Recent advances and new challenges in managing pain
By Lesley Colvin
“The aim of the wise is not to secure pleasure, but to avoid pain.” –Aristotle
Pain is one of the most feared symptoms whether it is after surgery, in the context of chronic disease, or related to cancer. Around 18% of people will be affected by moderate to severe chronic pain at some point in their life, with chronic pain having as big a negative impact on quality of life as severe heart disease or a major mental health problem. Five years ago we dedicated a whole postgraduate issue to pain medicine, based on the inaugural meeting of the Faculty of Pain Medicine of the Royal College of Anaesthetists, London. As the number of patients suffering from chronic pain continues to increase, with our aging population and improved longevity, so does the need to improve our understanding and management of pain.
A first step in the successful management of any pain problem is proper assessment. The medical school teaching of “history and examination” underpins this in the clinical setting, and in the research setting, this is perhaps equally as important. It is widely acknowledged that what have appeared to be good animal models of different chronic pain syndromes have often failed to translate into clinical practice. Some of the reasons for this failure include how we might better align pain assessment in the laboratory with the clinical syndromes being studied. By only focussing on the sensory aspects of pain, the complexities of pain will be missed, and the dynamic interplay between mood, thoughts and sensations that help to define the pain experience will be lost. While there are limitations to laboratory models, they have delivered some successful treatments to the clinic: future success may be improved by a closer conversation between clinicians and scientists.
Irene Tracey‘s group in Oxford is world-leading in the use of neuroimaging techniques to advance our understanding of pain. We intuitively know that personality and expectation will influence our pain experience; it is fascinating to see how there are discrete neural mechanisms that explain this. The basis of the placebo response has been studied, with it becoming clear that this powerful tool may be used positively. What a bonus for economically stressed healthcare systems with restricted drug budgets if we can utilise the placebo response to minimise pain! The quote from Hippocrates — “It is more important to know what sort of person has a disease than to know what sort of disease a person has” — may apply very particularly to the management of pain.
For some time, it has been suspected by many that there are differences between men and women, with suspicion that they may even come from different planets on occasion (Mars or Venus?). There are myths and sometimes contradictory literature on the differences in pain sensitivity and response to analgesics between men and women. This area still remains somewhat murky, with a likely contribution from genetics, hormones, and psychosocial factors. The suggestion for sex-specific treatments in the future is interesting — perhaps “man flu” needs stronger drugs!
While clinical trial design may seem like a somewhat dry topic, those of us in clinical practice recognise the mismatch between what we see in day to day clinical practice the published literature: the potential of having missed what might be very effective treatments for particular subgroups of patients, or how complex analysis techniques may significantly over-estimate how effective a treatment is and skew the evidence base. Other topical areas include pain management in the elderly, challenges of cancer-treatment related pain, chronic pain after surgery, and the effect of opioids on the immune system. I hope for a stimulating update in the field of pain medicine and to emphasise the importance of ongoing close collaboration between multidisciplinary groups, from basic scientists, to epidemiologists, neuroimagers, and psychologists, in order to improve the lot of our patients and reduce the burden of suffering from poorly managed pain.
“When we are suddenly released from an acute absorbing bodily pain, our heart and senses leap out in new freedom; we think even the noise of streets harmonious, and are ready to hug the tradesman who is wrapping up our change.” –George Eliot
Lesley Colvin is the Editor of the British Journal of Anaesthesia (BJA). This year’s postgraduate issue of BJA is dedicated to the challenges that face anaesthetists, and the new advances that may help anaesthetists to improve the experience of patients who have the misfortune to suffer pain. When selecting the reviews for this issue, Dave Rowbotham (guest editor) and Lesley Colvin aimed to have a broad range of articles from exciting new basics science developments, through to the use of neuroimaging techniques to tease out the complexities of pain perception and its modulation, as well as broader societal aspects of pain and how we manage it. This issue also presents a first: a collaboration with the British Pain Society to publish an expert commentary alongside two of their new Pain Patient Pathways, on particularly challenging and common pain syndromes: low back pain and neuropathic pain. It is hoped that these clearly laid out pathways can be adapted for use in a variety of healthcare systems to improve management for these patients.
Founded in 1923, one year after the first anaesthetic journal was published by the International Anaesthesia Research Society, British Journal of Anaesthesia remains the oldest and largest independent journal of anaesthesia. It became the Journal of The College of Anaesthetists in 1990. The College was granted a Royal Charter in 1992. Since April 2013, the BJA has also been the official Journal of the College of Anaesthetists of Ireland and members of both colleges now have online and print access. Although there are links between BJA and both colleges, the Journal retains editorial independence.