Translate

Wednesday 5 March 2014

On pain, brains and drugs. And Vultures

Your standard GP struggles to treat pain.  I think it would be hard to find a GP who did not agree with that statement to some extent.  That's because pain isn't a thing.  It is lots of things.

For a start pain can be chronic or acute.  Or in some cases chronic acute.  The treatments for these are different, for complex reasons.

For another thing, pain is not what people think.  Or rather thinking plays a big part.  Because pain is not nociception.

Nociception is the nerve stimulus, the signal that tells the nervous system that Bad Thing Happen.  This is then processed into pain, which is the feeling.  Feeling is a good word for it because there is a strong emotional component there.  Now you may think that this is the same stuff, because the feeling arises from a signal.

Well no.  the same stimulus will give you different amounts of pain depending on mental state.  How you feel mentally affects how much pain you feel.  Bigtime.

Painkillers work in many different ways but they focus , for the most part, on the nociception end of pain.  Reducing the signal.  This is particularly true of the NSAIDS which don't do very much else.  It is also true of the opiates to a degree.  However some of the opiates have other effects which cross over into emotionsville, particularly Tramadol and Buprenorphine.  Tramadol has a lot of cross activity which makes it act very much like an SNRI antidepressant such as venlafaxine.  Buprenorphine plays with the kappa opioid receptor, which has effects on the emotional processing of pain.

Any drug based therapy for pain will have limitations because it is trying to fix a moving problem.  the same amount of stimulus feels different on different days, so the same amount of drug may not cope.  It may be fair to say that breakthrough pain is emotional in origin. So for long term use its best to have an emotional therapy as well as a pharmaceutical one. However despite limitations drug based therapies are probably the best we have, showing the strongest results.

Drugs do have limitations.  In the context here addiction is not one of them.  Dependence yes, addiction no.  Study after study has shown that when you are using the drugs for actual pain then addictive behaviour is unlikely.  Dependence and habituation are likely, and are difficulties with drug treatment.  Pain management programs can help a lot, but it depends who runs them and how they are run.  The intent should be to give the patient their life back by any means.  Anecdote alert but I have several friends whose experience of these programs is that all they are interested in is getting you off drugs.  never mind if you suffer, never mind if the result of this is that you have to spend all day every day thinking about your pain to manage it, drugs are bad mmkay.  This is what happens when ideology enters medicine.

A well run pain program should focus on reducing drugs where that can be doen without impacting quality of life.  Its main focus should be reduction of pain.

So we have an imperfect world, with no real answer to pain, just some strategies to make it a bit better.  Enter the vultures.

Its hard to talk about pain without someone bringing up some of the tired old bollocks beloved of the worried well.  You know, homeopathy, chiropractic, acupuncture, reiki, having your underpants chanted over, that sort of thing.  The people offering this are, in my honest opinion, either idiots or vultures.  Idiots in that in the face of all reliable evidence they believe this witchcraft works or vultures in that they know it doesn't but still prey on the desperate.  In the case of Ehlers Danlos even the support organisations have this stuff.  The HMSA in the UK has form here  where they say magnet plasters help some people.  Well yes, if your pain is being caused by iron filings, or by having geographically puzzled pigeons migrating into you.  But if its real this is just a distraction.  The Ehlers Danlos National Foundation in the US suggests in this tome that acupuncture or acupressure may help despite increasing evidence that its simply being in the room with someone who appears to care that reduces pain as acupuncture , sham acupuncture and placebo acupuncture ( synonyms) have the same effect.

Essentially selling hope to the hopeless makes you rich.  It also makes you pond slime.

No comments:

Post a Comment