Though pain was once considered a consequence of a pathology, the medical profession now recognises it as a separate problem that requires specific treatment.
According to a study by Pain Alliance, around 20% of the European population suffers from chronic pain, whether in the form of back pain, neurological pain or pain caused by cancer, that decreases the quality of their daily life. This problem is so widespread in fact that pain is now considered a disease requiring its own treatment plan.
There is an increasing number of medical centres dedicated to pain management. These facilities employ a multi-disciplinary approach that uses medicine, physical therapy and complementary therapies such as acupuncture and hypnosis. Despite the progress made in the past few years, the effectiveness of treatment remains limited in some cases, in particular because pain is a complex mechanism that is experienced subjectively.
Even thinking about pain as an individual experience represents a change. “After a painful stimulus occurs in the body, the brain interprets the signal based on past experiences, the context of the situation, the person’s mood as well as their culture and education,” explains Yolande Kottelat, director of the Institutional Pain Programme at the Lausanne University Hospital, which was created in 2007.
“Our role as professionals is to legitimise this subjectivity and offer personalised strategies.”
Nowadays, the universal definition of pain (see inset) also includes an emotional dimension that is just as important as the sensory aspect.
As a result, suffering is difficult to objectify. However, this isn’t the goal. “We accept that each person has a different experience of pain, even if we don’t always understand why,” says Marc Suter, an associate physician with the Pain Treatment Centre at the Lausanne University Hospital. “Useless suffering is unacceptable.” Even though patients are listened to more closely, the therapeutic tools that are currently available are sometimes not enough. “Chronic pain, especially neuropathic pain, is particularly resistant to known treatments.” As for results obtained through research, their clinical application remains unsatisfactory.
“As much as possible, we encourage the patient to provide us with a maximum amount of information about their pain starting from day one of their treatment,” says Yolande Kottelat. To do this, various evaluation tools have been developed, starting with verbal, visual and numeric scales ranging from 0 to 10. More recently, doctors have started using diagrams that help patients pinpoint their pain and a survey that lets them provide qualitative, sensory (burning, radiating, etc.), and emotional (worrying, all-consuming, etc.) information. For patients who cannot communicate, the observation of clinical signs, such as cardiac frequency, pupil dilation and a behavioural scale can be used.
In the case of chronic pain, healthcare professionals agree that a treatment’s effectiveness can be evaluated by looking at its impact on quality of life, and not just on the patient’s level of suffering. Anxiety, depression and quality of life scores are systematically analysed and patients’ perception of pain in their day-to-day lives is taken into account as a whole.
“The patient can be caught up in a vicious circle. Anxiety, stress and the lack of sleep increase pain and vice-versa.”
The result is a challenging ordeal – nearly half of all patients with depression are in pain and up to 40% of people with chronic pain go through periods of depression. “It’s critical to provide the patient with relief as soon as possible to avoid a cascade of adverse effects.” Indeed, another risk is prolonging the hospitalisation of patients who are recovering from surgery.
Up to 10% of patients develop a debilitating pain after surgery. To diminish post-operative pain, special pumps allow patients to self-administer morphine or local anaesthesia intravenously. For the past few years, ultrasound can be used to place a catheter or inject anesthetic medication much more precisely.
There are other tools to reduce acute or persistent pain in addition to drug therapy and psychotherapy or physiotherapy. Targeted injections, acupuncture, relaxation therapies (yoga or meditation) and electric neurostimulation are also effective tools against pain. Patients who practise hypnosis are able to better manage their pain and receive less medication. In addition to these non-exclusive treatments, the therapeutic relationship is crucial. When this relationship is positive, the body and mind react well to the medical act in itself. It is one of the components of the famous placebo effect.
Nevertheless, pain medicine is at the top of the list of the treatment protocol and is adjusted based on ranges of intensity established by the World Health Organization (WHO). Some antidepressants and antiepileptics, adjuvants commonly prescribed to treat neuropathic pain, decrease pain by 50% in only one out of every three patients according to a study by doctors from the International Association for the Study of Pain (IASP). However, these medications have a lower risk of addiction than opioids. Moreover, few truly innovative pain medicines have been invented in the past 15 years. “We need new medication targets and better prevention,” says Marc Suter.
The “Dolografie” project was created last year by two Bern-native graphic artists to help patients express their pain when words aren’t enough. It’s made up of a set of 34 cards, each of which illustrates a feeling.
Every year, the International Association for the Study of Pain (IASP) launches a global campaign against pain. In 2017, the organisation focused its attention on post-operative pain, which affects all surgical patients. More generally, pain management has become a holistic field of medicine that takes into account the overall well-being of the patient. “We are on the right path,” says Yolande Kottelat. “We are trying to expand our therapeutic arsenal while still maintaining a customised approach for each patient.” The 2018 theme of the IASP campaign is pain education. This implies better training of caregivers and patients, but also informing policy makers and decision-makers of the need to further improve pain management and to continue research to better understand it.
Pain comes in various forms and intensity levels, and lasts for different amounts of time. Many definitions have been developed, but there is actually a universal definition of pain. The International Association for the Study of Pain (IASP) defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
Acute pain is a symptom caused by a potentially harmful stimulus. It is considered useful because it alerts the body to the danger of a potential or real injury or any other pathological process. By treating this type of pain immediately and aggressively, such as after an operation, the risks of it developing into a chronic condition are reduced.
Pain is considered chronic when it lasts longer than three months. It can be inflammatory (as a result of osteoarthritis, for example) or neuropathic (due to a nerve lesion). Neuropathic pain is the hardest to treat because it responds relatively poorly to even powerful pain treatments. In these situations, certain antidepressants and anti-epileptics can be administered. Chronic pain affects around a fifth of the population and seriously deteriorates the quality of life of the people suffering from it. The 11th Revision of the International Classification of Diseases, which is scheduled to be published in May 2018, lists chronic pain as a diagnosis for the first time.
