This morning I was dragged from my paperwork by a very excited colleague. He wanted me to see with him a patient I had sent for a trial of a new treatment. Before I go further, I’d like to give you a bit of background about this patient.
Paul suffered a workplace injury eight years ago that was pretty awful. He was trapped for some time under a large oxygen cylinder which had fallen on him. He escaped relatively uninjured apart from some bruising around his chest wall and an area of intense burning pain between his shoulder blades. Understandably, he was psychologically traumatised by the ordeal, not helped by being the object of a very public tirade of abuse which occurred a couple of weeks later when his soon-to-be-ex employer spotted Paul in the main street of the small town where they both lived.
Numerous interventional procedures, medication trials and hundreds of hours of psychology sessions later, Paul remained out of work and although he could get by passably well on a good day, the burning pain in the middle of his back persisted essentially unchanged. During this time, his family went through disclosures of sexual abuse, life-threatening illnesses and major financial hardship caused by Paul’s ongoing inability to find an employer willing to take on a late middle-aged man with a work-related bad back.
It was not only his prospective and former employers who discriminated against him. He was surveilled by private detectives on a number of occasions and accused in court of malingering. During the time he was on high-dose opioid patches, he was regularly accused by locum GPs of being a drug addict. His regular GP had known him before the accident and could see, as I did, that he was doing his best through some very difficult times. A few years ago, he stopped using medications and undertook an intensive CBT-based pain program which certainly helped him become a capable self-manager of his pain. The injections we had done were capable of giving him new complete relief for a few hours at a time due to the effect of the local anaesthetic. Our shared frustration was not being able to manufacture even a modest reduction in the intensity and unpleasantness of the pain to allow him to use his self-management skills to much better effect.
Having sat through some presentations about the new generation of neuromodulation devices (implantable electrical stimulators) at conferences, I raised the possibility of a trial with Paul a few months ago. We had previously discussed such things but Paul was worried about the invasive nature of the treatment, and I did not feel the evidence warranted much optimism for the sort of pain that he had.
Instead of simply aiming to scramble pain signals in the spinal cord like first-generation devices, modalities such as high-frequency and burst stimulation aim to feed misinformation into the nervous system to affect pain processing upstream in the brain. They are some of the first fruits of the blossoming of pain research in the last 20 years.
My colleague ushered me with a barely concealed smirk of satisfaction into his office where Paul stood like a man transformed. Gone was the haunted, hunted look I had become very familiar with. He had driven an hour and a half to the appointment and was barely in any discomfort. He reported knowing that his pain was still there but more like a dull ache than a savage howling in his head. For the last two weeks, he had been able to dial the stimulation up or down as the situation demanded, and for the first time in eight years he felt in control of his pain. He had energy, optimism and contentment I had not seen in him the whole eight years I have been his doctor.
Paul’s wife, who has stood by him with dignity and love through the ordeals and innumerable petty humiliations of those years simply thanked us quietly for giving her her husband back.
Unfortunately for Paul, his trial leads will come out today and he will need to go back to coping as best he can until the implantation is arranged. I dearly hope when he is implanted that he will go on to take his place among the legion of inconspicuous triumphs generated by good scientific medicine.
Smarter treatments, rigorously evaluated and then introduced sustainably into practice with care and compassion are what the medical profession does at its best. Although not at all cheap, the cost-effectiveness argument for these implantable devices is overwhelming. Getting a single taxpayer back in the workforce pays for the implant within a couple of years in saved costs, including future pension costs and extra superannuation savings. Even if you can’t get everyone economically productive, shouldn’t freedom from needless pain be a universal right?
The effect of new technology intelligently applied on the lives of those who live with pain and their families can be priceless.
Note : Paul is clearly not his real name, and his medical history is used with his permission