"In Dr. Scott Fishman we have a model of compassion in a technological setting. . . .I feel rare confidence as I read his advice."

--Thomas Moore, from the Foreword

For centuries, pain has been our most formidable and elusive adversary. But astounding breakthroughs in pain medicine have turned the tide in the age-old battle against suffering. In this comprehensive book, eminent pain specialist Scott Fishman, M.D., takes us to the front lines of this war, arming readers with the information--and inspiration--they need to understand and manage the full spectrum of pain: from chronic back pain to the acute discomfort of postsurgical pain, from migraines and arthritis to the suffering of terminal illness.

As a physician and psychiatrist--and as the chief of a leading pain center--Dr. Fishman has a rare perspective on suffering. He understands that beyond the physical anguish, chronic pain isolates its victims while it devastates families, relationships, and careers. Too often, pain sufferers must do battle against a medical culture that is largely ill-prepared to cope with their needs. And yet, as Dr. Fishman reports, breakthroughs in neuroscience, pharmacology, and mind-body therapies have given doctors and their patients the upper hand.

Through the personal journeys of real patients, we learn about the anatomy of pain and explore its pathways through the body and mind. We explore the full range of pain-fighting techniques that get results, from surgical nerve blocks to acupuncture, from common analgesics to opioids, from psychiatric drugs to cognitive behavioral therapies. As Dr. Fishman has learned from his unique clinical experience, the best chance of defeating this enemy is an integrative arsenal of traditional and "alternative" weapons.

Writing with eloquence and compassion, Dr. Fishman offers an insider's view of how the secret language of pain is decoded and disarmed. After reading this book he hopes that you will be able to act as your own best advocate throughout the healthcare system. Dr. Fishman believes that the war on pain demands a mix of combat and diplomacy, of strategy and tactics, of carefully choosing one's battles and knowing how to step out of the crossfire. In the end, we all fight our own war on pain. And this book goes a long way toward fortifying each of us in the struggle.

The War on Pain

HarperCollins Publishers

Illness is the doctor to whom we pay most heed. To kindness, to knowledge, we make promises only. Pain we obey.

-- Marcel Proust

You know what acute pain feels like. The stubbed toe, the burned finger, the scraped knee. It's an inevitable and universal part of the human experience, an unpleasant sensation that seizes your attention and demands treatment. As Proust astutely observed, pain is a tyrant whose commands everyone is impelled to obey. Yet much of what pain commands is for your own good. While pain may seem like your adversary, it's also your protector and ally of health. Most people know from experience that you ignore pain at your own peril. You must pay attention to it or risk further physical harm.

When I talk to patients about pain, I frequently compare it to a sophisticated alarm system designed to protect you from impending damage, as essential to your survival as eating and sleeping. Ordinary pain, what doctors call acute pain, is a barometer of tissue health. Like a warning system around the edge of a house, it raises an alarm when it has been breached and you have been injured, alerting you to potential danger and the need for help.

Pain is a daily reminder that we are little more than a fragile collection of cells and fluids that can be easily pierced, burned, torn, or broken. Unlike many of nature's other creatures, we have no armor, no rough scales or thick hides to protect us from assault. All we have is our skin, a surface area of about twenty-one square feet composed of microscopically thin layers of cells that not only protect us from invasion by microorganisms but, more importantly, contain millions of sensory nerves specially designed to detect all sorts of sensations, including pain.

Paradoxically, this delicate epidermal perimeter is your body armor; your ability to feel pain enables you to avoid or survive life-threatening incursions on your body. Without pain, you would be in constant danger of fatally harming yourself and would not be aware of when you need medical attention. Acute pain is the reason most people seek out a doctor--after a sports injury, a car accident, a mishap in the home, a change in our health, after suffering fractures, sprains, strains, lacerations, wounds, contusions, and burns. According to government experts, Americans experience about sixty-four million such injuries a year. Most people experience acute pain about four times a year, usually lasting between one and five days.

If you have any doubts about pain's role as your protector and ally, consider what happens to people who don't feel pain. People suffering from a rare syndrome called congenital analgesia are born without innate pain sensors, leaving them senseless to any kind of physical assault. The story of Edward Gibson, who called himself"the Human Pincushion," is portrayed in the fascinating book The Culture of Pain. Gibson performed in vaudeville shows in the 1920s where twice a day he invited audiences to stick needles into him. Each day, they pushed in fifty or sixty pins up to their heads, yet Gibson felt nothing.

People like Gibson can tear tendons, twist ligaments, even break bones and feel close to nothing. They are constantly hurting themselves without knowing it. They burn their skin, suffer damage to internal organs, and live with dangerous infections completely unaware of the danger they are in. Not surprisingly, most of these people usually die by the time they reach their thirties, often from unfelt injuries. Unlike most of us, they don't have knee pain that says "lay off" or chest pain that might warn of a heart attack.

When I'm treating a patient, I often begin with the question "Where does it hurt?" But understanding a patient's pain really begins with another question: "What is pain?" There are many answers -- true, and all incomplete. Pain has many definitions because it's an intensely subjective experience that we filter through our emotions as well as our bodies. It's any sensation amplified to an uncomfortable level, and it's a constellation of negative emotions called "suffering." When you feel pain, there is much more going on than just nerves signaling the message "Ouch!" If you've lived with any sort of chronic pain, you know that "Ouch!" is a complicated phenomenon that quickly can turn a constant, unpleasant sensation into a life in pain.

Because pain is an intangible sensation, it challenges doctors and patients alike to describe and fathom it. It's usually a symptom, not a disease. I can't see it under a microscope or in a blood test. It's not an event, like a heart attack, that concentrates on a single organ or system in the body. And it's not solely an emotional or cognitive phenomenon, like a mental illness. Yet, pain is all these things, and more.

Compounding the riddle is the subjective nature of pain. There is no single accepted pain experience--no one feels it the same. Like the perception of beauty, it's very real, but only in the eye of the beholder. What hurts me may not hurt you. "Pain is what the patient says it is" is one of the few definitive, universal statements about pain. What is the difference between a patient who complains of the pain from losing a leg or the pain from losing a loved one? I hold emotional distress and physical torment to be equally painful experiences. I often see patients who claim a physical cause for their pain yet also tell me about great psychic pain, such as deep depression. Pain comprises a wide spectrum of feelings and is as individual as our fingerprint. Pain's inherently emotional quality is what makes it so difficult to define. Emotions like sadness, fear, anxiety, and anger, as well as childhood memories, all contribute to the landscape of pain.

Excerpted from The War on Painby Scott Fishman Copyright © 2000 by Scott Fishman. Excerpted by permission.
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