Chapter 08: Understanding the Problem of Pain Management in the 70s and 80s –at MD Anderson and Beyond
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Description
In this chapter, Dr. Hill talks about pain management issues at MD Anderson. He begins by talking about the Pain Clinic, an ad hoc clinic that undertreated pain, a typical approach at the time, since chronic pain is a problem for patients who live, and cancer patients were just starting to live longer. He explains the three major causes of pain for the cancer patient and talks about his philosophy of addressing “pain in the cancer patient,” rather than cancer pain. He talks about the knowledge base about pain that needed to be created, including information about dosages, drug mechanisms and administration protocols, the individuality of patients, etc.
Identifier
HillCS_02_20120217_C08
Publication Date
2-17-2012
City
Houston, Texas
Interview Session
C. Stratton Hill, MD, Oral History Interview, February 17, 2012
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Building/Transforming the Institution; Multi-disciplinary Approaches; The Researcher; The Clinician; Overview; Definitions, Explanations, Translations; Human Stories; Offering Care, Compassion, Help; Patients; Cancer and Disease; MD Anderson Impact; Critical Perspectives on MD Anderson
Transcript
Tacey Ann Rosolowski, PhD:
Okay, so why don’t we talk a little bit about the— We’ll talk about the ambulatory care a little bit later. I mean, I was wondering, could I just ask you just to—? You were saying it’s like picking up a greased watermelon out of a pool, which is an amazing metaphor for a complex problem, I have to say. When you began work in this area, which was in the late ‘70s, early ‘80s, it sounds like— Tell me about what you saw at that time and then how you’re seeing it now.
C. Stratton Hill, MD:
Well, what I saw at that time was that we—when I say we, I’m talking about Anderson—had no real organized approach to pain treatment, and actually that was not, shall we say, on the front burner at that time because it was just about that time that cancer patients were beginning to live longer and chronic pain was becoming a problem. And so that was what made me— And in my dealings with the clinical aspect, or at least the administrative aspect of running the clinic, was that we had a pain clinic that was kind of run by the anesthesiologist but not really. If they didn’t have anything else to do, which they almost always had something else to do, then they would have a pain clinic, but most of the time they didn’t. They then got some people to come over from the medical school and Psychology, so it was just a haphazard approach to pain. I realized that, from what I was seeing before I’d gotten into the administrative job, a lot of people were having chronic pain that didn’t seem to get it adequately—
Tacey Ann Rosolowski, PhD:
I wanted to ask you just because I think we’re talking about a period of time that maybe a lot of people who will be listening to this, they weren’t around then or they weren’t professionals at that time. What were you seeing? How do patients—? How did patients at that time experience chronic pain? What was it like for a cancer patient? What were you seeing?
C. Stratton Hill, MD:
I was just seeing what you’d call in general the undertreatment of pain. I can remember some of the early patients that we had would say, “I wonder why my doctor didn’t do this?” because it wasn’t anything magic that we were doing. “I wonder why my doctor didn’t give me this medication.”
Tacey Ann Rosolowski, PhD:
What medications were you giving?
C. Stratton Hill, MD:
Well, I can remember specifically, at that time, that was before they had the longer-acting drugs like MS-Contin and OxyContin and delivery systems that lasted over eight to twelve hours. But the half-life of methadone was much longer, so it was the only drug that we had that would last longer periods of time that would allow the patient not to have to take medication so frequently. But because of the long half-life, it made it difficult to manage, because you built up a level over a period of time, and you had to figure out at what time that was going to plateau out to where you wanted it. You oftentimes got into too much medication, and they got real drowsy about a week after they started taking it. It was kind of hard to manage. I remember I gave this patient methadone, and she was saying “I wonder why my doctor didn’t give me this?” Now—
Tacey Ann Rosolowski, PhD:
Can I ask you just for a sec—I mean—this may sound like a very ignorant question but—
C. Stratton Hill, MD:
No questions are ignorant. (laughs)
Tacey Ann Rosolowski, PhD:
Well, I wonder if you could talk a bit about what the sources of pain are for a cancer patient.
C. Stratton Hill, MD:
Yeah, they’re basically divided into three different categories. First is the cancer involves pain-sensitive structures in the body either by pressure of the tumor growing and putting pressure on a nociceptive nerve or just infiltrating into that tissue, just related to the presence of the tumor itself. It can be related to treatment, particularly chemotherapy, because at Anderson we started doing regional perfusions of particular extremities for melanoma and things like that, trying to save the extremity because the method of treatment. Like at Memorial, if you had a melanoma on your leg, you got your leg amputated. Well, John Stehlin, at MD Anderson, was one of the early pioneers in regional perfusion. He would isolate the extremity with certain pressure controls of the blood supply, and it was almost like a heart/lung machine. You would perfuse that—or possibly a lethal concentration of the drug into that extremity and recirculate that blood into the extremity over a period of time. But that would also perfuse the nutrient arteries of the nerves, and so they got a whopping dose of this medication that was actually toxic to that nerve, so then you had what was called neuropathic pain. The difference between neuropathic pain and nociceptive pain is neuropathic pain occurs in the setting of a damaged nervous system, whereas nociceptive pain, which is the most common type of pain that everybody has, is in the setting of an intact, or normal, nervous system. The big difference there is that neuropathic pain does not respond to the ordinary analgesic drugs like nociceptive pain does. For instance, if someone comes in with a broken leg into the emergency room, you can give them a shot of morphine, and it takes their pain completely away. In the case of neuropathic pain, that helps some, but then—I mean—usually analgesic drugs—but then you have to use different drugs that are not ordinarily classified as analgesic drugs, such as the anticonvulsant drugs and the antidepressant drugs. You hear these advertised on TV all the time now. Those are the two big categories of the types of pain. With treatment, you usually end up with a neuropathic type of pain because all you’ve got to do to damage the nerve is to cut it, and that in and of itself caused neuropathic pain. That took a long time to get through to surgeons. They had the tendency to say, “Wait a minute. I know what nerve that is. I’ll just cut that.” And they’d cut it, and then the patient would have neuropathic pain. Their pain was worse than it was before, so you don’t see them doing that much anymore. So it can be due to the tumor per se, due to the treatment, and then the third type is unrelated to both. That’s pain for anything else. A diabetic can have a diabetic neuropathy. A rheumatoid arthritis patient can have it, joint pain secondary. A patient who has had a back injury can have back pain, all that, so there are three general categories. We saw all of that, and so we were very reluctant to say or call it cancer pain because pain is pain. We would say it’s pain in the cancer patient. Basically, we saw all kinds of pain. Another type of neuropathic pain is pain that’s seen in shingles and so-called postherpetic neuropathy that can be a chronic pain. Because of the depression of the immune system in cancer patients with cancer therapy, you often get increased incidence of shingles in those patients. We saw all the different kinds of pain.
Tacey Ann Rosolowski, PhD:
Now, when did you begin to realize that you had to do something about this in an institutional way and in a research way?
C. Stratton Hill, MD:
Well, I don’t know that I looked at it as I had to do something about it. It was that I thought that we needed to just look at the problem, see what it is, try to define it. And when I looked at it from my own standpoint, about my own knowledge, even when I was up there with Dr. Houde at Memorial, it wasn’t broken down into these different categories. We didn’t quite do it that way at that time, I think mainly because cancer patients didn’t live long enough, so you didn’t have a chance to look at the cancer patient very long. The first thing I noticed was the fact that patients would come in, and they would simply not be given enough medication. That was related to what was in the literature about what the usual doses were for severe pain, but those studies were done in acute pain that was self-limiting, so nobody had any notion about tritrating a dose of pain medication to an effective level, and that would be relief of pain. And so one thing that I developed was what we call the morphine test. I would simply put a little butterfly needle into a vein and give patients medication until their pain went away. It seemed to be pretty simple to me. However, there were some people who didn’t get complete relief, so I realized that my knowledge about pain was deficient in this regard. So we started doing that on practically every person that we saw because it gave us some idea about what dose of medication that we were going to prescribe for the person that was an outpatient. In other words, if we know that if you’re going to use morphine, the difference between giving the patient oral morphine as opposed to parenteral, like we were giving into the vein—that there’s about a three to one ratio. You’ve got to give three times more orally than you do intravenously because of the first-pass effect through the liver. Oral medication has to be absorbed. It goes into the portal vein and goes through the liver before it gets to the binding sites where the action takes place, so you have to give the patient enough to know that after it passes through the liver, the dose is adequate to relieve. So if you had to give them 10 mg of morphine intravenously to relieve their pain, and that would last about four hours for immediate release morphine, then to get 10 mg into the veins systemically you had to give them 30 mg orally. Then you would prescribe that. If you had to give them 20 mg intravenously to relieve the pain, then you’d have to give them 60 mg orally.
Tacey Ann Rosolowski, PhD:
I have another question. In terms of the management of pain—I mean—there certainly is the immediate benefit of relief to the patient and just their experience of their own—the relief of suffering. Is there something about pain management that actually helps—or how does the pain management help their long-term healing and survival? Is there a mechanism in there?
C. Stratton Hill, MD:
Oh, God, have you got a couple of weeks? (laughs)
Tacey Ann Rosolowski, PhD:
I imagine you’ll have to boil it down, but I’d love to hear some of the ways.
C. Stratton Hill, MD:
Well, one of the guys that is a contributor to this book, Dr. [John] Liebeskind, he was a fantastic guy. [Redacted] but he wrote—and there’s a library out in—I think it’s at UCLA. He wrote an article, an editorial, one time, “Pain Kills.” Actually, he was a psychologist, but he was very much of an experimental psychologist, and in mice he showed that when you created a painful stimuli in a mouse, that if you injected cancer cells into the vein of a mouse, the ones that— Say, for instance, you ligate a nerve to cause the pain, so the animal had chronic pain. They had a lot more metastasis in the lungs, or a lot more of those cells grew in the lungs, in those animals who had that painful condition, chronic painful condition, than the ones who did not have that. Now, granted, that’s an animal experiment, but there had been some studies done whereby they’ve looked at some patients. But it was very difficult to do this—to get it controlled where you can see in a human whether or not a person who has chronic pain has more metastases than a patient who does not have. But that’s the short answer to your question is that there is evidence to indicate that lack of control of pain makes whatever condition you’ve got worse, cancer or any other condition. Chronic back pain due to motor vehicle accident or anything like that, patients just don’t do as well because of probably a lot to do with the psychological effect that causes change in the immune system so that you’re susceptible to a lot more things or vulnerable to a lot more things than you would be otherwise. That’s the short answer, yes, that failure to control the pain will cause the condition to be worse. I think there have been some hospice studies done where they’ve looked at patients whose pain is well controlled. They seem to have done better than the ones—they live longer, with a fairly decent quality of life, too, because just quantitative differences in how long you survive is not really what you’re looking for. It’s the qualitative—what quality of life do you have in that period of time?
Recommended Citation
Hill, C. Stratton Jr. MD and Rosolowski, Tacey A. PhD, "Chapter 08: Understanding the Problem of Pain Management in the 70s and 80s –at MD Anderson and Beyond" (2012). Interview Chapters. 1047.
https://openworks.mdanderson.org/mchv_interviewchapters/1047
Conditions Governing Access
Redacted
