Painkillers - do we really need them?

Dr Bernard Lee

Although chronic pain makes life miserable for millions of people worldwide, only a small percentage are referred to the proper specialists.

This does not mean other doctors are not able to treat pain effectively, but diagnosing the cause and designing a treatment to suit a specific patient proves to be very complex. Unlike for a patient's temperature and blood pressure, doctors do not keep a chart on pain.

Chronic pain, especially, remains the biggest challenge because it is less well understood than acute pain.

In severe cases, physicians might resort to prescribing addictive narcotic-based painkillers, antidepressants or even local nerve-block injections (with varying results), which makes this a challenging and tedious task if a physician is not well trained in pain management.

Pain experts have divided the physical causes of pain into two types: nociceptive and neuropathic pain.

Nociceptive pain refers to the discomfort that results when a stimulus causes tissue damage to the muscles, bones, skin or internal organs. When most people think of pain, they think of nociceptive pain. Nociceptors themselves are the nerve endings that exist throughout the body (but outside of the spinal cord) to detect any kind of stimuli. They signal tissue irritation, impending injury or actual injury. When activated, they transmit pain signals to the brain. The pain is typically well localized and usually causes people to experience sensations they describe as achy, sharp, stinging and throbbing.

"Nociceptive pain is usually time-limited, meaning when the tissue damage heals, the pain typically resolves *with the notable exception of inflammation caused by arthritis*," says Dr. Bernard Lee Mun Kam, founder and director of the Pacific Pain Care Center in Singapore.

Common causes of nociceptive pain include sprains, bone fractures, burns, bruises, inflammation (from an infection or arthritic disorder), obstructions and myofascial pain (which may indicate abnormal muscle stresses).

In the process of diagnosing nociceptive pain, doctors will ask patients about their medical histories, as well as their experience with their identifiable symptoms.

Since nociceptive pain results from an outside stimulus and is typically localized to the affected area, doctors can usually diagnose it after performing a thorough physical exam and conducting some imaging tests (such as X-rays, CT scans and/or MRIs).

Because nociceptive pain subsides once the body has had the proper time to heal the damaged tissues, most cases of this pain are highly treatable. In general, treatment for nociceptive pain revolves around taking medication, including:

* Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or acetaminoph.

* Opioids.

* Tri-cyclic antidepressants. (Because these medications are less effective against short-term acute pain and can have significant side effects, doctors tend to use them as a last resort when prescribing medication for the treatment of nociceptive pain).

To promote faster healing, doctors may also recommend that patients undergo physical therapy or try alternative treatments, such as acupuncture.

While nociceptive pain is essentially a healthy response to tissue damage, much of chronic pain is considered neuropathic - the result of inappropriate nerve signals. It is described as "burning", "electric", "tingling", and "shooting" in nature. It can be continuous or paroxysmal in presentation.

In this setting, pain signals no longer represent an alarm about ongoing or impending injury but instead the alarm system itself is malfunctioning.

Neuropathic pain is the result of an injury or malfunction in the peripheral or central nervous system. The pain is often triggered by an injury, but this injury may or may not involve actual damage to the nervous system. Nerves can be infiltrated or compressed by tumors, strangulated by scar tissue, or inflamed by infection.

Lee cites examples of neuropathic pain, which include post-stroke pain, components of cancer pain, diabetic pain and phantom limb pain following an amputation, multiple sclerosis and alcoholism, among others.

He notes that with neuropathic pain, the function of the nerves becomes compromised and nerve activity increases. Left unchecked, this activity causes other nerves to become ultra-sensitive and the intensity of the pain can be so extreme that patients will do almost anything to get rid of it.

"I've had patients removing half their teeth because they didn't understand where the pain was. These episodes can be so distressing that patients will turn depressed and their whole life gets turned upside down," says Dr. Lee.

As a pain expert, Dr. Lee has helped many suffers get their lives back. Diagnosing the cause and designing a treatment varies from one patient to the other.

"For some patients, a minimally invasive surgery that includes laser injection into the nerve and taking medication to help change the nerve function to keep it from firing could be enough. For others, a morphine device called SynchroMed could be necessary. Normally, we need to do extensive tests before deciding on the best solution," he continues.

When a patient is in such agony, his or her condition would deteriorate at a much faster rate. When a patient cannot move about in bed, the risk of life-threatening blood clots increases. When they hurt too much to cough after chest surgery, the risk of pneumonia jumps, and the list goes on.

"If you are unsure whether you have a neuropathic condition, it's best to consult a doctor. You don't have to live with the pain but you must get the right treatment and the right drug," Dr. Lee says.

Among cancer specialists, pediatric surgeons and many other doctors, the tough-it-out attitude toward pain is changing. Worries about the psychological and physical risks of using large doses of narcotic-related drugs have largely been proven unfounded.

Technological advances have enhanced the efficacy and safety of analgesics. And, perhaps most important in an era of cost cutting, doctors have learned that not only is pain management humane, but it also speeds up recovery and saves money.

c FlyFreeForHealth2009

Articles in this column, which appears every two weeks, are provided by a panel of doctors from www.flyfreeforhealth.com, a leading multimedia medical tourism platform dedicated to providing adopters of healthy lifestyle with travel and lifestyle incentive. The doctors include Dr. Bernard Lee, director for Interventional Pain Management Services at the Singapore Pain Care Center. Join FlyFreeForHealth's online seminar for free, titled "Fertility Management", by SMSing your email address to +65 98473224. Hurry, limited space! Email us at info@flyfreeforhealth.com.