SCIENCE: AN END TO SUFFERING

For many chronically ill people, suffering becomes a way of life - and death. Yet techniques to rescue them from pain are available. Roger Dobson asks whether the medical profession is failing those who most need their help

ONE OF the last and most enduring images of Dennis Potter is of the playwright sipping morphine from a flask during his television interview with Melvyn Bragg. By then, in the final throes of cancer, Potter was, like a growing number of terminally ill patients, using the opiate to help keep his unbearable pain under some kind of control.

But for too many suffering people, pain is not so well managed. Individuals frequently die in agony because they have been denied the right treatment, while others live for years with chronic, debilitating pain that could and should have been treated. Some doctors and nurses remain reluctant to prescribe powerful doses of opioids to patients in the spurious belief that it may turn them into addicts, even when those patients are close to death.

Although a sixth of the world's population suffers serious pain at any one time, it has traditionally been seen as a symptom of other conditions rather than a problem in its own right. While there are scores of charities raising money for research into cancer, Aids and heart problems, pain is still marginalised. "Charitable organisations dedicated to encouraging information, education, training and research on the subject of pain remain astonishingly rare. In Britain there is only a single charity that concentrates on supporting one research group," says Patrick Wall, professor of anatomy at University College, London, founder of the journal Pain and co-author of a new book, Defeating Pain. He argues that all pain is controllable, if not by a single means then through a multidisciplinary approach. If it is not controlled, he claims, the medical establishment is not doing its job adequately.

Pain is usually caused by some kind of damage to tissue, either as a result of injury or disease, or of deterioration. Pain is how we sense that damage, as a signal relayed to the brain via a network of nerve cells whose branches - the dendrites - reach out into the tissue, ever-vigilant for changes in temperature and pressure, and the chemicals released when it is traumatised. The nerve impulses race at speeds of up to 225mph along the nerve pathways to the spinal cord and then on to the brain. It is there that they are experienced as pain.

One of the problems in treating pain is that it is almost impossible for anyone except the sufferer to assess, since there are often no visible symptoms, no injury to X-ray, no rashes or spots, no abnormal temperature to measure. While physical disease and injury can be diagnosed objectively by doctors, pain is only experienced subjectively by the patients.

"Unfortunately, you cannot measure pain like you can blood pressure and if you haven't got the pain it is difficult to judge it in other people. But it has to be assessed and when people die in agony it is because their pain was not assessed properly. There may have been inadequate drugs prescribed, or the wrong drugs, or the wrong approach," says Professor Leo Strunin, who is currently President of the Royal College of Anaesthetists.

At a basic level, of course, acute pain has been controlled for many decades. Most of us have experienced a local anaesthetic at the dentist's. While the drill is working in the mouth, the nerves want to tell the brain what is happening, but the local anaesthesia jams those signals. No messages of any kind get out, not even the normal ones of sensation, which is why we feel only numbness.

Pain managers now have a wide range of sophisticated drugs and other therapies in their armoury, from aspirin to morphine, which can be tailored to a problem. There are non-narcotic analgesics, of which non-steroidal anti-inflammatory drugs, including aspirin, are the most commonly used. These work by stopping the inflammatory process. There are around 32 million prescriptions a year issued for this family of drugs in Britain alone.

Steroids are more powerful and are usually applied locally to painful tissues or injected into a joint. Antisympathetic therapy involves destroying nerve cells either by surgery or using chemical agents, to stop the transmission of pain. Other therapies range from cutting nerve roots to nerve stimulation where electrodes are used to create a diversionary "tingling" in the problem area.

Narcotics - from the Greek narkotikos, "to numb or stupefy" - are some of the most powerful drugs in the weaponry of the pain specialist, particularly in the treatment of cancers, and they work on the central nervous system. With such a wide choice of drugs now available, most pain should be controllable, and yet many people still report cases of relatives who suffer agonising deaths, and there are patients who endure chronic pain for years.

"Most pain is treatable and there is no reason why anybody should die in agony, that is simply not acceptable. There are various ways of managing pain, so if this happens then it is a failure of the system,"says Professor Strunin.

"It seems to be ingrained in the medical-nursing establishment that opioids are bad for you because they'll turn you into an addict. If you're dying of cancer, so what? What you need is a drug to get rid of the pain, maybe very large amounts, but not all my colleagues are comfortable with administering them.

"You can also come across patients who are given large doses of morphine but are still in pain. People say they have done their best, but it may be they haven't prescribed the right drug. If morphine isn't working, that shouldn't be the end of it. There are a number of other treatments available, including other drugs."

In a report in the British Medical Journal, a team at the pain relief unit at the Churchill Hospital in Oxford says that ill-informed prejudice often gets in the way of common sense.

"Opioids are the first line of treatment for severe, acute pain. Unfortunately adequate doses are withheld because of traditions, misconceptions, ignorance and fear. Doctors and nurses fear addiction," the team says in the BMJ report.

The growing number of pain management centres, which work on a multi-disciplinary team approach, including anaesthetists, physicians, surgeons, and psychiatrists, can offer a wider choice of expertise and better service. This concords with Professor Wall's views expressed in Defeating Pain: that if one measure does not work, another must be tried, until the suffering patient gets adequate relief.

The good news is that now, 152 years after the first anaesthesia was used, Britain is poised to recognise specialist pain doctors under plans drawn up by the Royal College of Anaesthetists, which could get the go- ahead by the end of this year. The Royal College wants to see a sub-speciality created, so that doctors can choose to spend a year of their training studying pain management. The proposals, currently with the Specialist Training Authority, are likely to be approved later this year. It is hoped that such a move will give further impetus to better treatment of pain in Britain.

Another incentive for improvements, which will perhaps prompt change more rapidly and effectively, is the growing realisation that the treatment of pain has now become one of the biggest drains on NHS resources.

"People think that transplant surgery is the most expensive procedure, but you usually only have one transplant in a lifetime," says Professor Strunin. "Often, these chronic pain patients can cost much more money over a lifetime. When I was working in the US, we were told that chronic pain sufferers were not expensive patients. When we looked into it, we found five patients who had cost the system more than a million dollars each over the years."

'Defeating Pain' by Patrick Wall and Mervyn Jones is published by Plenum, priced pounds 20