Dr Kanika Gupta
‘Pain is a more terrible lord of mankind than even death itself”. These words by Albert Schweitzer underline the profound impact of pain on human existence. Pain is the most common reason people seek health care and is one of the leading causes of disability in the world. Often encountered within every household, it affects approximately one-third of the adult population in our country. Despite its prevalence Chronic pain is yet to be acknowledged as a significant public health concern.
The International Association for the Study of Pain defines Chronic Pain as pain that continues beyond the typical duration for tissue healing, typically exceeding three months. A wide array of common ailments is linked to chronic pain, including Cancer pain, degenerative spine conditions- low back pain and neck pain, osteoarthritis, fibromyalgia, migraines, diabetic neuropathy, and postherpetic neuralgia. Evolution of Pain In the initial phase, pain is usually seen in response to tissue injury and related inflammatory processes. Thus, this pain possesses a survival value and plays a role in healing. However, once the acute danger period has passed, the pain no longer becomes a necessity, but a burden. If not addressed, the pain has the potential to develop a more complex pathophysiology compared to the pain originating from the initial injury or ailment. These modifications may include both structural and functional changes within the nervous system, leading to a transformation where pain is no longer just a manifestation of the original cause, but rather evolves into a distinct and independent “Disease” in its own right. Effect of untreated pain In our country, many people continue to silently suffer from this condition without realising the serious consequences of untreated pain. This persistent pain condition not only poses substantial economic and societal burdens, but it also has far-reaching effects. It extends beyond being solely a physical and emotional challenge for the patient; it also impacts their family and social network. “Impact on Physical health – Patients suffering from persistent pain often experience diminished strength and decreased functional capability. Pain can have a detrimental impact on muscles, nerves, and joints. This can result in muscle weakening known as disuse atrophy, nerve malfunctions referred to as neuropathies, and the development of permanent tightening in muscles, tendons, ligaments, or skin, also known as contractures. “Impact on Mental health- Persistent pain has been linked to elevated occurrences of major depressive disorder, anxiety, suicidal thoughts, and efforts at self-harm. The occurrence of mental health disorders among people with chronic pain conditions varies from 33% to 46%. “Impact on Brain function and Sleep- Research reveals that pain also has a negative impact on cognitive abilities like memory, attention span and problem-solving skills. More than 50 % of patients suffering from chronic pain have disrupted sleep patterns. “Cardiovascular health- Frequently, experiencing pain raises the likelihood of developing hypertension. Moreover, individuals with a background of coronary heart disease face an elevated risk of cardiovascular morbidity due to this heightened pain-associated risk. “Financial strain- Pain imposes both direct and indirect financial burdens on patients. The direct costs encompass expenses related to medical investigations and medications, while the indirect costs involve diminished work performance and absenteeism, contributing to financial challenges. Thus, the consequences mentioned above, which include mental well-being, sleep pattern disruptions, strained personal relationships, and employment issues, collectively contribute to a decline in the overall quality of life. Therefore, addressing the symptom of pain becomes increasingly crucial. Assessment of Pain Assessment of the patient experiencing pain is the cornerstone of optimal pain management. This entails actively listening with empathy, acknowledging and validating the patient’s pain, and striving to comprehend, to the best extent possible, the nature of the patient’s experience. A self-report by the patient has traditionally been the mainstay of pain assessment. Many pain assessment tools exist to standardize the pain assessment and should be used according to the patient’s age and cognitive status. For adequate treatment of pain, it is important to realize that Pain is a subjective individual experience often influenced by genetic features as well as emotional, and psychological states. Pain thresholds have inter individual variations often related to past experiences with pain, cultural and social influences, and general health. Multi-Disciplinary Approach to pain management Pain management often requires collaboration between various healthcare professionals, including doctors, nurses, pharmacists, physical therapists, and psychologists. This multi-disciplinary approach ensures that all aspects of a patient’s pain are addressed comprehensively. Various treatment modalities that are available for the management of pain are: 1. Pharmacological treatment: In healthcare settings, pain is often managed using medications following the WHO analgesic ladder. For mild pain, options like acetaminophen and NSAIDs are used, while opioids are reserved for moderate to severe pain, especially in cancer patients. Adjuvants such as antidepressants, anticonvulsants, and muscle relaxants complement pain control. 2. Non-Pharmacological Techniques: Pain management encompasses more than just medication. Non-pharmacological methods are vital for pain control and encompass Cognitive behavioural therapy, physical therapy, massage, heat or cold therapy, relaxation techniques, distraction therapy, and music therapy. These techniques can either enhance medication-based approaches or serve as independent strategies for managing pain. 3. Interventional pain management: Interventional techniques have a definite role in pain management especially when it is refractory to medications. These minimally invasive methods include nerve block techniques, epidural injections, intra articular injections, and radio frequency ablation of targeted nerves which aim to halt ‘pain signals’ from reaching the brain via nerve signal disruption. Misconceptions about intervention risks often delay referrals. However, Ultrasound and X-ray-guided precise needle placement techniques easily mitigate these risks, enabling effective early control of intractable pain. 4. Advanced procedures- Progress in pain management encompasses a range of innovations, including the utilization of spinal cord stimulators, implantable intrathecal drug delivery systems, procedures for vertebral augmentation, and the implementation of regenerative therapies. Additionally, there’s a focus on enhancing non-invasive neuromodulation techniques like transcranial magnetic stimulation and transcranial direct current stimulation to achieve accurate and personalized pain alleviation. 4. Individualized Patient Care: Customizing pain management strategies according to the specific needs of each patient is imperative as pain tolerance and preferences for pain relief methods can differ among patients. Adopting a patient-centered approach ensures that chosen strategies align with each individual, promoting effective pain management. 5. Future advancements-Current research in advancements in drug delivery is focussed on developing innovative drug delivery systems, including nanotechnology and targeted delivery methods, to optimize the delivery of pain-relieving agents to precise pain sites. Gene therapy offers a promising approach to pain relief by utilizing both viral and non-viral carriers to alter the expression of certain genes determining pain threshold. Thus, pain is a complex and multifaceted phenomenon, leading to challenges in its effective management. It becomes crucial that the individuals suffering from pain should express and report the discomfort they are experiencing, making sure not to overlook or disregard it. The current demand is for a meticulous analysis of different pain types and sources, followed by a holistic treatment approach customized to individual needs. Recent progress in pharmacological therapies and the array of available interventional techniques may all be vital in addressing this complex disease that is affecting so many lives. “Endurance is admirable, but when it comes to pain, seeking relief is both wise and self-compassionate.”
(The author is Assistant Professor, Department of Anaesthesiology, All India Institute of Medical Sciences, Jammu and can be reached at Kanika.gupta@aiimsjammu.edu.in).