The word “pain” comes from the Latin word poena which also means punishment. So there is nothing new in the association of these two ideas. The child is educated to a complicated system of values and behaviour which allows him to take his place in society. This is achieved primarily by the process of reward and punishment. Love and physical rewards are given for being good; and hostility and physical punishment for being bad. This is the learning process in its simplest form, and as a means of leading the child to acceptable behaviour it is very effective. However, the constant association of pain with punishment conditions us to lose sight of the biological

purpose of pain as a simple and helpful warning against injury. The child is constantly reminded of this association so that it persists into adult life. If in fact corporal punishment is not inflicted, the threat of it is usually still there, and even if it is not actually threatened it is referred to obliquely, “If you had been properly punished when you were younger, this would not have happened.” This is the child’s ordinary experience, so the two ideas, pain and punishment, become fused together in his mind.

*112\57\2*

Q. What about side effects? We seem to read about adverse conditions occurring from time to time. Are these serious?

A. I suppose every known drug has an adverse side effect on somebody somewhere. It is a fact of life. Why, even most foods can be found to disagree with somebody. Considering that by 1984 around 30 million patients are said to have been treated with cimetidine, the number of adverse side effects is surprisingly small. Certainly researchers will dig up a wide range of symptoms which are claimed to have been produced by cimetidine, but in the total picture, these are very small and probably of little consequence.

The same doctors will also point out that simple, old fashioned aspirin, which has been around for nearly 100 years, may cause allergy reactions, asthma, bleeding from the stomach and bowel, nausea and vomiting, diarrhoea, and many other symptoms. But this does not preclude it from being one of the most valuable and widely prescribed drugs of all time.

If adverse side effects occur, then appropriate steps can be taken at once. On the other hand, if they are minimal, then the benefits of treatment will often outweigh any problems.

Q. Are other drugs in this family available, or is cimetidine the only one?

A. In 1982, another drug called ranitidine became available in Australia. Like cimetidine, it is a product of original research in Britain. It is marginally different, works in a similar manner, is claimed to have certain benefits, as all new drugs claim. Time, however, will show if this is really the case. Some major British trials have indicated that it may be of special benefit in the few cases in which cimetidine therapy fails to work. No drug will be effective 100% of times and a related drug may prove effective, this appears to be the case with ranitidine. Another preparation is a drug called oxmetidine, which is also similar in activity. Yet another named omeprazole has also been developed. How these will compare to the others, time will tell. It has all been succinctly put by a Sydney gastro-enterologist who recently wrote in an Australian medical magazine: “It is difficult to envisage that these drugs will be any safer or more effective than cimetidine in equipotent dosage.”

Q. Can the patient still take other medication with cimetidine if necessary?

A. The most likely medication will be antacids, and this is often taken in the early days along with cimetidine. It does little more than reduce pain. As pain disappears, most will cease using antacids, but they may be taken if desired. Often the decision is left with the patient.

It is pointed out that the doctor will be careful in prescribing other non-ulcer type drugs in the event of high dosage levels being required. Sometimes, in severely ill patients, cimetidine is given by injection, either directly into the blood stream (intravenous) or the muscle (intramuscular injection). This helps it work more rapidly.

In ageing patients, when the liver and kidney are not working as efficiently as in younger days, the drug may further reduce their working efficiency, and drugs such as warfarin, phenytoin, theophylline, which go to the liver also, must be taken with care. Nevertheless, this is the doctor’s concern. He is well aware of these special circumstances in certain patients and will offer the appropriate advice.

*15\61\2*

Just because you’re referred to a surgeon does not necessarily mean that an operation will be performed or even suggested. Surgeons will invariably make their own assessment of what they think is best. Although surgeons as a group do tend to have a bias towards their own speciality, they do also recognise that an operation is not always the best nor only answer. It is not rare for someone who was referred to a surgeon to then later on be referred to yet another specialist because the surgeon concluded that this was a case where less intrusive treatment might work just as well.

If surgery remains indicated, there are numerous possible procedures with an excellent track record. However, it also has to be pointed out that every form of surgery carries its own set of risks.

The decision to undergo an operation should therefore always be weighed up most carefully.

To help you make up your own mind about having an operation if one is offered, The National Back Pain Association suggests a number of questions you should ask your surgeon, these including:

What is my exact diagnosis?

Do I have signs of nerve root compression? And are the symptoms that I have directly related to nerve compression?

What are my chances of good pain relief if I opt for a surgical intervention?

Are there any alternatives to conventional surgery that I could try?

How many of these procedures have you performed? What is your success rate for the surgery you have offered me?

What the NBPA is essentially saying through these suggestions is that any patient should make sure that the problem has been fully and accurately diagnosed, that an operation is likely to yield a good result, and that the surgeon is fully experienced in the intended procedure.

Additionally, the NBPA suggests that “the decision as to whether to have surgery and what type, is difficult, and needs very careful consideration. The only person who can really answer your questions about the effectiveness of surgery for your particular problem is your own surgeon. Ensure that you attend appointments well-prepared with your questions written down and, preferably, with someone else to listen to the response.

A similar message comes from the Agency for Health Care Policy and Research, a part of the Department of Health and Human Services in the USA, which somewhat more bluntly states:

Even having a lot of back pain does not by itself mean you need surgery.

Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.

People with certain nerve problems or conditions such as fractures or dislocations have the best chance of being helped by surgery. In most cases, however, decisions about surgery do not have to be made right away.

Most back surgery can wait for several weeks without making the condition worse.

If surgery is recommended, be sure to ask about the reason for the surgery and about the risks and benefits you might expect.

You may also want to get a second opinion.

*13\124\2*