we want to have a specialized pain research and treatment center at the UI."

Working with other departments is key to the success of both the UI Pain Clinic and the pain medicine program as a whole, says Brown. "No one department has the answer for every kind of pain," he adds. "We have to focus on the issue as an institution, not as a department."

What is pain?

Over 75 million Americans live with serious pain, according to the American Academy of Pain Medicine. Of those people, 50 million suffer from chronic pain and another 25 million people a year experience pain as a result of injuries or surgeries. Although pain is a part of everyone's experiences, we rarely think about how and why it occurs. In fact, it helps keep us alive. One of the body's normal protective systems, pain signals when something is wrong, when we may need medical care, and it prevents us from repeating harmful behaviors, such as touching a hot stove or stepping on something sharp.

When a painful stimuls occurs, special receptors in the skin and organs, called nociceptors, register the stimulus and transmit it to the nerves. The nerves send this information to the spinal cord, which transmits the stimulus to the brain where it registers as pain. It's a lightning-fast process.

Nociceptors are more densely packed in areas where we need good response to pain, such as the hands, and less densely packed in areas such as the back, which are less likely to encounter painful stimuli. Nociceptors can provide information on a range of stimuli, including thermal damage, such as a burn or frostbite; mechanical damage, such as a cut or puncture; or chemical insult, such as acid on the skin.

Once that information reaches the brain, the body reacts in many ways. The eyes dilate, perspiration begins, and heart rate, repiration rate, and blood pressure all increase as the body prepares for assault. There's also an emotional response. It's all designed to get your attention so you can get away from the danger.

"Pain is a highly individual and personal experience," says Gerald Gebhart, 69MS, 71PhD, a faculty member in pharmacology since 1973 and one of the UI's pioneers in pain research. "Your background, gender and social and cultural history are different than anyone else's. When pain gets to your brain, your interpretation of it is different than anyone else's."

Imaging technologies such as CAT scans, PET scans, and MRI have allowed researchers to see what part of the brain is affected when someone is given an experimental painful stimulus. Even when given the same painful stimuli, different people will process it in different parts of their brains. "There are some incredible individual differences," says Gebhart. "That's what makes this so interesting and complicated."

The nervous system may actually change in people who have experienced pain, a process known as plasticity. One area of Gebhart's research is hyperalgesia, a heightened sensitivity to pain that develops after a painful injury or event.

"The nervous system is a very plastic system. Painful input leads to a learning in the nervous system, and changes occur based on prior experience," Gebhart explains. "Newborns routinely undergo heel sticks for blood samples and circumcisions, and that used to be done without anesthesia. now we know that those events likely lead to changes in pain behaviors when they grow up."

This knowledge is leading investigators to explore whether preventing pain in the first place will minimize pain later on.

"Theoretically, if someone is coming in for surgery, and if you treat the individual with analgesics before the skin is cut, you can reduce the amount of change in the nervous system, and thus reduce the amount of pain the person will feel after surgery," Gebhart says.

Donna Hammond, chair of research in the Department of Anesthesia, says most anesthesiologists now feel that having control of the pain while the patient is undergoing an operation, and keepin it under control in the post-operative period, is more important than pre-operative pain relief.

"Anesthesia does not mean pain-free," Hammond explains, "It means you will be unconscious. You may not have memory of the pain, but your body will."

Exploring the way the central nervous system changes and rearranges itself in response to pain is the next frontier or pain research.

"In the last decade, this has been the key realization in this field," says Hammond. "In individuals with chronic pain, neurochemicals that are normally dormant in a person without pain appear in large quantities and exist in neurons where they didn't before. We want to understand these changes in order to develop new pharmacological and physical therapy treatments."

The UI Pain Clinic

Of course, the ultimate goal behind all pain research is better treatment. At the UI Pain Clinnic, innovative treatments combined with more traditional approaches provide state-of-the-art pain relief to more than 300 patients a month, and the number is increasing steadily. The clinic treats patients who have chronic and acute pain from any number of illnesses or injuries.

The clinic has three main focuses. The Acute Postoperative Pain Service has someone on call around-the-clock to provide epidural and nerve block analgesia and other pain relief services to those undergoing surgery. The Inpatient Consultation Service helps patients who have pain from cancer, injuries, or surgeries, while the Outpatient Pain Clinic treats patients with chronic pain.

Patients whith chronic pain usually end up at the clinic through a referral from their personal physician, after standard pain relief measures have failed. The clinic is staffed with nurses who are trained in pain medicine and psychologists to treat the mental and emotional aspects of dealing with chronic pain.

"We want to deliver multidisciplinary care," says Richard Rosenquist, director of the clinic. "Treatment of pain is improved by treating it with a number of different approaches, so we try to develop good relationships with other departments."

One example of this interdisciplinary approach is the clinic's collaboration with Ken Follett, 90R, associate professor of neurosurgery. Follett is an expert in interventional pain medicine, which includes spinal cord stimulation, radio-frequency ablation to temporarily deactivate minor nerves around the spine, and intrathecal pumps that deliver analgesics directly to the spinal fluid.

Another example of the interdisciplinary approach is the work being done by William Hammonds, professor (clinical) of anesthesia, and the Department of Urology to develop treatments for testicular pain, something that's fairly common but typically undertreated.

Clinical patients are treated in a number of ways. In addition to routine pain management with drugs such as opioids and narcotics, nerve blocks—injections of a solution, usually anesthetic or steroids, into the nerve—are regularly performed to prevent or treat pain in a specific area of the body. Physical therapy is also used to help relieve pain. Newer treatments include the use of certain anti-seizure medication for nerve injury pain, sustained-release narcotic pain preparations that last 12 to 24 hours, and topical analgesia patches.

Some patients are also referred to the UI's Alternative Medicine Clinic, which specializes in natural holistic approaches to pain.

Staff in the Pain Clinic also conduct clinical trials of new pain treatments and are working toward making the clinic a leader in outcomes research, an area of pain medicine that has traditionally been neglected.

As the clinic's scope is expanding, so is its physical space. An expansion currently under way will provide a larger, updated clinic by spring 200w. Planned additions include more exam and procedure rooms and separate recovery, family counseling, and psychology areas all in the same location.

Rosenquist hopes that eventually, as the clinic and research program grow, the UI can become a leader in translational pain research, which is the process of making new discoveries, developing and testing them, and eventually employing them in the treatment of patients, all at the same institution.

A changing attitude toward pain

While pain is not a new area of research, it is gaining momentum as physicians become more educated about the value of pain control. Traditionally, pain was frequently accepted as a part of treatment and pain control was often an afterthought.

"Tradition is something that dominates attitude in this area," Brown says, "Many physicians still think that because you've just had surgery or because you have a chronic problem, pain is just a part of that."

But, physicians are becoming more enthusiastic about pain control as they see how it can help their patients recover faster.

"The change in attitude is due in part to the physicians walking into the patrients rooms and seeing the difference."

Another driving force behind that increased attention to pain control is public awareness. Due to the efforts of individuals and organizations such as the American Pain Society, people increasingly realize that adequate pain control is possible and available.

"What's changed is society's attitude toward pain," Hammond says. "You can't picture pain like you can picture a broken bone or a cut, but we have a much better societal picture of pain and how it affects people's lives now. It's being recognized as the fifth vital sign."

In fact, the Joint Commission on Accreditation of Healthcare Organizations recently passed new standards requiring hospitals to measure every patient's pain regularly and to administer proper pain relief. If they don't, they could lose accreditation.

"I think this will have a big impact," Gebhart says. "The Rules will improve awareness among physicians and force them to deal with pain conrol."

Even with the new standards, the responsibility still cannot lie solely with the physician or the hospital. Patients also need to be their own advocates whenever possible to make sure their pain is being addressed.

"Improvement in this area will be driven by patient expectation," Brown says. "We need to educate patients. We need to have patients expect that we will provide the latest and most effective analgesia. They need to depand pain control."