"The War on Pain."

Show: FRESH AIR
Date: JANUARY 24, 2000
Time: 12:00
Tran: 012401np.217
Type: FEATURE
Head: John Irving Discusses `The Cider House Rules' and Its Adaptation Into a Movie
Sect: Entertainment
Time: 12:06

This is a rush transcript. This copy may not
be in its final form and may be updated.

TERRY GROSS, HOST: From WHYY in Philadelphia, I'm Terry Gross with FRESH AIR.

On today's FRESH AIR, John Irving talks about adapting his novel "The Cider House Rules" into a movie, and why it took 13 years. Irving's novels "The World According to Garp" and "The Hotel New Hampshire" were also made into films, but he didn't write the screenplays.

Also we talk about pain and new techniques for treating it with Dr. Scott Fishman, author of "The War on Pain" and chief of the division of pain medicine at the University of California-Davis.

That's all coming up on FRESH AIR.

First, the news.

(NEWS BREAK)

GROSS: This is FRESH AIR. I'm Terry Gross.

When John Irving decided to adapt his novel "The Cider House Rules" into a movie, he never expected it would take 13 years. His new memoir, "My Movie Business," is about those 13 years and what he learned about the differences between writing books and movies.

He didn't write the screenplays for the earlier adaptations of his novels "The World According to Garp" and "The Hotel New Hampshire."

The movie version of "The Cider House Rules" is set in the 1940s. it stars Michael Caine as Dr. Larch, who runs an orphanage where he also delivers the unwanted babies of women, babies who will remain at the orphanage. And he performs abortions.

His apprentice and surrogate son, played by Tobey Maguire, is a young man who grew up in the orphanage and has learned how to deliver babies but won't perform abortions.

Here's a scene with Caine and Maguire early in the film.

(BEGIN AUDIO CLIP, "THE CIDER HOUSE RULES")

MICHAEL CAINE, ACTOR: First pregnancy?

TOBEY MAGUIRE, ACTOR: Yes, for both.

CAINE: I presume you'd prefer handling the delivery.

MAGUIRE: All I said was I don't want to perform abortions. I have no argument with you performing them.

CAINE: You know how to help these women. How could you not feel obligation to help them when they can't get help anywhere else?

MAGUIRE: One, it's illegal. Two, I didn't ask how to do it. You just showed me.

CAINE: What else could I have shown you? The only thing I can teach you is what I know. In any life, you have to be of use.

(END AUDIO CLIP)

GROSS: "The Cider House Rules" was inspired in part by John Irving's grandfather, Dr. Frederick C. Irving, an obstetrician who graduated from Harvard Medical School in 1910.

JOHN IRVING, "THE CIDER HOUSE RULES": He was the chief of staff of the Boston Lying-In, which was the country's foremost maternity hospital. He was a professor of obstetrics at Harvard. I know him better through his writing, through his several books on obstetrical and gynecological procedure, than I ever knew him as a kid. I can't recall, in fact, a single intimate conversation with him. He died Christmas Eve when I was 15.

So it's through his writing that he made a principal and powerful influence on me. For reasons that are still unclear to me, I was 14 at the time I felt certain that I wanted to be a writer. It was about the time I started reading Charles Dickens, my earliest fictional hero. And I told my parents I wanted to be a writer when I grew up. And they said, "Oh, you should read your grandfather's books, and he's a writer."

I'm not sure that obstetrical and gynecological procedure was entirely suitable for a 14-year-old, but...

GROSS: What was it like for you at the age of 14 to be...

IRVING: Riveting.

GROSS: Were there illustrations of...

IRVING: It was riveting.

GROSS: ... gynecological surgery and of childbirth and things like that?

IRVING: No, no. No illustrations, except for the fact that he wrote very descriptive, if Victorian, prose. And I think I learned more about human reproduction from those books than I probably learned in school for -- well, maybe ever.

GROSS: Do you think that reading your grandfather's Victorian language in describing medical procedures affected the way you thought about the body or later wrote about the body?

IRVING: That's a good question, but I've not thought of it before. I don't know so much that I was affected in that way as that the life of a doctor of medicine at that time, and an obstetrician/gynecologist in particular, was one that I could imagine in full detail, so that in the early 1980s when I began research for a novel about an orphanage physician and his relationship with an unadoptable orphan who was born in his orphanage and who is unsuccessfully -- repeatedly unsuccessfully -- adopted, I had already in mind the kind of detail that I was looking for, the kind of detail that I would find.

The surprise, of course, was the abortion subject, because I hadn't set out to write a novel or, in the case of the film of "The Cider House Rules," a screenplay that was on or about the abortion subject. It was the relationship of that old physician and orphanage director and this unadoptable kid that I had foremost in mind.

But when I began to read the histories of abortion and the histories of orphanage hospitals and the lives of orphanage physicians, that procedure, and the life of an orphanage hospital, was inseparable, of course, understandably, because if any physician, qualified physician, would take the risk, in those days when that procedure was illegal, if any physician would take that risk and perform that procedure, who else but someone who had the sympathy for the condition of those women who came there and left children behind?

And more importantly -- or just as important -- the fact that many of those orphans would not be adopted. The older they got, the less likely it was that anyone would take them, and they would eventually become what at the time was called wards of the state. That made a powerful impression on me, and I decided that the issue of performing that procedure or not performing it would become a crucial area of conflict between the young orphan, whom the old physician apprentices, whom he trains to be a doctor, that that would be a point of contention between them.

Not that the orphan would ever disapprove of the old doctor of performing abortions, nor would that orphan believe that women shouldn't have the right to have an abortion if they wanted one. It's just that he didn't want to perform the procedure himself. That is the argument of the story. It is by no means the current political so-called right to life or pro-choice argument. The novel and the film of "The Cider House Rules" is unequivocally pro-choice.

GROSS: Now, you say that you were working on the screenplay over a 13-year period, and you worked with four different directors. The first director who you wanted to work with on "The Cider House Rules" passed away. What about the other two directors who were going to direct it before the final director, Lasse Hallstrom? Why didn't things work out?

IRVING: Well, I think that I got to know Wayne Wang, the director that I first tried to work with, after Philip Borsos' (ph) death, I got to know Wayne so little, we spent so little time together, and we seemed so immediately divided on where the story should go or what the principal story should be, that I can't really tell you why that relationship didn't work, except that it was clear from the beginning that I was listening more to the producer's notes on the script, Richard Gladstein's notes on the script, than I was to the would-be director's.

And both Richard and I felt that if the writer's paying more attention to the producer than to the director, if the writer and the producer are seeing the story more eye-to-eye than the writer and the director, well, that wasn't just a good match. And Wayne had the grace and the intelligence to see that, I think, before I did. I mean, he very politely and -- said that he just didn't think this was going to work out, and he was right.

GROSS: And the third director was?

IRVING: Michael Winterbottom. I loved Michael's film of the Thomas Hardy novel, "Jude." I thought that film was sensational, especially as a low-budget film, as it was. The performance he got out of Kate Winslet was amazing. The faithfulness to that novel was just indelible to me. I was very, very impressed. I was impressed that he could do period. I was impressed that he could do sort of sympathy for children, all the things that seemed to me to be integral or essential to making "The Cider House Rules."

I thought he'd be a good choice. But Michael felt that the romance between the young orphan, Homer, and the girlfriend of the young flyer who first brings the girl to the orphanage for an abortion and then goes off to the war, he felt that that romance was much more central to the story and more important to the story than Richard and I felt it ever should be. We felt that it was important to keep that love story a love affair, to keep it in perspective to the whole.

It is one-third of the story of "The Cider House Rules," but compared to the relationship between Dr. Larch and his beloved orphan, Homer, and the relationship between Mr. Rose, the black migrant apple-picker and his daughter, Rose Rose, and what that relationship precipitates in Homer, we felt that the love story between Homer and Candy was the small third of the three parts of the story.

Winterbottom didn't agree.

GROSS: My guest is novelist and screenwriter John Irving. We'll talk more after a break.

This is FRESH AIR.

(BREAK)

GROSS: My guest is John Irving. His new memoir, "My Movie Business," is about adapting his novel, "The Cider House Rules," into a movie.

You created a compressed version of the story of "The Cider House Rules" for the screenplay, and you say the passage of time is so important in your novels, but that's not easily captured in a film. Can you talk a little bit about the difference in how time elapses in a novel as compared to on the screen?

IRVING: I felt it was essential in taking a long novel and bringing it down to film size -- and remember, this is a two-hour and five-minute film, short by today's standards. I see a lot of films today that I might have liked if there were a half an hour shorter. I felt it was essential that we not indulge the length and the complexity of the material that's in the novel, and give ourselves some justification to making a three-hour movie.

I don't like three-hour movies. I didn't want to see a three-hour movie. I wanted to see a movie that was even a little short by conventional standards. I think that just works better with an audience.

So the first decisions, the most radical decisions, were, what were you going to lose? Who are the characters and their attendant story lines that had to come out of the story whole? Because I feel strongly that if you can't honestly say that a character has the same emotional effect on an audience that that character had on readers, that character shouldn't be in the story to begin with. If you're only going to marginalize that character's emotional effect, lose the character.

Those were essential choices, and, well, painful ones. But the most radical decisions of what to cut out of "The Cider House Rules" were made before I'd collaborated with the first of these four directors. They were made when I wrote the first draft of the screenplay. I made them myself.

GROSS: Is pruning your own novel to make a screenplay a little bit like performing surgery on yourself? You know, that you're too close to it?

IRVING: No, I don't think so. I think it's a matter of how wholeheartedly or not you believe in the potential of the novel to be a film in the first place. In some of -- in some cases, I look at my novels, and I just don't see the potential film that's there. Or if I do, it seems too much of a compromise at the outset, and I'm not interested in it.

The thing about "The Cider House Rules" that made it instantly attractive to me as a potential film, almost from the moment the novel was finished, is that unlike all of my novels, or unlike most of the others of my novels -- it was the sixth, I've written nine, I'm finishing a 10th -- but it alone has the symmetry that only a journey away from home which ends up back in the same place can have.

And symmetry is very gratifying in films. It's very gratifying. And it had, another words, a structure that was instantly visual to me at the outset. I could see that orphan coming back to that orphanage. That was always the end of the story. And I could see it in film terms.

I believed in its possibility as a film, which is why I wanted to be involved not only as a screenwriter but to have approval of the director, to have approval of the cast, to ensure that the director had approval of final cut, all those things that writers aren't generally afforded, and which, in the case of other novels of mine made into films, I really haven't been concerned enough to ask.

GROSS: I think often when a viewer, a movie viewer, has read the book before seeing the movie, they really resent some of the changes that the movie's made, if a character's life is condensed, if the story is condensed, they feel, you know, that the movie has, like, cheated the novel. From your experience, I mean, you realize that there are changes that have to be made in order to accommodate the larger story of the novel into the short amount of time that's covered by -- you know, the short amount of time in the movie theater.

You write a little bit about Dr. Larch, the doctor at the orphanage, and how you had to kind of pare down some of the characteristics that you'd given him for the book. How did you decide how to change his character, you know, how to alter it for the movie?

IRVING: I didn't change his character or alter it for the movie. Your first way of putting it is the best. I did tone him down. Lasse additionally toned him down, and brilliantly, I thought. Michael Caine, who played Dr. Larch, also toned the doctor down. In the case of Larch, his dialogue, what he says, is of such a polemical and didactic nature, he's such a moral tyrant in the life of this young orphan -- he's right, of course, but he's a tyrant nonetheless -- we thought it was essential that we not deviate in the film from what he says in the book. And the truth is that every line of dialogue or voice-over Larch speaks in the film is from some text in the novel.

The difference is that the Larch of the novel is a shouter. He's a brow-beater. He's a moral bully. And Michael played him much softer, as if he were much more tired out. Your sense of the doctor's ether addiction and its ongoing effect on him, I think, is greater in the film even than it was in the novel. And that's what I would call a soft choice. And I think it was a wise one.

I'm happy to see the screenplay being praised as much as it is, but I think that many of Lasse's choices as a director and many of Michael's choices as an actor have made me look better.

GROSS: Did adapting your novel, "The Cider House Rules," into a screenplay lead you to reconsider any of your opinions of your movies that were adapted by other screenwriters?

IRVING: No. I liked those films. I liked George Roy Hill's "The World According to Garp." I liked Tony Richardson's "The Hotel New Hampshire." I just felt detached from them. I liked Mark Steven Johnson's "Simon Birch," as it was called. I simply didn't think it was close enough to the novel to be called "A Prayer for Owen Meany" or to use the names of my characters. And Mark and I were in agreement about that from the moment I read his screenplay. I just felt it was too divergent from my novel to use my novel's titles or the names of my characters.

Contrary to everything I've read, wherein I'm described as alternately despising the film or whatever, I liked "Simon Birch." I just didn't think it should be called "A Prayer for Owen Meany," and it wasn't.

GROSS: In the 13 years that it took to actually get "The Cider House Rules" to the screen, did you lose interest? Did you ever feel, I'm just really sick of this?

IRVING: No, you don't lose interest in an experiment as long as you don't change your mind. The experiment was -- I've seen films of my novels made other ways, namely by letting them go. Let's see if I don't let one go, how long it takes, and if it'll ever get made. I was prepared at the outset that the film would never be made. But I knew that if it were ever made, it would be made with my approval.

And so that was the game. If somebody had told me at the beginning it was going to take 14 years, I might not have been so eager to play the game. But once you start, I don't think you can back out. I mean, you've got to be faithful to something and follow through on it. And however long it takes, I intend to do the same thing with "The Son of the Circus."

GROSS: When you're on a plane or a train, and you see a passenger reading one of your books, do you introduce yourself?

IRVING: No. No, I kind of hope I won't be recognized. I wouldn't want to interrupt them from reading the book. They're much better served to be reading the book than they are to be having a conversation with me.

GROSS: Say they're just carrying the book, and they're not reading it at the moment. You see them. Wouldn't say anything?

IRVING: Well, that would make me cross, yes.

GROSS: (laughs)

IRVING: I would think, What are you doing instead of reading this book? I did see -- I had the misfortune once of seeing a woman on a plane, back from Los Angeles, actually, I was traveling with my eldest son, and a woman across the aisle, diagonally across the aisle, was reading "The World According to Garp." And at some point she closed the book and stuffed it into the airsickness bag in the little envelope in the seat in front of her and never took it out again.

And my son was dying to draw her attention to the fact that the man who had offended her so was sitting right across the aisle. So we had a very tense trip all the way to New York. But I was never identified as the culprit who had written the offending passage. Whichever one it is that made her close the book, I'll never know. But it was a highlight, I'll never forget it.

GROSS: Well, John Irving, I want to thank you very much for talking with us.

IRVING: Thank you.

GROSS: John Irving's new memoir, "My Movie Business," is about adapting his novel, "The Cider House Rules," into a movie.

I'm Terry Gross and this is FRESH AIR.

(BREAK)

GROSS: Coming up, diagnosing and treating pain. We talk with Dr. Scott Fishman about new pain medications and how they work. Fishman is the author of the new book, "The War on Pain."

(BREAK)

TO PURCHASE AN AUDIOTAPE OF THIS PIECE, PLEASE CALL 877-21FRESH
Dateline: Terry Gross, Philadelphia
Guest: John Irving
High: Prize-winning author John Irving has turned his novel "The Cider House Rules" into a movie. Irving writes about "The Cider House Rules" and the process of turning it into a screenplay in "My Movie Business: A Memoir." Irving is the author of nine novels, including "The World According to Garp," "A Prayer for Owen Meany," and "Hotel New Hampshire."
Spec: Movie Industry; Art; Entertainment

Please note, this is not the final feed of record
Copy: Content and programming copyright 2000 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 2000 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: John Irving Discusses `The Cider House Rules' and Its Adaptation Into a Movie

This is a rush transcript. This copy may not be in its final form and may be updated.

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross. Pain is often more than just the physical hurt. It can create fear and emotional suffering. My guest, Dr. Scott Fishman, is the author of a new book about the latest techniques for treating pain, called "The War on Pain." Dr. Fishman is the chief of the division of pain medicine at the University of California-Davis. He's the former director of the Massachusetts General Hospital Pain Center. I asked him (inaudible), what is pain? DR. SCOTT FISHMAN, "THE WAR ON PAIN": That's the very heart of why we have pain specialists, because pain is almost impossible to define. We've been trying to define it for thousands of years, and those of us who specialize in treating pain have come to be understanding that pain is ultimately what the patient says it is. That's the guiding definition that most of us follow.

GROSS: What does that mean, and how is that useful?

FISHMAN: Well, it means that when somebody comes to me or goes to another physician or complains of pain in general, we believe them. And I always assume that someone is suffering from something. The problem with pain is that it's intrinsically subjective. And when one person says they have pain, they may have a completely different experience than another person who says they have pain, even though they may say their pain is just as severe. So when someone complains of pain, it may mean that they are feeling a sharp stabbing sensation, whereas another person might mean that they're missing a loved one.

GROSS: What function does physical pain serve?

FISHMAN: Physical pain has an important function, and life is not of very high quality if we don't have the pain system, because the pain system serves as our alarm. It's our sensor to the outside world that tells us that we have impending danger or have been harmed. And it gives us an advantage of being able to potentially react and preclude any further damage or avoid damage from happening to us. So if we are getting close to a stove, we may feel a burning sensation, we may pull back, and that's why we all have that kind of a reflex. If we didn't have our pain sensors or pain nerves, and there are actually people who are born genetically without pain sensors, they tend to have really serious injuries because they're not able to modulate the world around them. And they get burned, they get injured, they wind up actually losing limbs sometimes. Life is not a comfortable place without a pain alarm. The problem is when that alarm gets overtriggered and then loses its purpose.

GROSS: Chronic pain. FISHMAN: Either chronic pain or pain that has -- even, in fact, the pain of childbirth. Now, some people might argue that that does have a purpose. But for someone who is in the midst of severe suffering, the -- I would argue that the pain of childbirth has really potentially lost its evolutionary role, in that in primitive times, the pain of childbirth would force you to stop what you're doing and take heed to the event that's occurring. In modern times, we're already taking heed, and we're controlling the situation so further suffering may be interpreted as unnecessary. And I think there are many women in the world who would testify that turning that alarm off at that time is a real blessing.

GROSS: Now, a lot of common pain is caused by inflammation. Why do pain and inflammation go hand in hand?

FISHMAN: Well, because inflammation -- pain occurs at the time of injury or impending injury. And when injury occurs, the healing process is enlisted. And that healing -- the first step of that healing process is inflammation. Inflammation is really the biological phenomena of rushing in all the different kinds of cells that we need to not only start healing but continue to protect an area. So for example, if one were to bump their elbow, the elbow might swell if it was a severe enough bump. And that swelling would serve to do a bunch of different things. One would be to start the healing process in case blood vessels were broken or tissues were damaged, and it would do so by bringing in white cells that would fight off bacteria, and other what we would call inflammatory mediators. The secondary function's going to be to sensitize the tissues so that that elbow might remain sore. And the purpose of the elbow remaining sore is that the threshold for it to elicit pain is decreased. And anybody knows this intuitively, that when we have an injury, we tend to protect it. And that protection is the purpose of the link between inflammation and pain.

GROSS: There's some inflammation that isn't helpful at all, like arthritis.

FISHMAN: With arthritis you have an underlying process of joints being constantly injured by the disease of arthritis. Typically in osteoarthritis, it's an inflammatory process, and that process is stimulating the normal system to ring out its alarm, because damage is occurring. And so we try to treat arthritis by two different mechanisms. One is to reduce the inflammation and treat the pain by that mechanism. But now the -- a very promising way to treat the pain is to treat the underlying disease and slow down that process of inflammation. So there are now new medications that really go at the heart of arthritis and are slowing down the actual effects on the joints before the pain occurs.

GROSS: What drugs are those?

FISHMAN: Well, there are numerous drugs. I won't go into detail on them with their names, but there are different drugs that decrease the cell turnover that occur in the joints themselves.

GROSS: There's a new class of anti-inflammatories that operate differently than, say, aspirin or ibuprofen. And we've seen advertisements for a lot of these all the time on TV, Celebrex and Vioxx are two of these new anti-inflammatories. What are they, and how are they different from drugs like Tylenol and Advil and Motrin?

FISHMAN: Well, I'll start off answering that by talking about the more standard drugs, like ibuprofen, aspirin, and Tylenol. These are drugs that have been exquisitely successfully used for managing all sorts of pain by consumers around the world, and all you need to do is walk through the analgesic section of any drugstore to see how many choices there are in these -- this different class of drugs. They're thought to be very safe, and they're safe enough to be over the counter. However, even these drugs, when used in too high doses or for too long a period of time, can have serious side effects, and even side effects that can be life-threatening. The big side effects for drugs like aspirin or ibuprofen is that they cause ulcers and they cause bleeding problems. And that has been what has been addressed with this new class of drug, which is very much like an ibuprofen-type drug or an Advil-type drug, without the propensity to cause ulcers or bleeding problems.

GROSS: So how do they function in your body? Maybe you could give us a layman's explanation of how they manage to reduce the swelling without causing the ulcers.

FISHMAN: Well, the -- CO2 refers to the cycle oxygenase type II enzyme. Enzymes are mediators of reactions in the body. And what these drugs do is, they block the enzyme, the enzymes required for the process of inflammation, as well as generation of pain. So when we block the enzyme, we can help block pain. The problem is that the enzyme does other things other than causing pain. And in the stomach and on the platelets within the blood, the enzyme has a vital role of protecting the stomach and in maintaining our ability to clot our blood. So when we go to block the enzyme, either in the spinal cord or in the elbow or wherever we're feeling our pain, we simultaneously block it in the stomach and in the blood when we use medicines like ibuprofen. The safety factor for the COx2 inhibitors, and what's really brilliant about these drugs, is that the developers were able to find out that the enzyme in the stomach and in the blood is slightly different than the one that main -- modulate -- may be involved with inflammation and with pain. So they've been able to select out just that enzyme, so that the new drugs only block the enzymes that we think are involved with pain and don't block the enzymes in the stomach or the blood, thus allowing for normal stomach function and normal bleeding function. The problem with them is that the enzyme that's involved with pain and inflammation is also an enzyme that is in the kidney, so it's something that we watch chronically, any of these drugs, including ibuprofen, aspirin, or the new COx2 products like Vioxx or Celebrex can cause some problems with the kidneys long term. So it's something that we watch closely.

GROSS: These new anti-inflammatories are very new. How much do we know about the long-term effects? How much do we know about what the side effects are if you're using it for chronic pain?

FISHMAN: Well, we -- it's a good question. With any of these new drugs, we really don't have a long historical view of what they do. But they do appear to be safe, and they've undergone very, very rigorous testing, initially in animals, and then in humans. And the FDA really puts them through their paces to make sure that they're safe. So they look pretty safe. But as your question implies, you never know until they're time tested.

GROSS: And what are they mostly being prescribed for?

FISHMAN: Well, they're being prescribed for a lot of different things, primarily for arthritis kind of pain. But we're now using them for all kinds of chronic pains across the board, from pain that's related to different tissue damages to pain that's related to nerve damage. We're using them in any patient that really has a high risk of either ulcer formation or particularly bleeding problems.

GROSS: My guest is pain specialist Dr. Scott Fishman, author of the new book, "The War on Pain." We'll talk more after a break. This is FRESH AIR.

(BREAK)

GROSS: If you're just joining us, my guest is Dr. Scott Fishman. He's chief of the division of pain medicine at the University of California at Davis and is the author of the new book, "The War on Pain." Why is chronic pain often so difficult to treat?

FISHMAN: Well, the problem with chronic pain, as I said before, it's pain that has lost its real purpose. It's the alarm system gone awry, and it's pain that has lasted beyond a reasonable period of healing. The problem with that is that it doesn't make sense, and it's not serving a purpose. So it's essentially a problem in the body that's become intractable. And as we said before about the definition of pain being so difficult to define for every individual, over time pain has different meanings for different people. You can't have pain without a mind, so it's always a mind-body phenomenon. And because of that, it becomes very individualized. It's hard to have cookie-cutter solutions. And it requires really looking at people's bodies and their minds and their lives.

GROSS: Well, we'll get to the mind and pain some more in a bit. You describe lower back pain as being particularly problematic, and for anybody who's had lower back pain, they know that's true. (laughs) Why is lower back pain very difficult to treat?

FISHMAN: Well, you know, low back -- if you look at the statistics on low back pain, it's hard to treat, but for most of us it comes and goes and isn't a big problem in our lives. For others of us, low back pain can become intractable and can really limit our ability to get on with our lives, if not enjoy our lives. It's difficult to treat back pain because we've not understood it in its entirety, and we probably don't understand it completely now, but we understand it better than ever. In fact, now when someone has an acute flareup of low back pain, we no longer send them directly to bed. We know that it's best for them to do the activities that they can do that don't cause pain without ceasing their function. And we also make sure that they don't overdo it as well, because they can further injure their back. So we don't throw people also into aggressive physical therapy any more. So we're coming to understand the balance of how the body heals once the back has become inflamed or otherwise irritated. The back has a multitude of different reasons to cause pain, which really reflects the incredible organ that the spine is. The spine does an amazing job in terms of being able to make our bodies flexible and move with ease despite carrying an enormous amount of weight on it, and force. So as we get older, the back starts to wear. And as it wears, the pain signals, the pain fibers, are triggered. And for most of us, we're able to manage that. But for some of us, that wear and tear causes pain that just doesn't stop. And for those kinds of patients, we take what we call a regional approach, where we look at the spine and look at the areas that can cause the pain. And kind of like a Columbo-type medical detective, we step by step look for these, the common suspects, rule out those who aren't involved, and go after the nerves that might be involved and help target treatments that go right to the point of pain. These are treatments like epidural injections or nerve root injections or other kinds of joint injections in the back that either use steroids to block inflammation and pain, or local anesthetics to turn off the nerves that may be inflamed. There's something about turning the signal off that allows the body to heal, and we really try to rely on that as much as we can.

GROSS: Well, I know for some people who have back pain, they have these little -- like, little vibrators put on their back, and it's -- it kind of, like, goes back and forth on your back, just kind of, like, tapping it a lot is my understanding. And is the goal of that to distract you from the other pain?

FISHMAN: Well, this is something called Tenz (ph). It's a Tenz unit. And essentially it delivers a little bit of an electrical shock to the skin. It's probably -- we don't know exactly how it works, and it doesn't work for everybody. But for some, they feel that it makes an enormous amount of difference. And what it does is, it provides a bit of sensation to the nervous system that is not necessarily noxious or painful, but that signal, when it reaches the spinal cord, can crowd out the pain signal that's coming in. And this is probably no different than what we're doing with products like Icy Hot or Ben-Gay, something that I would call a counterirritant, which substitutes a sensation that is bearable for one that isn't bearable. It's based on the idea that the central nervous system or the spine can only take so much sensation in at once. And if you crowd it with sensations that are bearable, the ones that aren't won't get through. This is probably also the reason why, if you bang your shoulder, even before you know your shoulder's banged, your arm may go to it, and you may be rubbing your skin. Or when you cut yourself, you may want to touch the skin, and that makes it feel better. This is a very interesting area for us, because there's a new technology that we're using that takes us one step further, or one step, really, inward. It's a technology called spinal cord stimulation, where we take a very fine filament and place it just like an epidural catheter, really the same way that we place an epidural catheter for temporary pain relief for a pregnant woman, into the spinal cord area, in an area called the epidural space. And we deliver a tiny little charge just like the one that we would use on the skin. But this is directly at the level of the spinal cord. It's barely perceptible for the patient, but it's enough to crowd out the pain. And this has become a very, very successful technique for treating chronic low back pain or chronic pains in other areas of the body for certain conditions.

GROSS: My guest is Dr. Scott Fishman, and he's written a new book called "The War on Pain." Let's take a short break here, and then we'll talk some more. This is FRESH AIR.

(BREAK)

GROSS: If you're just joining us, my guest is Dr. Scott Fishman. He's chief of the division of pain medicine at the University of California at Davis, and the author of the new book "The War on Pain." You say in your book that some patients say, Don't try to dismiss my pain by saying the pain is in my mind, I really feel this. But you point out that pain is in your mind, that it's the mind that processes the reaction that we describe as pain. Therefore, are you more optimistic about ways of using mind-body therapy to deal with pain?

FISHMAN: Well, I would say my patients' worst fear and probably their worst fear when they see any of their doctors is that their doctor is going to tell them that their pain is all in their mind. And the problem with that is the misconception that if we consider the mind, we're implying to the patient that they're somehow a crock, or we don't believe them. Well, as I would argue just the opposite, that as you mention, you can't have pain without a mind. If we're going to treat the most difficult problems with chronic pain, we're not going to be successful unless we consider the full entity of the pain, and that always includes the mind. I'm not suggesting that everyone with pain needs psychotherapy or psychological intervention. In fact, many patients do not, and I'm able to very successfully treat pain with just physical modalities. But when pain exceeds those kinds of treatments, I think it always requires looking at it in what I would call a holistic manner, in terms of that interface between the mind and body, to look at all of the factors that may be impacting pain. So...

GROSS: Have you worked with treatments like acupuncture, hypnosis, biofeedback, relaxation techniques, to deal with pain?

FISHMAN: We have, and I have, and we continue to in our program and many other wonderful programs throughout the country. The issue with the mind and body is that each of us, I think, knows from watching television and other experiences that people have done incredible things with their mind in terms of blocking pain. We've all seen athletes who have played the end of a championship game with a broken leg, mothers who have lifted cars off of children, and people who have done superhuman Ironman triathlons by psyching themselves out. And what that implies is that intrinsically, we have enormous pain-relieving properties that we can harness. And that's what our therapies try to do. The opposite is also true, that our intrinsic properties can also magnify pain and make pain worse, particularly when pain has become chronic and is around for a long time. It's kind of like the stereo being turned up louder and louder. And what we try to do is turn that volume down using our own intrinsic healing processes that have been exceptionally well harnessed through modalities like hypnosis and biofeedback, guided imagery, meditation. We really don't know how therapies like acupuncture work, but acupuncture appears to be exceptionally safe. So when the therapy appears to be effective and is safe, while I would like to know how it works, that's not a requirement for using it. So we also use therapies like acupuncture for these cases.

GROSS: Are there any of these alternative therapies that you have found to be particularly effective in pain, or do you think it really depends on who the person is and what the pain is?

FISHMAN: Well, it depends on the person, and I think to be able to harness one's internal pain-relieving properties, you have to want to. And not everybody wants to. One of the problems is that patients often fear that if they do allow these psychological techniques to help them feel better, it will imply that they were a crock, or that it will mean on some level that their pain wasn't real. So they may be hesitant on some level to engage in them. I think anybody who's willing to can benefit from these therapies, because there's no question that we have a lot of control over how much we sense.

GROSS: What is the new thing on the horizon that you're most looking forward to now in pain relief?

FISHMAN: Well, there are too many new things to just pick out one. But there are many new receptor systems that have been discovered that are going to now help us much more specifically target pain treatments to exactly the nerves that we need the medicines to go to. There are better treatments that will have less side effects. There are treatments that will help us not use drugs but to use other things like these spinal cord stimulators. There are drug delivery systems that are going to allow us to give medications without using needles or injections. There are exciting therapies like inhaled morphine-type therapies, modalities that drive medicines right through the skin with an electrical charge so that one doesn't even have to take pills. All sorts of exciting therapies. And then there are -- there's very, very exciting work going on in terms of understanding how to undo the knot of chronic pain on patients' quality of life, in terms of psychological approaches. And this will really bear greatly on treatment successes in the future.

GROSS: Dr. Scott Fishman, thank you so much for talking with us.

FISHMAN: Thank you.

GROSS: Dr. Scott Fishman is the author of "The War on Pain" and chief of the division of pain medicine at the University of California-Davis.
FRESH AIR's executive producer is Danny Miller. Our engineer is Audrey Bentham. Dorothy Ferebee is our administrative assistant. Roberta Shorrock directs the show. I'm Terry Gross. We'll close with music from a new CD by composer and soprano saxophonist Phillip Johnston, who is, among other things, the co-founder of the Microscopic Septet, which performs our theme. This is the title track from his new CD, "The Merry Frolics of Satan."

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