Reilly, Richard L. Living with Pain: A New Approach to the Management of Chronic Pain, Published by Deaconess Press, a service of Fairview Riverside Medical Center, a Division of Fairview Hospital and Healthcare Services. 2450 Riverside Avenue South. Minneapolis, MN 55454, first printing April 1993, reprinted in the United States of America 1994, 1995, 1996, 1997, 274 pages, $9.95 USA and $11.95 Canada soft cover.

Reviewed by Mitchell A. Kaplan Ph.D., CPSP, Beth Israel Medical Center New York City.

Dr. Richard L Reilly is a board certified osteopath and addiction medicine specialist who has devoted more than 20 years of his professional career to the development of aftercare programs for chronic pain patients with a medical history of drug and alcohol use. Dr Reilly’s latest book Living with Pain: A New Approach to the Management of Chronic Pain represents the application of medical knowledge and clinical skills that he has acquired over two decades of working with chronic pain patients addicted to prescription drugs and alcohol and their families. Dr. Reilly estimates that about 10% of patients receiving treatment for chronic pain in the United States are addicted to prescription drugs such as tranquilizers and sleeping pills. One of Dr Reilly’s most significant accomplishments has been the establishment of three major inpatient chronic pain management units at two major hospitals that specialize in aftercare treatment for pain patients with chemical dependency. Based on the self-help principles of alcoholic’s anonymous, narcotics anonymous, overeaters anonymous and other similar addiction support groups, Dr Reilly’s 12-step program provides patients with chronic pain with an inexpensive aftercare alternative to more traditional forms of addiction treatment.

Dr Reilly’s book is divided into two main volumes. Volume one entitled Problems and Solutions gives health care professionals an in depth comprehensive overview of the complex dynamics of chronic pain disorders and the impact these conditions have on the lives of pain patients. In the first two chapters of volume one Dr Reilly defines the difference between chronic and acute forms of pain. He also describes the physiological and psychosocial, processes that contribute to the manifestation of pain disorders.

Later chapters of the volume focus on a discussion of the interconnected analogues similarities between the major psychosocial characteristics associated with persons with chronic pain and those who are addicted to drugs and alcohol. Some of the key characteristics of the chronic pain sufferer, which the author describes, include loss of control, preoccupation with pain and continued misuse of pain medication despite possible adverse consequences of harmful addiction. Reilly argues that unchecked, chronic pain can have a major negative impact on all aspects of an individual’s home, work, and social life. He points out that like the drug addict and alcoholic patients who suffer from benign intractable pain have a strong need for behavioral change. Reilly believes that the majority of pain patients recognize that their lives are on an out-of-control downward spiral of self destruction and that they need to make some concrete lifestyle changes in order to alter this path.

He contends that most pain patients see themselves as victims of an unalterable fate that they are powerless to change. He also contends that the first step in the process of change is for pain patients to learn to cope with their situation by taking more active responsibility for the magnitude of their suffering because most will never be entirely pain free even with treatment intervention. In addition to psychosocial characteristics, Reilly also discusses the role that genetic cultural and environmental factors play in influencing patient perceptions of their pain.

The remaining chapters of volume one present patients and professionals with a detailed, descriptive survey of the various medical procedures, pharmacological and psychological, used to treat chronic pain. Topics discussed include surgical interventions, nerve blocks, analgesic drug therapies, physical exercise, hypnosis, muscle relaxation techniques, guided imagery, individual psychotherapy, group therapy, and the role of the family environment in the pain management process. The author also discusses the criteria that pain centers utilize to select patients for admission to their pain management programs.

Volume two of Reilly’s book called Chronic Pain Anonymous reviews the basic relationship between the corresponding psychosocial characteristics of chronic pain patients and patients addicted drugs and alcohol. Reilly points out that like the drug addict most patients with chronic pain who enter treatment at a rehabilitation center are addicted to variety of narcotics and alcohol and need to go through withdrawal before they can begin the recovery process that will put their lives back on track. Reilly states that most pain management treatment facilities have chronic pain anonymous self help support groups set up to help patients cope with the specific problems associated with living with chronic pain. The remainder of volume two gives a detailed description of the components of the twelve steps and traditions that underlie the philosophical foundations of pain management recovery programs.

From the perspective of this reviewer, Living with Pain: A New Approach to the Management of Chronic Pain is an excellent book that should be on the reading list of university and medical school faculty teaching courses that train physicians and other health care providers who want to understand the complex inner world of the patient with chronic pain. The book would also make an extremely useful educational resource for health care professionals who work in community based facilities that provide treatment and aftercare services to chronic pain patients and their families.

"The Station Agent"

Tom McCarthy, Writer and Director. Starring Peter Dinklage, Patricia Clarkson, Bobby Cannavale, and Michelle Williams. Released October 2003, Distributed by Miramax Films. Running time: 88 minutes.

Reviewed by Beth Haller, Towson University

This is the type of "disability" film that should win the Academy Award for Best Picture and Best Actor. Although disability is central to film, it is a subtle undertone and doesn’t hit the audience over the head with "inspiration" or tears. It shows a person with a disability with a quiet strength, who influences those around him, just as they influence him. All the characters learn that isolation is the true "disabling condition" for both non-disabled and disabled people.

Another significant contribution of the film is focusing on attitudinal barriers (although it may not know that’s what it was doing). The main character, Finbar McBride, played by Peter Dinklage, is a little person who stands about 4 feet, 5 inches tall. Although under the American with Disabilities Act, he is considered disabled, he has few architectural or communication barriers to deal with — only attitudinal barriers. He stoically endures the stares and comments about his size. In fact, it is these negative attitudes that drive the plot of the movie.

Fin has a tolerable life working with his best friend, Henry Styles (played by Paul Benjamin), at Styles’ train-themed hobby shop in Hoboken, N.J. He and Henry, an older African American man, have a strong bond, and Henry truly understands the attitudes that Fin has to endure. They also share a love of trains and railroads. Theirs is train knowledge that reaches the level of intellectual, unlike the "train geeks" whom they must endure at frequent train chasing (people who videotape trains by driving beside them or while riding on them) movie events at the hobby shop. During the movie, Fin and Henry sneak off to the roof to chat, smoke, and watch the real train activities at the local station.

But early in the film, Henry drops dead in the hobby shop. This sets into motion the major journey for Fin. In his will, Henry left Fin an abandoned train station in an isolated part of western New Jersey. Fin sees this as an opportunity to escape from a world that doesn’t seem to accept him. He walks (yes, walks) to western New Jersey on the train tracks that he knows so well. His plan appears to be to hold up in the train station by himself. His only activities are walking the tracks, train watching, or reading about trains.

However, a few of the people who populate the tiny town where his train station is located have other ideas. Joe, played by Bobby Cannavale, is the first to intrude upon Fin’s solitude, and he never lets up. Joe runs his father’s food truck outside the train station. He’s bored out of his mind and pours all of his energy into making friends with Fin. In a unique twist on the typical "friend of the disabled person" role, Joe is so focused on building a friendship he barely notices Fin’s size. In several scenes, the film plays tricks on the audience, making them believe Joe is about to make a comment about Fin’s height, and then instead Joe asks an innocuous question about trains. It’s a nice effect because it causes the audience members to examine their own thoughts about Fin’s size.

Another townsperson who bonds with Fin is Olivia, played by Patricia Clarkson. They get off to a rocky start after Olivia runs Fin off the road with her car a few times. Olivia is a local artist who is still in grief over the death of her son and is estranged from her husband. In her own isolation and loneliness, she reaches out to Fin, who at first barely tolerates her intrusion. Gradually, however, he begins to care about her and her problems.

The three build a relationship and in the sweet humor of the film find themselves conforming to Fin’s single-minded interest in trains. They watch the trains together, walk the tracks, and even do a bit of train chasing, thanks to a video camera from Olivia. But, as happens with any friendship, tensions arise: when Olivia’s husband drops by after Joe and Fin have slept over at her house, or when Joe says he will meet Fin at the local bar and never arrives. Fin, who never wanted friends in the first place, comes to a turning point in which he has to decide whether total isolation is really what he wants.

Peter Dinklage as Fin does a brilliant acting job. For much of the first half of the movie, he only has a few lines but he conveys so much more of Fin’s story through his face and eyes. It’s wonderful to see an actor so good that the audience can actually read his mind when he doesn’t speak. One can only hope that more movies will be written for Dinklage as star because he is most deserving. He is no newcomer to drama, having worked in the New York theater scene for a number of years and having been in eight other films. Dinklage was scheduled to appear in the Lincoln Center production "Toulouse Lautrec" in 2003.

The entire cast does a fantastic job. Cannavale exudes a kind of electricity with his mouth that never stops talking, and Clarkson gives her character a nuanced depth so we know her pain, but her continued activities seem believable.

Two other smaller roles play off Fin’s isolation quest as well. Michelle Williams of TV’s "Dawson’s Creek" plays the town library clerk who has some troubles of her own and sees that beneath Fin’s silence is someone caring and vulnerable. Raven Goodwin plays Cleo, an elementary school girl who is interested in trains, and pursues Fin’s friendship so he will speak to her class for "show and tell."

In the end, it is Cleo who provides the catalyst for Fin to face the negative attitudes from which he has tried to isolate himself. Through something as simple as an elementary school show and tell, Fin learns that facing attitudinal barriers is the only way for them to fall. And all the characters learn that meaningful friendships are better than isolation, with or without a disability.