Pain. When the Symptom Becomes a Disease.

Dimitris Papadopoulos MD Fellow Of Interventional Pain Practice (FIPP)

Updated 15 August, 2011

Reissue of interview with Mr Dimitris Papadopoulos in VITALITY magazine 22/1/2011

Mr Dimitris Papadopoulos is Pain Physician – Anaesthesiologist, Fellow of Interventional Pain Practice, Member of the World Institute of Pain (WIP), Head of the Interventional Pain Treatment Institute at the Interbalcan Medical Centre in Thessaloniki.

According to the American Academy of Pain Management, pain is a silent epidemic. Only in the U.S.A.,  50 million Americans suffer from chronic pain due to diseases, disorders and accidents.

Chronic pain has a major effect on the patient and his/her family.  It undermines quality of life, limits mental concentration, physical exercising, personal and social activities, sleep and rest. This condition leads to the frequently occurring phaenomenon today of depression. Depression is the most common reaction to chronic pain, while stress is the most common reaction to acute pain.

According to CHRONIC PAIN journal, patients with chronic pain have difficulty to find physicians who can treat their pain in a satisfactory way.

Relief of patients with subacute or chronic pain (of either neuropathic or non-neuropathic aetiology) needs a multi-factorial approach that is provided in specialised Pain Management Centers. In these centers, the patient suffering from chronic pain and its concomitant symptoms is treated in a holistic and integrated way combining pharmacotherapy, invasive techniques, psychological support, family support and physicotherapy.

1. What is the Pain Institute and what are its objectives?

The Pain Institute is the special Pain Management Center where patients suffering from subacute pain (lasting from six weeks to three months) and chronic pain (persisting for more than three months) should refer to in order to find specialised care and therapy. Also palliative treatment is provided in the Pain Institute for patients in the terminal stage of certain diseases.

There are Pain Management Centers that treat persisting pain by administering special pharmaceutical regimens with specialised modern invasive techniques.

The objective of the Pain Institute is to provide pain relief, improve quality of life of patients and their families and help them resume soon their activities.

2. Why are we in pain?

Acute pain is a sensation that is activated by the nervous system with the occurrence of an injury or impairment or some disease. It serves as a warning sign to remove the harmful factor and search for the pain aetiology. Thus, acute pain is useful, for it constitutes the protective alarm of the human organism.

However, when this alarm keeps on ringing continuously, it stops being useful; on the contrary, it becomes disturbing and has to cease. So, chronic pain may continue for weeks, months, years and persist longer than the usual period of time required for the healing of a lesion or/and treatment of a disease. In this case, the pain itself has become a disease that requires treatment, either aetiologic (identifying the aetiology and applying a directed therapy) or symptomatic (when the cause cannot be clearly identified despite the thorough investigation). Common cases of chronic pain are headache, low back pain, arthralgia, neuropathic pain and cancer pain.

3. Is there a case of being in real pain although there is no organic aetiology?

In several cases, someone may suffer from chronic pain without having identified a clear and evidence-based cause. Such examples of chronic pain syndromes are: various types of headache, phantom limb pain (the patient feels pain in the limb that does not actually exist since it has been amputated), chronic abdominal pain and others.

4. Can someone who suffers from chronic pain disorientate the physician leading him/her to wrong diagnosis?

This can happen in any patient visiting any physician of any specialty, as long as the physician, when taking the  medical history, is carried away by the patient’s poor description.

What actually happens very often is the opposite: a patient with chronic pain may end up to the Pain Institute after having first visited several physicians of various specialties without anyone having resolved the problem. In addition, the patient may have been wrongly labelled as “malade imaginaire” (“an imaginary patient”) and probably “mentally ill” with all the tragic consequences this may bring for his/her life, family and working environment. However, when coming to the Pain Institute, the patient is thoroughly examined by physicians having the special knowledge and experience of chronic pain syndromes and it is there proven that the patient was right in complaining of suffering and that s/he needs special therapy.

5. Is the pain threshold different from person to person?

The human body has nociceptive receptors which, when receiving stimulation of sufficient intensity, are activated transmitting the stimulus to the brain through the nervous system and translating it into pain of the respective area.

The lowest intensity of stimulation that is required for the activation of nociceptors is called “pain threshold” and differs from person to person. Besides empirical data, there is also evidence for genetical differences attributing to each one of us a different neurophysiological profile in how pain is perceived.

However, this threshold may change over even in the same person under certain conditions. Characteristic and impressive is the example with the Chinese water drop torture: the person to be tortured is immobilised while water is slowly dripping onto the same spot of his body for many hours. In the beginning, water dripping does not get above pain threshold. However, the continuous local stimulation ultimately exceeds pain threshold and the water drop causes more and more unbearable pain.

6. Are pain sensation and intensity of pain affected by gender and age? What other factors affect pain?

The subjective final evaluation of the degree of our pain and how unfortunate or weak we become, depends primarily on the prioritisation of our needs per case and on how much we focus our attention to the various pain stimuli.

It is well-known that even the most severe pain can be undertreated if at the same time there is priority for another action. For instance, in a war battle, a wounded person who struggles to survive, will not get immobilised due to pain alone. Under other circumstances, however, pain of the same intensity and type would be unbearable and would probably make the patient incapable of any action.

To these subjective parameters affecting pain perception and evaluation, we should also add other socioeconomic factors, such as cultural traditions and convictions, feeling of security in an environment, previous experiences, education, age, gender and race. These are only some of the numerous factors that may intermediate until the final expression of pain is formed in every individual patient.

7. Does chronic pain cause depression? Can depression cause chronic pain?

The issue of pain is composite and complex. There is clear interaction between somatic pain -on one hand- and psychological pain and overall mental mechanisms –on the other hand. In other words, chronic somatic pain may lead to a mental illness as psychological conflicts may be projected into somatic pain. Also, we see cases of individuals seeking mental catharsis through pursuing pain (self-flagellation of hermits), as well as the symbolic “mental pain investment” of some ceremonies of initiation to various cultures or sects.

8. Ιs there a pain measurement scale?

Objective evaluation of pain is not easy because it is based on subjective pain evaluation by the patient. Lassagna in 1960 made the following statement:“The physician who deals with pain is at the patient’s mercy! It all depends on the patient’s ability and willingness to communicate with the physician.” Various scales giving indications for the magnitude of pain (intensity and duration) have been used. Some of these are the following:

Verbal Descriptor Scale (VDS)
Usually by using 5 words: moderate, annoying, torturing, excruciating, unbearable. This is not a reliable method. Patients usually choose the middle words.

b. Numeric Rating Scale (NRS)
Visual Analog Scale (VAS)

Numeric scale from 0 to 10 (0 = no pain, 10 = the worst pain)
It is simple and easy to use.

c. Continuum of Smiling to Crying Faces

It is used mainly with children.

d. The McGill Questionnaire (MPQ)

Written questionnaire for describing elements of pain. It refers to twenty units.

e. Pain Diary

f. Minnesota Multiphasic Personality Inventory (MMPI)

MMPI includes questions concerning the mental sphere, social, vocational and economic status of the patient. It is considered to be a more objective method but requires experience, time and ability of communication with the patient.

g. Attempt is also made to evaluate the degree of pain with the use of:
- Auditory and Somatosensory Evoked Potentials (ASEP)
- Pain Meter or  Pressure Algometer (PA)

h. Experimentally, the pain is usually investigated by recording tolerance to hot stimulation (the experimental animal is forced to step on the heated surface).