Managing pain requires multi-pronged approach

So what can be done? As we’ve been hearing, pain is experienced by many different people in many different ways. This makes treatment options a case of tailoring what might work best for you and what you’re experiencing - but even then there are many people for whom we just don’t have the answers. Alan Fayaz…

Alan - For acute pain, you've injured yourself or we've injured you, you've had an operation, you've had surgery or something like that, pharmacological measures are actually quite effective. So you've got simple painkillers, things like paracetamol and anti-inflammatory, these are things that you can quite often buy yourself over the counter. And especially when you use some combination, they're usually quite effective at reducing inflammation, which is the main driver of acute pain. And then you've got, when the pain is stronger, you've got stronger things like opioids, which if I must emphasise for acute pain, are very effective. When that pain becomes what we call dysfunctional chronic pain, those painkillers are far less effective often because it's no longer inflammation that is driving the pain, it's some form of dysfunction of the nervous system. Somewhere along that pathway, from the foot to the spinal cord to the brain, there is some signalling error going on. And no matter what happens at the foot, if you take that thorn away and you've calmed it down and sat down and rested and relaxed, for some reason that message is still firing off in the spinal cord and going up to the brain. Or the brain is not functioning as it should do by saying, listen, we don't want to hear anymore, calm it down. So something goes wrong and it's probably more of a nervous system or a processing problem. So we tend to veer away from the medicines that we use for acute pain and tend to veer a little bit more towards medicines that rationally might calm down the nervous system. Things like antiepileptic, pregabalin, gabapentin, antidepressants, amitriptyline, and duloxetine. But actually the evidence for these treatments and most types of chronic pain isn't fantastic.

Chris - Many people also say the side effects are really horrible.

Alan - Let's take the best evidence for these treatments which would be in a subset of chronic pain patients who've got neuropathic pain. So if we think about 44% of the population have got chronic pain, only about 10% of the population have got chronic neuropathic pain. And that's where these nerve pain killing drugs, if you like, work best. But even in those populations, you'd need to treat between four and seven people for one person to report notably improved pain. And that won't necessarily last for life because the body develops tolerance to it. And as you say, somewhere in the region of one in three people will report significant side effects from these drugs with their use. Drowsiness, dizziness, sedation, disorientation, and the most common thing is weight gain.

Chris - Given that really the message coming through loud and clear here is that chronic pain is not amenable easily to reaching for a packet of pills like a headache, a short-term headache is, given the prominent role that you pointed out for an emotional component, do things like homoeopathy or reflexology or even acupuncture, is there an evidence base for those kind of interventions?

Alan - There is an issue with evidence and pain, which is that it's very, very difficult to get good evidence for anything in pain medicine. This is partly because pain is so hard to define. When you look at things that produce blood pressure, you've got a definitive endpoint, you've got a number on a machine that's fairly reliable that you can print and you can measure and you can compare from one day to the next. Pain is entirely subjective. So it is the report of the patient and, as we've said, it's so contingent on not just the lifetime that they've experienced, but that moment they're in. So day-to-day, the context that they're in and how they feel. So being able to filter all of that stuff out and look at one individual factor, like one tablet or one drug, or one spinal injection, or one needling technique or homoeopathy, is notoriously difficult. And what you'll find is that a lot of the data is weak, and doesn't really support an intervention across this very large population of pain patients. So acupuncture isn't going to work for the 44% of patients who've got chronic pain, but actually there is probably a subset of patients with a specific type of pain for whom acupuncture is remarkably effective.

Chris:
So is it reasonable then for a patient who comes to see you to have an expectation that you're going to have to try a few things and it's going to be a bit of a suck it and see approach to work out what works best for them and it's going to be a range of things which are going to be behavioural changes, some psychological things, but also possibly some packets of pills, but there is no magic bullet. Is that a reasonable summary?

Alan:
Yeah, I think so. I'm a firm believer we're at an age, in a day, where patients have resourced information. They come informed and that's helpful. I like to share decision making with a patient, discussing the various options. But part of that is accepting that just because something has worked for somebody else, it doesn't necessarily mean it's going to work for you. And it doesn't necessarily mean it's going to be appropriate to be offered to you. Let's try and break down what we think is the main driver of your pain. If we can, treat that accordingly, but look at the big picture as well.