Mètode Science Studies Journal ISSN: 2174-3487 [email protected] Universitat de València España
Pain shows its face. SCIENCE AND ETHICS OF A UNIVERSAL SYMPTOM Mètode Science Studies Journal, núm. 2, 2012, pp. 105-145 Universitat de València Valencia, España
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Monograph coordinated by Francisco José Morales-Olivas pain face shows tis
ain is the most common symptom of human disease and has accompanied living beings since their advent. It has been argued P that pain is part of human identity, not only as an unpleasant sensation –complex from the neurological viewpoint– but because it is accompanied by affective factors, which make us question our reason for being. The fi ght against pain dates back to the beginning of time. It is no coincidence that the two reference drugs for its treatment, aspirin and morphine, originally came from herbal remedies, the white willow and poppy. References to their usage can be found in ancient texts and images and they are cultivated or grow wild almost anywhere in the world. monograph Progress in neurophysiological research and the proliferation of effective pain relief treatments have changed the signifi cance of pain –at least in the so-called developed world– transforming it from an unavoidable element of most diseases, to something avoidable, considered to have no place or even to be undignifi ed for humans. Currently, the treatment and, as far as possible, the avoidance of pain has become a right of every patient and, likewise, failure to treat it effectively is considered unethical. This monograph attempts to review the fundamental aspects of pain from the conceptual and ethical viewpoints, and also looks at approaches to treatment, considering the means available and their scientifi c underpinn ings, as well as the individual and collective assessment of pain and the effects of analgesics.
Francisco José Morales-Olivas. Professor of Pharmacology, Department of Pharmacology. School of Medicine and Dentistry. University of Valencia.
The different dimensions of pain have triggered the creative experimentation of Greta Alfaro and Marusela Granell. These artists have contributed to this monograph in an attempt to capture the most hidden and impenetrable faces of pain. An additional tempt ation to venture into these pages. Marusela Granell. Towards the Other Side , 2011. Photograph, variable dimensions.
2012 MÈTODE Annual Review 105
PAIN MEDICATION
A HISTORICAL OVERVIEW
Javier Moscoso
This article addresses the advent of the theory and treatment of chronic pain from the second half of the nineteenth century until the mid-twentieth century. It would appear that pain medication emerged from the confl uence of practices related to treating patients with terminal diseases and those suffering from incurable pain. Although the distinction between acute pain and chronic pain is
important, this distinction alone does not explain the importance attached to a condition that is an pain shows face tis anomaly within the theoretical framework while being perceived vital within the cultural context.
In a paper published in December 1832, Professor the Þ nger. In the absence of improvement, the dose Elliotson described a case of neuralgia resistant to was increased to one grain of morphine every night. all forms of treatment. Th e record alternated clinical He then dispensed with the iron and introduced speci Þ cation with its inability to produce not only strychnine, Þ rst locally and then orally. At the same a cure but even temporary relief of the symptoms time, he increased the daily dose of morphine, but the (Turnbull, 1837). Pain appeared in the legs, arms patients general health began to deteriorate without and wrists, as well as on the right side of the face, any signi Þ cant change resulting. He then began in the submaxillary nerve. The patient had been in treatment with arsenic. When the amount of morphine this situation for some years, had reached eight grains per but the illness had started even day, the agony was such that the earlier. At Þ rst, an agonising, «DISCOMFORT THAT STARTS patient begged for ever higher monograph excruciating pain, like a blade doses of the opioid. Otherwise, BUT DOES NOT STOP cutting his Þ nger, concentrated he said, he could barely exist on the index Þ nger of his left MAKES ONE QUESTION THE (Turnbull, 1837). Extracts of hand. The slightest touch caused RATIONALITY OF A SYSTEM stramonium or belladonna were a very violent reaction, like an THAT HAS STRIVED TO also ineffective. Amputation of electric shock. The despair was EXPLAIN THE EXPERIENCE OF the Þ nger insistently requested such that he reached the point of by the patient would not solve ILLNESS FOR CENTURIES» biting all his nails on his healthy the problem, because according hand as if with this gesture he to Elliotson, it was a «chronic could make the extreme suffering illness, connected with some of the other disappear. The doctor, who said he did organic disease impossible to detect not even after not know the immediate cause of the pain, in this case death, as occurs with epilepsy or paralysis» (Turnbull, made no reference to hypnotism or mesmerisation. 1837). By contrast, he tried to build a diagnosis based on the Just as pain without injury suggests the presence of negative features resulting from patient exploration: a psychological dysfunction that can be characterised there was no in ß ammation, no reddening, nor as delusional, chronic pain also creates distrust. The temperature increase. «There is nothing at all he presence of discomfort that starts but does not cease said except the agonising pain». makes one question the rationality of a system that Elliotson started by administering iron carbonate has strived to explain the experience of illness for combined with a quarter of morphine muriate. A centuries. Faced with the every-day experience of solution of potassium cyanide was also applied to pain, anaesthesiologists, surgeons, psychiatrists and
On the left, Greta Alfaro. Pain 1 , 2011. Collage, 21 x 28 cm.
2012 MÈTODE Annual Review 107 monograph pain shows tis face 108 Annual Review MÈTODE 2012 MÈTODE Review Annual 108 and opium, among others. among opium, and fi in the used morphine medicines cocaine, ofincludes natural the shows some group The century. photograph This ofhalf twentieth rst the 1822). (Falret, suffering woman, One who felt if as own lives their who aresult taken as had of prolonged many examples contains beings book ofhis human suffering; withmoral more resignationis endured than century, physical earlysubject nineteenth the pain in on toDr. whoabook the according Falret, wrote However, was death. torture endless this to ultimately escape death) by means of treatment. would lead to the cure (or to that, based on the symptom, contradicted established protocols a form of suffering that was it rare, but clearly abnormal: transient state in itself. Not only anomalyan in a that occurred as exceptionan to illness, as understood form this of anxiety health professionalscare always For along only way the time, GROWTH OFSPECIALISED SPECIFIC INSTRUMENTS, DURING THELASTSIXTY PALLIATIVE CAREUNITS EXTENT TOWHICHPAIN- INSTITUTIONS ALREADY «JUST LOOKINGAT«JUST THE YEARS SHOWSUSTHE ASSOCIATIONS AND EXIST» of most the preciousof 1822). possessions» (Falret, disorder to their wills, imposed on them the sacri the on them imposed wills, totheir disorder having capabilitiesand of brought harmony their the having destroyed pain, orimaginary real life, but «the towards existence orweariness was not indifference their women men led and what tojeopardize actually this expert on hypochondria, on hypochondria, expert this dozens by ofIn studied cases cases. many other are there and hospital; Salpêtriere the in grains withpoisoned opium herself cancer uterine from suffered end toheragony.an who Athird toput pleaded with herfriends on herown, herself constantly kill couldnot and rheumatism from Another, whoceiling. suffered tothe tied with arope herself devouring her she was bitten being by dogs ß esh, strangled esh, strangled Þ ce ce ■ CHRONIC PAIN
The onset of pain as a focus of medical practice, one targeted by the pharmaceutical industry and the market, is a twentieth cen tury phenomenon. Only then did the so-called faithful friend , the cry of life , Gods punishment , Christs weapon , the punitive instrument , the educational rule become the subject of research programmes and of institutional care. In our time, although still limited, the pain experience has achieved corporate recognition and become a Þ eld of scienti Þ c development. Just looking at the growth of specialised palliative care units during the last sixty years shows us the extent to which pain-
speci Þ c instruments, associations and institutions pain shows face tis already exist (Baszanger, 1998; Beinart, 1988; Szabo, 2009). In 1967, while the pictures and bodies from the Vietnam War reached the West, the clinical and academic interest in this new order led to the founding of the Intractable Pain Society. The journal entitled Pain , part of the International Association for the Study of Pain, was Þ rst published in 1974 (Natas, 1996). For those involved, the emergence of this new branch of medicine seemed to be the culmination of a process, the last chapter in a narrative sequence that had led humans from the logic of resignation to
the technology of resistance. After the «abolition» © Science Museum, London of surgical suffering in the mid-nineteenth century Empty bottle of morphine used for pain in the nineteenth and the massive introduction of analgesics in the century. The name refers to Morpheus, the god of dreams in ancient Greece. monograph consumer culture of the twentieth century, we were still to Þ nd an effective treatment to combat suffering associated with incurable or terminal diseases, included providing patients with the means required but also for what is today called Þ bromyalgia, to prevent their suffering. This English physician and rheumatoid arthritis, facial neuralgia or post-traumatic historian believed that opium should be used both to syndromes, i.e., different varieties of prolonged or relieve pain and the feeling of fatigue and depression, intractable physical agony. Surgeons and neurologists exhaustion and anxiety, which are sometimes present 1 always interpreted the history of pain in this way: the during that last journey (Munk, 1887). result of a proliferation of abnormal phenomena that Almost one hundred years later, in a 1982 the inherited theoretical framework seemed unable to publication, Patrick D. Wall and Ronald Melzack explain but, also, as the necessary culmination of a wrote an account of the same pain that had tormented longer historical process that involved a humanitarian the patient described by Elliotson and other thousands concern for pain and death. of people before and after him. This text was based Often, this «humanitarian concern» called for the on an initial distinction between acute pain, which use of opioids in terminally ill patients, promoting since early times had been one of the visible signs a policy (not always accepted socially) to make of disease, and chronic pain, which they described available to patients the tools and chemicals necessary as a disease in itself or, more precisely, as a group to reduce their suffering (Clark, 2003). In 1890, the of syndromes. In the 1980s, many members of the physician Herbert Snow promoted the widespread use of opium in the treatment of incurable cancers (Snow, 1890). Three years earlier, William Munk 1 Munk mentions Ferriars treatise (Manchester) On the Treatment of the © UN Photo/MB Dying , and the works of Paradys and Sir Henry Halford. Although, in his had also begun his pioneering treatise on euthanasia, opinion, death was a transition that usually happened without suffering, calling for the medical supervision of death; this also medicine should strive to improve the adverse conditions that may arise.
2012 MÈTODE Annual Review 109 monograph pain shows tis face pain revolving a new of group around people: of form treatment institutionalised an and community 110 Annual Review MÈTODE 2012 MÈTODE Review Annual 110 and theories and to the formationof tothe anew and scienti theories and effectively multiplication tothe leading of names context experience, ofthe an of fragmentation the 2 key2004). is list The word this in 2003; development on the Jeffreys, see of aspirin, ofsyndromes a non-speci other and neuralgia trigeminal rheumatoid arthritis, of cases migraine, in treatment pain chronic and patients ill of severe terminally treatment in pain, pain symptomatic relief the discourses: of acutemedical related subject the of become three has day pain present tothe century mid-nineteenth the from that claims Meldrum Marcia a new researcher The light. tookon diseases, with incurable associated suffering conditions, Some other of such viscera. the the as pain and limbs the in between pain pain, central and pain between suffering, peripheral clinical and useless pain and between suffering, laboratory pain between useful todistinguish began of Medicine adichotomous nature. the syndromes, divisions subdivisions and of harmful to quickly 1976).(Bonica, whatsoever reasoning any clinical its couldnot justi presence be awhole alotas of while suffering, society and families patients, their causing adisorder as interpreted (chroniclatter pain) couldonly be underlyingof an condition the it possible presence the toanticipate least making at of utility degree a couldrepresent pain, asharp being former, the while that recognised neurologists anaesthesiologists and scienti nonspeci con always medication pain of developed areas their in developed lines research independentlyalthough Throughout the nineteenth century, improved living conditions led to to led conditions living improved century, nineteenth the Throughout regarding the social nature of disease, Barron H. Lerner (2001). Lerner H. Barron ofdisease, nature social the regarding interesting Equally (2007). Aronowitz A. Robert also see cancer, breast of 1983). history the On Moulin, (De century twentieth early the in scienti serious requiring problem a as perceived be to began only immemorial, time from known forexample, Cancer, diseases. chronic suffering people more in resulting expectancy, life increased Although this new began disease this Although ß uence. The terms terms uence. The . 2 Þ c community physiologists,c community Þ c diseasec Þ ll upll bookshelves, with its Þ rst taxonomies wererst taxonomies can only be understood within within understood only be can acute Þ c nature (Meldrum, (Meldrum, c nature , chronic Þ ed byed association , terminal patients in in patients Þ c attention attention c since since and and Þ c
© UN Photo/UNPDAC/NJ between 1880 and 1940. and 1880 between used & Co., Wellcome Burroughs company pharmaceutical British the from ofopium, oftincture abottle Top, left, properties. analgesic its on based cancer incurable of treatment the in ofopium use widespread the promoted Snow Herbert as such doctors century, nineteenth late the Since seventies. early the in Thailand flOpium northeast in cultivated ower «SURGEONS ANDNEUROLOGISTS ALWAYS«SURGEONS A LONGERHISTORICALPROCESSTHAT INVOLVED AHUMANITARIAN CONCERN AS THENECESSARY CULMINATION OF INTERPRETED THEHISTORY OFPAIN
FOR PAIN ANDDEATH» © Science Museum, Londres Although there was already a distinction between acute and chronic pain in romantic physiology, it only appeared explicitly in the second half of the twentieth century. The International Association for the Study of Pain, founded in 1973, depended so much on this distinction between transient and chronic pain that when the concept of pain reached full recognition in the Þ eld of clinical research, it did not do so as a single object, but as several. 3 Its emergence coincided with the partial dissolution of what had hitherto been called by that name. Human suffering is dissolved into a typology of intermediate states or harmful syndromes (Wall and Melzack, 1996). Some, such as causalgia , the phantom limb or trigeminal neuralgia, were old acquaintances of pain shows face tis medicine, but not always known by those names. Many others, however, appeared as a result of the new subdivisions. In 1986, the Association for the Study of Pain proposed the Þ rst major classi Þ cation of so- called «chronic pain syndromes» (Merskey, 1986). Fibrositis, the burning mouth syndrome, or tendinitis began to coexist with the diversi Þ cation of migraine or persistent back pain. The world was full of newcomers: allodynia, painful anaesthesiam dysesthesia, hyperalgesia, hisperaesthesia, paraesthesia, neuritis or peripheral
pain described realities that until then had only existed © Science Museum, Londres in literary papers, hidden by the incomplete stories, A bottle of Papine, trade name for an analgesic of the opiate sometimes incredible, of affected human beings. family in the early twentieth century. The illustration on the label monograph Although the diagnostic value of pain was not in directly refers to the opium poppy fl ower ( Papaver somniferum ). question, suffering (chronic or terminal) was dissolved in a family of experiences that exceeded by far, if not
3 The IASP (International Association for the Study of Pain) de Þ nition of contradicted, the theoretical elements on which the pain is worth quoting in full: relationship between injury and pain had been built. «Unpleasant sensory and emotional experience associated with actual or That was always the Þ rst problem: «Doctors are potential tissue damage or described in terms of such damage. Note: the inability to communicate verbally does not prevent a person from possibly willing to quickly admit that pain is a defensive experiencing pain and from needing proper treatment to relieve it. Pain reaction, a fortunate warning that alerts us to is always subjective. Each individual learns the application of the word the dangers of disease. But what is a defensive from experiences related to injuries suffered during childhood. Biologists agree that stimuli causing pain can damage the tissue. Accordingly, pain reaction? Defence against whom? Against what? is the experience we associate with real or potential tissue damage. It Against cancer, which so often causes symptoms is undoubtedly a sensation localised on one or more body parts, but it when it is too late? Against heart disease, which is also always unpleasant and therefore an emotional experience. There are experiences that resemble pain but are not unpleasant, for instance, a develops in silence?». This is what the surgeon René prick, which should not be considered pain. In other abnormal unpleasant Leriche (1949) meant when he repudiated the false sensations (dysaesthesias) pain may also be present but not necessarily, conception that the presence of pain was associated because, subjectively, there may not be the usual sensory qualities of pain. Many people complain of pain with no tissue damage or any likely with «necessary discomfort» and that particularly pathophysiologic cause; usually this happens for psychological reasons. in France it had been the basis of physiological Generally, there is no way to distinguish this feeling from that produced research on pain since the early nineteenth century. by tissue damage if we consider the subjective report. If the subject believes that what he feels is pain and reports this in the same way as Semiotics of suffering, the translation of expressive if it were pain caused by tissue damage, this must be accepted as pain. gestures into clinical signs, had made it possible, This de Þ nition avoids linking pain to stimuli. The activity induced in the among other things, to talk about animal suffering or nociceptors and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, although we note that usually pain pain in childhood, but was always unable to explain has a related physical cause». what warning was provided by trigeminal neuralgia or
2012 MÈTODE Annual Review 111 monograph pain shows tis face their mechanical processes of processes objecti mechanical their notdid and easily comply practices with laboratory i.e., pain, which those visceral addressed hardly For physiology practices. one thing, clinical manuals approaches and experimental relatedto concealment ofwithout underwent process disease» atriple without «disease Both symptoms» «symptoms and ■ other,the were two sides coin. of same the toany «curable» not did on correspond disease, that of proliferation ofand the symptoms (also long-term) of one long-termon hand, the symptomless illnesses, prolongedand 1857). (Fell, suffering discovery The extreme produced even type of same others the many orwith only slightwithout discomfort, pain great signigreat division, latter extremely though This simple, a had (Snow, silentand tumours 1893; Bland-Sutton, 1903). well as painful as tumours, malignant and tumours divided benign into be to appeared sense, tumours with more primary classiwith more primary 112 Annual Review MÈTODE 2012 MÈTODE Review Annual 112 ulcer, epithelioma, blastoma, which, like rodentnames anumberof was acquiring disease same the hand, (Stoddard Holmes,treatment 2003). one the On forprogression many searched cases, palliative in and such, as shed light but on disease its rather the could no longer causesunderlying the address multiplied discourse ahost into of medical varieties, elements it. tovisualise necessary the lesion, extent but tothe science no also longer that had sign the of as hidden a nocould longer interpreted be signi it toany lost treatment any orcorrespond category into not did fall when someone. pain Indeed, protect could actually of carcinoma typical how suffering the TERMINALLY ILL PATIENTS ILL CHRONIC TERMINALLY AND THE TRIPLE CONCEALMENT TRIPLE THE The same occurred with cancer. As the disease with disease cancer. Asthe occurred same The PAIN, TREATMENT OF SEVERE PAIN IN SEVERE OF PAIN, TREATMENT THE SYMPTOMATIC RELIEF OF ACUTE OF RELIEF SYMPTOMATIC THE Þ OF THREE MEDICAL DISCOURSES: DISCOURSES: MEDICAL THREE OF «PAIN HAS BECOME THE SUBJECT SUBJECT THE BECOME «PAIN HAS cance, not only in the (obvious) not the onlycance, in it sense that Þ broma or lympho-carcinoma, coexisted coexisted broma or lympho-carcinoma, Þ cance, for while some tumours developed forcance, some tumours while PAIN MANAGEMENT» Þ cations. In a very general general avery cations. In Þ cation and cation and
© U. S. National Library of Medicine century, at the same time as in the medical and social fi social and medical the in elds. as time same atthe century, twentieth the until emerge not did industry pharmaceutical the of object an as Pain pharmacy. century nineteenth late A classic of disease. evil anecessary as ofpain concept the rejecting for known was Leriche René surgeon French The experimental manipulation (Ryle, 1948). Secondly, of diseases that are currently considered non-existent, clinical medicine and its efforts to objectify disease whose symptoms resemble some of our modern led it to inevitably ignore or conceal the human medical conditions. Let us consider neurasthenia factor. Rather than this disregard for the patient in for instance. The symptoms of this debilitating nineteenth-century medical cosmology (Jewson, condition, so fashionable in the second half of the 1979), hospital medicine should be concerned with nineteenth century, bear a striking similarity to some Þ nding a connection between manifestations of depression, the lesion and the illness, stress or, more speci Þ cally, based on close examination, the so-called chronic fatigue comprehensive questioning and «IN CONTRAST TO SCIENTIFIC syndrome of contemporary 4 a detailed description of the MEDICINE, THIS NEW societies. The same could be experiments that nature itself said of hysteria, considered as an CLINICAL PRACTICE SHOULD operated spontaneously in the epidemic by the psychiatrists of human body (Ryle, 1935). In NOT SEEK THE DISEASE the mid-nineteenth century.
contrast to scienti Þ c medicine, IN THE PATIENT’S BODY, Chronic pain plays a major pain shows face tis this new clinical practice BUT RATHER UNDERSTAND role in many intractable or should not seek the disease in EACH PATIENT IN THE incurable conditions. Likewise, the patients body, but rather it appears repeatedly in long- CONTEXT OF THEIR DISEASE» understand each patient in the term nerve diseases, whether context of their disease. For these diseases have an organic healthcare professionals, the or a psychological origin. physicians task was to cure when possible, and to This historical evidence suggests that the absence alleviate suffering when it was not. or presence of the term «chronic pain» does not Last but not least, the uneven distribution of alone clarify the nature of the disease. The problem illness among different population sectors also led does not depend on a name which did not achieve entire human groups to social invisibility and clinical widespread use until the 70s but on the way in oblivion. This latter form of invisibility affects not which patients understand their symptoms and the only the history of medicine, but is a far-reaching manner in which these could be framed in a medical phenomenon related to the cultural development of a and cultural context that give them meaning. The monograph disease, or of a group of them, which did not affect all distinction between acute pain and chronic pain, citizens in the same way, having special impact on the often supporting the historical explanation of the most vulnerable population sectors.
Although it can be said almost tautologically that 4 Regarding neurasthenia, see Drinka (1948). On PTSD, Brewin (2003) all diseases are man-made , chronic diseases owe a and Gijswijt-Hofstra and Porter (2001), especially Chapter 1: Porter, great deal to their social context; the mere recurrence «Nervousness, Eighteenth and Nineteenth Century Style: From Luxury to Labour». On chronic fatigue syndrome, which emerged in the mid- of symptoms does not determine a clinical condition. eighties, see Aronowitz (1998) Chapter 1: «From Myalgic Encephalitis to Indeed, the history of medicine has given us examples Yuppie Flu. A History of Chronic Fatigue Syndromes». Mètode, the popular science
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2012 MÈTODE Annual Review 113 monograph pain shows tis face 114 Annual Review MÈTODE 2012 MÈTODE Review Annual 114 Alfaro. Greta Life 3Life , 2011. Digital collage, 21 x28cm. 21 collage, Digital , 2011. emergence of pain medication or, as called by David BONICA , J. J., 1976. Proceedings on the First World Congress of Pain . Raven B. Morris, «postmodern pain», is not a prerogative Books. New York. CLARK , D., 2003. «The Rise and Demise of the Brompton Cocktail». In of the twentieth century nor can it alone explain the MELDRUM , M. L. (ed.). Opioids and Pain Relief: A Historical Perspective . development of palliative medicine (Morris, 1998). IASP Press. Seattle. DE M OULIN , D., 1983. A Short History of Breast Cancer. The Hague, Nor does the limited use of this expression explain the Dordrecht, Martines Nijhoff Publishers. Boston. systematic concealment of human groups whose living DRINKA , G. F., 1984. The Birth of Neurosis: Myth, Malady and the conditions would today be considered deplorable. Victorians. Simon and Schuster. New York. FALRET , J. P, 1822. De lhypochondrie et du suicide. Considérations sur les The emergence of a science of pain is not, causes, sur les siège et le traitement de ces maladies, sur les moyens den therefore, due to the internal development of science. arrêter et den prévenir le développement. Croullebois. Paris. The scienti Þ c and cultural colonisation of the FELL , W., 1857. Treatise and Cancer, and Its Treatment . John Churchill. harmful experience clinical concern in the Þ eld of London. GIJSWIJT -H OFSTRA , M. & R. P ORTER , 2001. Cultures of Neurasthenia. From subjectivity is neither based on, nor can be explained Beard to the First World War . Rodopi. Amsterdam, New York. by, a teleological sequence making pain medication JEFFREYS , D., 2004. Aspirin: The Remarkable Story of a Wonder Drug. the logical conclusion of all suffering of bygone Bloomsbory. London. JEWSON , N. D., 1979. «The Disappearance of the Sick Man from the Medical humanity. Chronic pain has emerged as a clinical Cosmology, 1770-1870». Sociology , 10: 225-244. pain face shows tis condition once the ß ow of life described by Elliotsons LÉRICHE , R., 1949. La chirurgie de douleur . [1937]. Masson & Cie. Paris. LERNER , B. H., 2001. The Breast Cancer Wars. Hope, Fear and the Pursuit patient could be transformed into an experience likely of a Cure in Twentieth-Century America . Oxford University Press. to last for days, weeks or years. Its appearance as an Oxford. object of science is not the end MELDRUM , M. L., 2003. «A Capsule History of the Pain Management». Journal of the of the story, but the beginning American Medical Association , 290: 2470- of another, which has allowed 2475. the recognition of a way of life «CHRONIC PAIN PLAYS MERSKEY , H. (ed.), 1986. «Classi Þ cation of Chronic Pain: Descriptions of Chronic Pain A MAJOR ROLE IN MANY that, until then, had been diluted Syndrimes and De Þ nitions of Pain Terms. and hidden, without clinical INTRACTABLE OR INCURABLE Pain , 3: 1-225. MORRIS , D. B., 1998. Illness and Culture in the signi Þ cance or cultural value. CONDITIONS. LIKEWISE, IT Hence pain medication Postmodern Age . University of California APPEARS REPEATEDLY IN Press. Berkeley, Los Angeles, London. partially corresponds to the MUNK , W., 1887. Medical Treatment in Aid development of clinical practice LONG-TERM NERVE DISEASES, of Easy Death. Longmas, Green and Co. London. linked to many long-term WHETHER THESE DISEASES NATAS , S., 1996. The Relief of Pain: The Birth monograph diseases, whose emergence in HAVE AN ORGANIC OR A and Development of the Journal Pain from the Þ eld of biomedicine is also 1975 to 1985 and its Place within Changing PSYCHOLOGICAL ORIGIN» Concepts of Pain . B. Sc. Dissertation. considered recent (Arney and University College. Bergen, 1983). Its emergence RYLE , J. A., 1935. The Aims and Methods of cannot be linked to the Medical Science. Cambridge University culmination of a historical process associated with Press. Cambridge. RYLE , J. A., 1948. The Natural History of Disease . [1928]. 2nd edition. the process of civilisation, for example, but must be Oxford University Press. London, New York, Toronto. framed in terms of how our contemporary world has SNOW , H., 1890. The Palliative Treatment of Incurable Cancer, with an been capable of transforming continuous pain into Appendix of the Use of the Opium-Pipe . J & A Churchill. London. SNOW , H., 1893. Cancers and the Cancer-Process . J & A Churchill. London. an experience worthy of scienti Þ c inquiry, clinical STODDARD H OLMES , M., 2003. «The Grandest Badge of His Art: Three treatment and, equally important, with a cultural Victorian Doctors, Pain Relief, and the Art of Medicine». In MELDRUM , M. L. (ed.). Opioids and Pain Relief: A Historical Perspective . IASP signi Þ cance. Press. Seattle. SZABO , J., 2009. Incurable and Intolerable. Chronic Disease and Slow Death in Nineteenth-Century France. Rutgers University Press. New REFERENCES Brunkswick, New Jersey, London. ARNEY , W. R. & B. J. B ERGEN , 1983. «The Anomaly, the Chronic Patient and TURNBULL , A., 1837. A Treatise on Painful and Nervous Diseases, and on a the Play of Medical Power». Sociology of Health and Illness , 5(1): 1-24. New Mode of Treatment for Diseases of the Eye and Ear . John Churchill. ARONOWITZ , R. A., 2007. Unnatural History. Breast Cancer and American London. Society. Cambridge University Press. Cambridge. WALL , P. D. & R. M ELZACK , 1996. The Challenge of Pain . [1982] Penguin. BASZANGER , I., 1998. Inventing Pain Medicine. From the Laboratory to the London. Clinic . Rutgers University Press. London. BEINART , J., 1988. «The Snowball Effect: The Growth of the Treatment of Intractable Pain in Postwar Britain». In Mann, R. D. (ed.). The History of Javier Moscoso . Research Professor at the Institute for Philosophy (CSIC- the Management of Pain . The Parthenon Publishing Group. New Jersey. Centro de Ciencias Humanas y Sociales, Madrid). FFII2010-20876 Project: BLAND -S UTTON , J., 1903. Tumors. Innocent and Malignant. Their Clinical «Epistemología histórica: historia de las emociones en los siglos XIX y XX » Characters and Appropriate Treatment . Cassell and Company. London, (Historical epistemology: the history of emotions in the nineteenth and Paris, New York. twentieth centuries).
2012 MÈTODE Annual Review 115
CAN WE MEASURE PAIN INTENSITY?
ASSESSING THE PATIENT’S SUFFERING
Elena Rubio
Pain is a subjective sensation, so to objectify its intensity different types of scales are used whereby the patient can indicate the degree of pain being treated. The effect of analgesic drugs is evaluated in clinical trials subject to strict rules in order to compare the effect of the medication with that produced by substances without analgesic activity. pain shows face tis
We assume that the sensation of pain is subjective visual analogue scale, the verbal numeric scale and and therefore the only person capable of knowing the the verbal ordinal or categorical scale. pain one suffers is the individual oneself. However, in In the verbal ordinal scale, the patient selects the order to treat pain we need to evaluate it objectively, degree of pain from a number of categories offered. so we can tell society, sufferers and specialists what The oldest has four degrees of pain: none, mild, medicine can be administered or the best way to moderate and severe. These four levels may easily combat pain. fall short in relation to the patients needs to express their OBJECTIVE EVALUATION OF pain and also some patients ■ «WE ASSUME THAT THE PAIN ITSELF say that the difference between SENSATION OF PAIN IS mild and moderate is less than Of course, the extent and quality SUBJECTIVE AND THEREFORE between moderate and severe. of the damage determines the THE ONLY PERSON CAPABLE Therefore other similar scales monograph pain, but this is modulated have been used with more OF KNOWING THE PAIN ONE by the individuals previous categories to choose from, such experience of pain and his SUFFERS IS THE INDIVIDUAL as the 5-point scale (no pain, emotional state at the time, ONESELF. HOWEVER, IN mild pain, moderate pain, severe hence the need to assess each ORDER TO TREAT PAIN pain, the worst pain imaginable) case. Health professionals tend WE NEED TO EVALUATE IT or the 8-point scale (no pain, to underestimate their patients barely noticeable, very mild, OBJECTIVELY» pain and to avoid this problem, mild, moderate, severe, very tools are available which help severe, unbearable). record the painful experience One way of avoiding reported by the patient in the most objective way misinterpretation of the terms that de Þ ne the degree possible. of pain and equalise the steps between the different Tools have been developed dealing with different categories is to use a rating-based scale. The most aspects of pain that are not independent and are widely used involves asking the patient to rate his therefore dif Þ cult to separate. We might say that the degree of pain from 0 to 10, the extremes being no questions to answer are: how much does it hurt? And pain and maximum pain. This numerical scale is how much am I suffering? easy to interpret and to use. To answer «how much does it hurt?» or, in other Generally, to apply the verbal scales little words, to measure the intensity of pain, scales explanation by the assessor is needed, so no have traditionally been used to record the patients specialised training is required of the person statement about the amount of pain experienced: the collecting the data, which can be recorded by the
On the left, Marusela Granell. Easy Blood , 2011. Photograph, variable dimensions.
2012 MÈTODE Annual Review 117 monograph pain shows tis face 1 3 5 7 9 10 9 8 7 6 5 4 3 2 1 0 imaginable pain Worst Maximum Intense pain Moderate No Mild pain No intensity. pain to measure help that scales of visual models Different elderly and the disabled. Depending on the cognitive cognitive the on Depending disabled. the elderlyand the ofyoung children, situation the consider must one cases, special as regard, this In patientscapabilities. the to ithurt?» «How does much ofinterest question the adapt to is aim the short, In categories. various ofthe list written a visually, using presented be can scale ordinal verbal the Also scales. visual into severe). and (mild, moderate of pain degree by division but alegend marks below isadded on the isnot represented line the scale. Sometimes numeric avisual to 10; becomes scale analogue visual the divisions, 0 line from numbered it are easier there To operation. and its meaning make understanding 118 Annual Review MÈTODE 2012 MÈTODE Review Annual 118 capacity may have intellectual diflimited elderlymost although used, patients with or those organ.affected of the changes function in todetermine useful be such anxiety, as nervousness,pain, etc... It may also accompany emotions can orother that suffering emotional component i.e., of of pain, degree the the toassess used be also of can scale type This individual. that in end intensity representsof the pain patients between the distance «no pain» the and mark pointwhich the hebelieves The pain. represents his at line imaginable». the patient tomark isasked The opposite worst the end and «the pain «no pain» 10 usually one length, line, end cmin of which is dif speech and hearing advantages, hand, are but other on features the These via telephonecollected remote orusingmedia. other patients be also It can orcarers. members family So we have seen how to transform verbal scales scales verbal we So havehowtransform to seen The simplicity of this scale makes it makes one scale of simplicity of the The this consists scale of analogue ahorizontal visual The Þ culties may problem. a be Visual categorical scale categorical Visual Visual analogue scale analogue Visual Visual numeric scale numeric Visual Þ culty culty is hardly treated, because, according to the de tothe according because, treated, is hardly patients whose pain historically population. They are a signihas due to age, illness or mental condition, disability with severe problems communication whether or cognitively patients. impaired elderly in not used ablebe italso patients toread, can still who for italthough are was children introduced for scale adults and, verbal tothe ordinal corresponds old. over years It children in used three be can that developed. have childs tools been the or age,different ability management. expression, upper-limb movement respiratory and for each of following facial domains: the three which ICU and usesfour the points different in Scale»,Pain for which used is also adult patients «Behavioural the Or heartbeat. blood and pressure movements, expression facial signs, vital such and as which (ICU), considerunits muscle the tone, body intensive evaluatein to children care «Comfort» expressions these account into such of as pain, it. treat and assess diagnose, to mayserve thus and pain to due maybe expression that facial or position body as such signs other or pressure) blood (respiration, signs vital etc..),their in changes disturbances, sleep nervousness, (restlessness, changes behavioural seek actively should them assisting professionals care health or patients the of care taking those that suffer any such pain». not does pain, to report conclusion: who fails would lead toalogical Such consideration believe it present. be to it not when and others when patient the reports words, present is pain by sufferer... the other In exists when sodeclared Professor Baños, «pain by described as and Study(IASP) ofthe Pain Association for providedof by pain International the In anypatients assessment case, in the In of pain scale facial graphic of best known isthe One the Different scales haveDifferent scales developed been take that necessary It therefore is Þ cant impact on these segments on of these impact cant the
© BananaStock Ltd. Þ nition
© BananaStock Ltd. © BananaStock Ltd. In any case, as noted herein, if it is not easy to standardise the process for measuring pain in people able to communicate, it is much more dif Þ cult when communication is limited. This situation requires more effort in research to determine the appropriate method for assessing pain in these circumstances. As noted initially, pain assessment also involves characterising the associated suffering including disability and vital condition. We can use the same type of verbal or analogue scales de Þ ned for intensity but applied to measure limitations in everyday, social or work activities affected by the pain and «how the person feels», i.e., if he feels happy or sad, down or very energetic, whether he is in pain or not; ultimately
the answer to «how much am I suffering?». pain shows face tis © BananaStock Ltd. ■ WHEN THE PAIN NEVER STOPS
«THE ASSESSMENT The quality rating of a painful OF PAIN IN PATIENTS experience acquires special WITH SEVERE signi Þ cance in chronic pain, which is interpreted as a COMMUNICATION disease in itself, unlike acute PROBLEMS –WHETHER pain, generally regarded as a DUE TO AGE, symptom of an injury or illness. CONDITION, DISABILITY Chronic pain, according to OR MENTAL ILLNESS– the IASP de Þ nition, is «that
which exceeds the normal monograph HAS A SIGNIFICANT healing period». The patient IMPACT ON THESE perceives this as an unpleasant SEGMENTS OF THE experience that does not serve POPULATION» to warn against damage, and easily leads to despair, with behavioural changes, isolation
© BananaStock Ltd. and affecting the individuals social, family and working life. Therefore, to properly address it, one must assess it in all its dimensions. Among pain-rating tools from a multidimensional perspective, one of the most recognised and used is the McGill Pain Questionnaire. It is a self- administered questionnaire, i.e., it does not need a survey taker, and has been translated into Castilian for the evaluation of Spanish patients. In its complete version, proposed by Melzack (1975), it comprises 78 adjectives divided into twenty groups. Generally an abridged version is used which includes 62 different aspects (descriptors) that are distributed in Þ fteen sections, which in turn are classi Þ ed into three types depending on the speci Þ c dimension evaluated (sensory, affective and evaluative
© BananaStock Ltd. 2012 MÈTODE Annual Review 119 monograph pain shows tis face 120 Annual Review MÈTODE 2012 MÈTODE Review Annual 120 situation.family patients habits, the health and treatments, social- pain life, previous on daily current of and pain of interview, the time atthe individual in the condition the of the of pain, record the a clinical includes data, personal Questionnaire Pain McGill index»rating (PRI). «pain value called numerical a scores, we obtain partial by these dimensions and adding givesthat avalue toeach of the isassignedcategory ascore Each islocated. where pain the which exactly one should mark on form of human drawing a the intensity, and scale acategorical for scale pain analogue visual or temporary). a It has also achecklist. following pain his rates himself he that so patient, by the completed be can questionnaire pain McGill The Put a cross (X) to show how much pain you feel at the moment moment the at feel you pain much how to show (X) a cross Put Stinging Smarting stitch Like Tingling Itching 7. Deep Penetrating Nagging Radiating Spreading 6. Taut Tearing Tugging 5. Sharp Gnawing Stabbing 4. Pressing Cramping Spasm Ramping Stiffness Pinching 3. Burning Hot 2. Shooting Flashing 1. Instruc No painNo pain your describes For a full rating of the patient with pain, the the of patient the with pain, rating For afull Numbness Superficial Heavy Pricking Dull Cold Pulsing ons ______: If a word a If , underline it. it. , underline within one within Unbearable Strong Intense Annoying Mild painNo Intensity Persistent Constant Growing Intermittent 14. Distressing Grippinga Nauseating Suffocating 13. Overwhelming Irritating 12. Incapacitating Exhausting 11. Vicious Grueling 10. Suffocating 9. Awful Frightful 8. Þ nal nal Momentary Depressing Uncomfortable Strenuous Punishing Sickening Fearful o h 4categories 14 the of EXPERIENCE THAT DOESNOT DAMAGE, ANDEASILY LEADS Unbearable painUnbearable THE BODY WHERE YOU WHERE BODY THE SERVE TOWARN AGAINST «THE PATIENT PERCEIVES THIS ASANUNPLEASANT SHADE THE PART(S) OF OF PART(S) THE SHADE FEEL PAINFEEL ß uence TO DESPAIR» is equal to drinking aglass of water af while todrinking is equal whose effect marketed couldbe medicines otherwise effect to testthe because of a drug, is necessary useof placebo The pain. the ortoalleviate himself patients tocure the something belief heistaking that patient in the group receiving placebo group effective the ofpatient in an isacure. medicine the that disease. It concerns clinical trials, comparing the the comparing trials, clinical Itdisease. concerns not only but used, forof for pain, treatments any method used. scale the conclusion same the reached had studies of regardless 17 effect of the treatment, rating scales between the despite differences placebo or medication and, the with pain patients treated in trials of twenty clinical analysisintensity. after results were These obtained of scale pain categorical and scale analogue visual most sensitive for effect followed detection, by the of scale concluded relief categorical the was that the analgesic the 1,500 patients effect in researching astudy respect, this effect In ofthe treatment. less sensitive are treatment before toassess after and 1 to 10) so he may choose his condition. moderate relief and complete relief) or numbers (from him preset categories (no pain relief, mild relief, question the patient about the degree of relief offering information of the effect. It is also possible to directly to that initially reported by the patient will give us of pain after treatment and the difference with respect assess the degree of relief we can measure the intensity that is, if the pain has decreased and to what extent. To it is interesting to know the outcome of the treatment, research studying the effect of treatment. In both cases medical measure in one patient alone or as ofpart a Pain assessment can be performed as a standard ■ TREATMENT EFFECTIVENESSTREATMENT In studies with analgesics, studies notIn soas todeprive the In the previous paragraph we previous mentioned the the In paragraph repeated found measurements It been that has par excellencepar may produce an effect onmay based an produce activity,pharmacological but but no has drug the looks like de participate. consent to informed, thoroughly who voluntarily, being after and effect on people ofthe medicines toevaluate planned experiment trials could be de couldbe trials withplacebo. Clinical drug for evaluating effectiveness the Þ Put simply,Put be placebo can ned as a substance that that a substance as ned Þ ned as an an as ned Þ rming rming
© BananaStock Ltd. © BananaStock Ltd. pain treatment (random allocation is required), he will be given the so-called «rescue medication». Patients are told that if, after a reasonable time after taking the medication, there has been no analgesic effect they may take another medicine previously selected by the researchers. This procedure avoids the volunteer suffering unnecessarily, either because he is in the group taking placebo or because the drug under study does not have suf Þ cient analgesic effect. In clinical trials of new analgesics, the placebo is used in short studies and generally in the early stages of research, for example to determine the dose to be chosen. It seems reasonable to believe that the greater the
need of rescue medication, the less the analgesic pain shows face tis effect of the drug, so rescue medication is also used to measure the effect of the painkiller. For this method to be truly useful and not prone to errors, it must be very clearly expressed how the rescue analgesic will be administered, because as we have said before, if
Pain rating can present interpretation problems depending on patient characteristics. These diffi culties are solved through «IN CLINICAL TRIALS OF NEW physician-patient dialogue and consensus of experts in cases of ANALGESICS, THE PLACEBO IS USED patient groups. IN SHORT STUDIES AND GENERALLY IN THE EARLY STAGES OF RESEARCH, FOR EXAMPLE TO DETERMINE THE DOSE TO BE
CHOSEN» monograph
left to the opinion of health personnel, they will tend to underdose. In order to assess the possible effect of a new drug on pain, not only do we have to select a sensitive and reproducible tool to measure pain, but also a suitable painful experience on which to apply it. That means selecting the painful stimulus, the disease that causes pain. Studies on acute pain usually refer to postoperative pain in patients not only having the same type of surgery (on the chest, urinary tract, etc...), but also when the same surgical technique is applied. In this sense, an extraction of the third molar (known as wisdom tooth) is a widely used surgical procedure as a method of rating analgesics for acute pain. It has the advantage of being a standardised surgical technique and above all it is usually performed on young and healthy individuals, with no other health problems that hinder the interpretation of results. This model highlighted the importance of the intensity of pain before administering the drug or
2012 MÈTODE Annual Review 121 monograph pain shows tis face 122 Annual Review MÈTODE 2012 MÈTODE Review Annual 122 Marusela Granell. Granell. Marusela Obsession , 2011. Photograph, variable dimensions. variable Photograph, 2011. , To evaluate the effect of an analgesic in cases of chronic pain, there is no particular experimental model, partly because there are very different diseases that cause chronic pain and they respond differently to analgesics. Examples are migraine, cancer pain or pain in rheumatic diseases. So if we wish to research a new drug for chronic pain, we must select the disease on which to test its effect and the fact that a drug may be effective in a case of osteoarthritis, does not mean that it is for migraine. If it is to be prescribed for the latter, effectiveness against it should be proved In studies of analgesia for chronic pain, the effect of the drug must be evaluated at various times throughout the study and it should be clearly speci Þ ed
when and how this is to be done. For this purpose the pain face shows tis so-called «patient diaries» are used, which record data on the patients pain as scheduled and which will serve to test the effect of the drug under study. The patients memory cannot be relied on to describe their pain, because, as mentioned, former painful experiences modulate current pain. In fact it has been found that if the pain is intense at one point, the patient recalls pain experienced in past episodes as more intense than it actually was and vice versa. In short, the evaluation of pain and its treatment presents dif Þ culties that can be solved by dialogue between doctor and patient in order to treat the individual and by expert consensus when referring to © BananaStock Ltd. studies 1 on groups of patients. The method par excellence for evaluating the effectiveness of the monograph treatment of pain or any disease is the clinical trial comparing the drug with placebo. 1 A good example can be found in papers published on the website
2012 MÈTODE Annual Review 123
PAIN MEDICATION
USAGE AND ABUSAGE OF PAINKILLERS
Luis Estañ
Numerous drugs with analgesic effect can be used to treat pain. Opioids are effective for moderate to severe pain, while nonsteroidal anti-infl ammatory drugs and especially paracetamol (acetaminophen) are useful to treat mild or even moderate pain. Analgesics should be used according to guidelines, and users should be aware of their adverse effects, avoiding them whenever
possible, and steering clear of overuse. pain shows face tis
Drug therapy is a mainstay of the therapeutic cancer patients is well established; however, their approach to pain and includes not only the use prescription for non-neoplastic chronic pain is of analgesics but also drugs to treat the sufferers controversial, even though they are safe and easy to affective factors. use. Years ago the use of opioids to treat non-cancer- Drugs used to treat pain can be classi Þ ed as: related chronic pain was reserved for patients only analgesic opioids, NonSteroidal Anti-In ß ammatory when other pain relief methods failed; however, Drugs (NSAIDs), simple analgesics and adjuvant nowadays its use is accepted for any persistent pain drugs including local anaesthetics, antidepressants, that causes distress, disability or having a negative anxiolytics, anticonvulsants, neuroleptics, impact on the quality of life. Its main advantage is corticosteroids, sympatholytic agents and an assorted that it lacks an «analgesic ceiling», as increasing group of substances without the dose increases the effect
direct effect on pain itself but inde Þ nitely. However, high monograph when used in combination with doses cause adverse effects, «IN SPAIN, OPIOIDS ARE analgesics may improve the such as respiratory depression, patients symptoms. USED LESS THAN IN OTHER which in practice prevents the NEARBY COUNTRIES DUE dose from being increased ■ DRUGS USED FOR TREATING TO IGNORANCE AND FEAR to the extent one may wish. PAIN OF THE POTENTIAL RISKS Furthermore, they can lead to dependence. INVOLVED» Opioid analgesics In Spain, these are used less The knowledge that opium can than in other nearby countries, relieve pain and induce sleep is which can be attributed to centuries old and has been put into practice by all ignorance of their pharmacological characteristics civilizations. The main active component of opium and fear of the potential risks involved. Constipation is morphine, and since the seventies we have known is the most common adverse secondary effect that this and other alkaloids extracted from opium and should be taken into account and prevented exert their action by stimulating speci Þ c receptors systematically, as many patients likely to use such called opioid receptors . We use the term opiate to medicines are elderly patients often prone to this refer to analgesics made directly from opium, while clinical condition. opioid refers to a fully- or semi-synthetic alkaloid For correct prescription, a good recommendation with the same mechanism of action. is to follow the guidelines set for the clinical use These drugs are useful to treat any type of pain, of opioids in chronic non-malignant pain by the and their use to combat acute pain and to treat American Society of Interventional Pain Physicians.
On the left, Greta Alfaro. Life 1 , 2011. Digital collage, 21 x 28 cm.
2012 MÈTODE Annual Review 125 monograph pain shows tis face from from ( willow ofwhite bark the from derived is which aspirin, is drugs used widely most ofthe One not only to local irritation but asystemic also effect, not irritation only tolocal kidney, kind). of allergic the or are (most digestive the affecting commonly system, eneb not provide dosedoes the which increasing after is dosedependent, but they have analgesic an ceiling colic, early stages of response soon. cancer, The and of types certain pain, postoperative posttraumatic and myalgia,dysmenorrhea, tendinitis, arthralgia, able relieve to wide a headache, of range discomforts: 126 Annual Review MÈTODE 2012 MÈTODE Review Annual 126 in (analgesic, therapeutic both anti- antipyretic and group, this within drugs toall effects common isresponsible mechanism for This the mediators. endogenous inof and prostaglandins, pain anti-inthe widely underlying mechanism are self-medicated. The excellence For NSAIDshave years painkillers the been Drugs Anti-Inflammatory NonSteroidal ß ammatory) and adverse (gastrointestinal, renal...). adverse and (gastrointestinal, ammatory) Related gastrointestinal complications are due complications are Related gastrointestinal NSAIDs have analgesic moderate ef Dioscórides renovadoDioscórides Þ ts but does imply greater risks of adverse risks but implyts effects does greater ß (taken whenever patient the feels pain) and ammatory action is to inhibit the synthesis the action istoinhibit ammatory , Pius Font i Quer. i Font Pius , Salix albaSalix ). Above picture taken taken picture Above ). Þ cacy and are are cacy and ß ammation ammation par par
© Botanical Garden Library of the University of Valencia histamine Hhistamine such analogues, misoprostol, as of prostaglandin use the is possible patients through high-risk in Simple analgesicsSimple lacks both anti-inlacks both low in doses. or aspirin metamizole paracetamol, without anti-in an NSAIDs, but as described tothose similar properties with analgesic substances are group this Within (PPI), such inhibitors proton omeprazole. pump as 1 opium. the toextract made slits with a capsule renovado,Dioscórides ( poppy opium the shows picture The centuries. for known been has pain to relieve potential Opium’s to complications,to oral. by than routes other administered which explains why even they may causeinjury when Factors increasing the risk of gastrointestinal complications are previous previous are complications gastrointestinal of risk the increasing Factors corticosteroids. with therapy concomitant and alcohol tobacco, of NSAIDs, doses high age, of over years 65 bleeding, gastrointestinal previous ulcer, peptic Paracetamol has asigni has Paracetamol There are risk factors that make patients prone make factorsthat risk are There 2 -receptor blockers, like ranitidine, or blockers,-receptor ranitidine, like 1 ß but pharmacological prophylaxis but pharmacological ß ammatory and gastric-related gastric-related and ammatory Pius Font i Quer. One can see afl see can One iQuer. Font Pius and ower ammatory effect. These include effect. These ammatory Þ cant analgesiccant effect but Papaver somniferumPapaver ) from ) from
© Botanical Garden Library of the University of Valencia pain shows tis face monograph TOXICITY TOXICITY CONTROLLED PAIN CONTROLLED PAIN PAIN LIMITED OR NONEXISTENT CONTROL LIMITED OR NONEXISTENT CONTROL PAIN 2012 MÈTODE Annual Review 127 cult to achieve proper analgesia. to achieve cult Þ Drug administered every four hours PAIN For a correctFor pain-free remains which condition, ADMINISTERING ANALGESICS Medication on demand steady over time, regular administration over steady (scheduled) is recommended at pre-established intervals, according to the pharmacokinetics the active of effects the possible Thisingredient chosen. way, important less be much would to overuse related kidney conditions and hypersensitivity. Of particular and hypersensitivity. kidney conditions importancea serious syndrome, and is Reye potentially fatal illness, occurs which in children after fromapparent viral recovery infections that cause aspirin the of use Therefore, is contraindicated fever. in children. ■ a pain to suppress is easier at the than onset It when has alreadyit in, set so treatment begin should as soon after the painful However, stimulus as possible. be used should that analgesics believe people some because demand), the is inpatient pain when only (on the used patient is only when in analgesic this way drugs theactually use of pain feels and prevents during pain-free periods. This practice actually makes dif it Analgesic effi cacy accordingAnalgesic dose/interval. effi Administering the drug at the onset of pain means there istime a lapse during which the cientpatient analgesic does not effect get a suffi (above). When the drug is administered on a regular or scheduled basis, unnecessary pain is avoided (below). 0 HOURS 4 8 12 16 18 24 0 HOURS 6 12 18 24 ammatory ß ammatory effect ß Aspirin has been acid regarded or acetylsalicylic Metamizole also an lacks anti-in Gastric mucosal erosion, gastric or duodenal ulcers (40% of patients treated for 3 months). hypertension in 3-5% those of treated). use). patients). potentially very severe). and gastric causes less irritation than Its NSAIDs. ceiling higher andanalgesic is similar is slightly is It opioids. doses of low with to that achieved relaxant, makingalso a smooth-muscle useful to it kidney can adverse cause it treat cramps; however, The serious most side reactions and hypersensitivity. (agranulocytosis conditions areeffects hematologic although the risk very low. is anemia), and aplastic at the dosage the However, top NSAIDs. of as one normally taken, has virtually it anti-in no effects, thus it is thought to have differentmechanisms have to thought is it thus effects, the is considered antipyretic It to NSAIDs. action of to NSAIDs, preferable drugand analgesic choice, of aspirinespecially preferred causes far over as fewer it there are risks adverse of However, reactions. adverse can aseffects it cause allergic usually reactions in urticariathe form of disorders frequently blood less or like thrombocytopenia. leukopenia or The most important which is the risk intoxication, drawback of necrosis and appears liver when can to severe lead grams mg and children 7.5 150 exceed adults exceed per kilo per day. effect, which requires which effect, 3 and between 6 grams doses of The of effects and antipyretic analgesic per day. aspirin are and obtained 325 between doses of with 6 hours every in mg Furthermore, adults. 650 has it mg/day) doses (75-325 at low effect an antiplatelet myocardial infarctionand in is thus used to prevent at risk. patients reactions The common adverse most by fall followed into the gastrointestinal category, Gastrointestinal reactions: Mild gastritis,dyspepsia, – heartburn (affecting of users). 15-25% – Bleeding and perforation (less common but more serious). Renal reactions: – Reduced renal function in people already affected. Retention sodium of water, and potassium– (causing Chronic renal toxicity (analgesic nephropathy– after chronic Hypersensitivity: Rhinitis, rash, urticaria,– asthma, anaphylactic shock (1-2% of Hematologic reactions: Agranulocytosis, aplastic – anemia, thrombocytopenia (rare but General adverse reactions ammatory of nonsteroidal anti-infl drugs. monograph pain shows tis face 128 Annual Review MÈTODE 2012 MÈTODE Review Annual 128 practice. risky a is drugs analgesics over-the-counteruse ofand prescribed without justi topeople use of analgesics corresponded sometimes frequent the that and of using drugs, these likelihood of depressionstates unemployment and the increased regions. conclusionssimilar extending Spanish to other made and of usewas inappropriate pattern the that mostly pensioners (66.4%). concluded authors The expenditure, showedpharmaceutical were consumers relationship and the and toprescription Andalusia, consumptionstudy assessing of the NSAIDsin one should analyse how A data, used. they are may exceed far the available many are and use over real their counter the easily accessible are drugs these that account into take adult consumeNSAIDsdaily, population but we if atleast of 20% System that the Health indicated has aceclofenac, for 70% accounts almost of consumption. ofuse ibuprofen, which, together with diclofenac and due increased to mainly is 45.81 rise This 2006. in 1992 day in per to medicines) inhabitants 1,000 per useof tocompare by established WHO doses, as the DDD 26.30 1992-2007 from (de period, the rosein of NSAIDsoutside setting hospital the use the Spain, in Products, Health and Medicines 28.3%while toself-medication. corresponded prescribed medically been had taken of medicine the of were these NSAIDsorsimple analgesics. 71.7% 8.3% for probably and rheumatism, percentage ahigh 6.1%women) painkillers, taken had for fever and 47.2% these,nearlyOf half, (39.1% 53.5% men and two survey. the weeks tothe in prior medication (55%of Spaniards 69.2% men and women) taken had Survey, National Health 2006 tothe According 62.2% ■ lapse between doses. time the in feelsand pain condition patient apain-free the isnot in control pain, plasma reach to the levels it takes to time required the and oradministered isrequested painkiller the time between the that, it tofeel means pain beginning when patient the isalready drug the one administers insufinadequate, (one due persists to that unnecessarily through patient the would that go pain potential the than HOW TO ANALGESICS USE In Finland, a study of 6,500 patients showed a study of 6,500 Finland, In that addition toassessing consumption-relatedIn A comprehensive study by Spanish the information Agency by Spanish the toareport According for Þ able symptoms and also that the joint the able that also symptoms and Þ cient ornonexistent treatment). If Þ gure mentioned above.gure Þ ned daily daily ned
© Fernando Morant chronic daily headaches. daily chronic of form the take paradoxically ofwhich some effects, have side can NSAIDs Abusing quantities. excessive in or indications medical of regardless by users, consumption indiscriminate totheir leads sometimes This counter. over the sold are most and available readily are (NSAIDs) anti-infl drugs Nonsteroidal ammatory An important aspect linked with the consumption In an epidemiological study of headaches of NSAIDs is the simultaneous use of gastroprotective caused by medication overuse conducted in Spain, drugs to prevent adverse gastrointestinal reactions. In 34.7% misused simple analgesics (most commonly the nineties, with the advent of proton pump inhibitors paracetamol/acetaminophen), followed by ergot- (PPIs), these drugs became the therapeutic option of containing medications (27.8%), opioids ( 12.5%) choice for treating gastroduodenal ulcers. In Spain 85 and triptans (2.7%), while the rest (27.8%) misused people out of 1,000 are estimated to be taking PPIs different combinations of drugs. daily, while in Norway the corresponding number is To treat this type of headache, the Handbook only 30 and in Italy it is 27. Accordingly, the use of written by the Cephalgia Workgroup of the these drugs is considered very high in our country. Sociedad Española de Neurología (Spanish Society In practice, the use of these inhibitors in patients of Neurology) recommends discontinuation of the taking NSAIDs is 46-60% of the total prescriptions, drug, and the treatment of migraine attacks with which shows that prophylactic use is well over that triptans or NSAIDs. It also recommends treating recommended for treatment. other factors predisposing to chronic use (sleep
disorders, obesity, stress, anxiety or depression) pain shows face tis ■ ABUSE OF PAINKILLERS or administering preventive treatment with beta blockers or neuromodulators in the case of migraine, The WHO (World Health Organization) de Þ nes and amitriptyline if there is a tension-associated abuse of analgesics as the consumption of component from the beginning. Relapses in these painkillers regardless of medical necessity or in patients are common. unnecessary quantities. This is subject to various In this respect, it is necessary to follow guidelines factors, sometimes due to the doctor who, despite to use analgesics properly. The right drug must be prescribing them correctly, does not give a proper chosen based on the nature and severity of the pain, explanation of how to take them, or it may depend on using the oral route whenever possible. Appropriate the patient, who at the slightest hint of pain, tries to doses must be used at regular intervals (according prevent it from developing by taking the painkillers to the clock and not on demand) and facilitate prematurely, or may even become dependent. The compliance with slow-release formulations. Finally, ease with which painkillers can be bought also secondary or adverse effects should be treated early on. In summary, in the treatment of pain, analgesics encourages their indiscriminate use. monograph One of the paradoxical effects of this abuse is should be used according to recommendations and chronic daily headaches caused by NSAIDs. This guidelines, and users should be aware of their possible complaint is common in clinical practice and is often side effects and avoid misuse. directly related to overuse of painkillers, to such an extent it has been de Þ ned as a disease in its own right with a prevalence of 1.5%. BIBLIOGRAPHY COLÁS , R. et al. , 2004. «Chronic Daily Headache with Analgesic Overuse: Headaches caused by medication overuse Epidemiology and Impact on Quality of Life». Neurology , 62: 1338-1342. are considered as secondary headaches by the GARCÍA DEL P OZO , J. y F. J. DE A BAJO , 2006. Utilización de antiin ß amatorios International Classi Þ cation of the Headache no esteroides (AINE) en España, 1992-2006 . Ministerio de Sanidad y Consumo. Available at: Disease , 2006. They can be de Þ ned as perpetuation
2012 MÈTODE Annual Review 129
A WIDESPREAD COMPLAINT
NOVEL TREATMENTS FOR ACUTE AND CHRONIC PAIN
Carlos Tornero
Pain is one of the symptoms for which patients seek medical treatment most. It affects 12% of the population and is considered severe in one third of these cases. This article reviews the different types of pain, both acute and chronic, and new pain-management treatments. Nowadays, we have multiple options available, which offer sufferers the possibility of a better quality of life. pain shows face tis
According to a recent European Union survey, pain is Chronic non-cancer pain persists more than three one of the main reasons why patients consult their GP. months or even six months, and on a daily basis or, Nonetheless, pain is still underestimated and under- at least, no less than Þ ve days a week. Its intensity treated by both health professionals and patients alike. is moderate at least and can impair the functional In Spain, endurance of suffering is part of our capacity of sufferers. Regarding Spain, the Pain in Mediterranean culture, as is character building Europe survey highlights that this type of pain is through pain. This, together with very limited public more common in women (52%) than in men (48%) resources for pain management, leads to a situation and 22% of respondents categorised it as severe and where when patients suffering pain, sometimes 18% as unbearable. excruciating pain, go to specialised treatment units, Within this category, the most frequent is knee they Þ nd they are totally overrun. pain (28%) followed by back pain (23%) with 20% of the patients taking Þ ve to ten years ■ PAIN IN SPAIN «PAIN IS ONE OF THE MAIN monograph to achieve optimal pain control. The Pain in Europe survey, the REASONS WHY PATIENTS This type of pain can be treated largest ever conducted on chronic CONSULT THEIR DOCTOR. effectively with analgesics and pain and including sixteen NONETHELESS, PAIN IS STILL adjuvants (antidepressants, European countries in 2005, UNDERESTIMATED BY BOTH neuroleptics, steroids...), although revealed that in Spain 12% of a considerable number of patients HEALTH PROFESSIONALS respondents stated they suffered require interventional techniques, from chronic pain, and 31% of AND PATIENTS ALIKE» meaning oral medication can be these were in constant pain. The withdrawn. average duration was found to Another category is chronic be 9.1 years, being more frequent in women (12.4%) cancer pain. This is long-lasting pain within the than men (6.4%). Furthermore, 3% of patients in context of cancer, which can be the direct or indirect pain had been forced to stay in bed more than half a cause of pain (immobilization, treatment, intercurrent day. The most frequent pain is in the back, joints and disease...) and is one of the symptoms most feared bones. Almost one in three respondents had taken a by cancer patients. Opioid analgesics are the main painkiller of some kind in the Þ fteen days preceding treatment but may be limited due to their side effects, the survey. which sometimes necessitate the application of The traditional classi Þ cation of pain, which is still interventional techniques. used today, distinguishes four different types of pain: Cancer pain affects seven out of every ten patients chronic non-cancer pain, chronic cancer pain, acute moderately to severely, and one in four does not postoperative pain and chronic postoperative pain. receive any analgesic treatment. The EPIC survey
On the left, Marusela Granell. Solitude , 2011. Photograph, variable dimensions.
2012 MÈTODE Annual Review 131 monograph pain shows tis face adequate pain relief, must program pain arehabilitation adequate thrombocytopenia...).failure, (nausea, vomiting, constipation,administration renal with drug associated risks the iteffects as decreases subjected tosurgery, side having thus limited area anatomical the to analgesia limited be to enable Regionalregional techniques. techniques systemically (orally or intravenously) or by using analgesics by controlled be administering can Pain ■ area.same anxiety, female gender previous or the interventions in factorssuch preoperative other as it, but are there 32%). isagenetic There component may that favour (4-53%) herniorrhaphy inguinal hysterectomy and (5- including: thoracotomy pain, (20-80%),chronic the should not be a continuation of a preoperative problem. months. Any other aetiology should outbe ruled and it surgerythat pain occurs after and lasts longer two than hospital. from discharge speedier and patients recovery better but mean italso comfort can protocol. analgesic the and of surgery type on the depending 132 Annual Review MÈTODE 2012 MÈTODE Review Annual 132 con hospital their experience it at some point during patients undergoingof hospitalised major surgery even 85% treated it be before can Around it appears. it As chronic. foreseeable is becomes most in cases, it unless duration alimited has and procedure, asurgical after experienced which type isthe previous the month. during pain experienced ismore, advice. 96% What medical of patients had reasonwhy patients seek primary isthe pain that 2009, published Europe, in reveals in pain on cancer TREATING POSTOPERATIVE PAINTREATING To achieve postoperative recovery and full more likely lead to to are of surgery types Certain Finally, chronic postoperative is ofpain the type management not isessential onlyPain for the Next, we acute postoperative differentiate pain, Þ nement. The percentages vary signi vary percentages nement. The MEDITERRANEAN CULTURE, ASIS CHARACTER BUILDINGTHROUGH SUFFERING ISPART OFOUR «IN SPAIN, ENDURANCEOF PAIN» Þ cantly,
© De La Ribera University Hospital, Alzira it is considered chronic postoperative pain. postoperative chronic considered is it months over two lasts pain When area. affected the and operation of type the on depending appear may pain surgery, After SURGERY, THEEXACTNERVE TERRITORY AFFECTED MUSTBECONSIDEREDTO ACHIEVE THEBESTPOSSIBLEPAIN «DEPENDING ONTHELOCATION OF RELIEF» take into account other factors that may hamper Meanwhile, patient-controlled analgesia, where recovery, such as hypothermia, immobilization, or the patient manages the level of analgesia required, the irrational use of catheters, hypoxemia and the provides high quality treatment with greater like. satisfaction, especially when continuous infusion is associated with bolus on demand. However, Pain relief this system is more costly and requires greater Depending on the location of surgery, the exact nerve participation of the patient and enough clear thinking territory affected must be considered to achieve the to understand how the system works. best possible pain relief. According to the location of the analgesic technique, differentiation is made Neuraxial techniques between neuraxial techniques (focused on blocking Neuraxial techniques are commonly used by the pain impulse in the spinal cord), which include anaesthesiologists, primarily because of their epidural and subarachnoid and peripheral nerve effectiveness during surgery. The epidural technique blocking techniques. The difference between epidural is most often used postoperatively, providing quality and subarachnoid neuraxial blockade lies in the pain relief with minimal side effects and remains the pain shows face tis place where the local anaesthetic or analgesic is most effective analgesic method after laparotomy administered. In the former, it is deposited outside in digestive surgery. In thoracic surgery, epidural the duramater and the latter inside the subarachnoid administration of local anaesthetics with opiates space, mixing with cerebrospinal ß uid. Peripheral is the recommended technique, showing a similar nerve blocks do not block the stimuli at the spinal analgesic ef Þ cacy as paravertebral block and better level but directly target the than systemic analgesics or nerve or set of nerves (nerve intercostal in Þ ltration. plexus) and the analgesic or local «NOWADAYS WE ARE ABLE The bene Þ ts of epidural anaesthetic is deposited nearby. with local anaesthetics are TO OFFER MOST PATIENTS A The success of any particularly clear when treating continuous analgesic technique BETTER QUALITY OF LIFE. AS pain within 72 hours of surgery lies in suitable recommendations LONG AS TECHNIQUES ARE when compared to patient- based on the surgical procedure, APPLIED APPROPRIATELY, controlled intravenous analgesia. proper positioning of the This system improves the PAIN BECOMES TOLERABLE, monograph catheter, the right choice of endocrine-metabolic impact of drugs to be infused, with IRRESPECTIVE OF ITS ORIGIN» surgery and provides signi Þ cant bene Þ cial association of local advantages in patients at high anaesthetics and opioids, and an risk of cardiac or respiratory appropriate pain management system. disease, and possibly reduces the likelihood of chronic pain. Painkillers Analgesics (anti-in ß ammatories, opioids, local Peripheral techniques anaesthetics...) can be administered as a bolus Single-shot peripheral nerve blocks provide quality (administering an amount of the drug directly into postoperative pain relief over a period of up to 24-36 a particular zone), by continuous infusion or in the hours, even using new-generation local anaesthetics. patient-controlled analgesic mode intravenously, as Since they were Þ rst described by Ansboro in epidural or perineural. 1946, continuous nerve block techniques by catheter The administration of bolus at regular intervals occupy a prominent place in bibliography dealing implies a lower overall cost; however, it does not with pain management and regional anaesthesia. meet the analgesic requirements of most patients The use of catheters for postoperative pain relief has adequately. This is because not all patients feel the extended the analgesic effects beyond the surgical same intensity of pain after surgery, and bouts of operation itself, and along with quality analgesia pain may arise between doses, when pain relief is has allowed early rehabilitation and speedy patient insuf Þ cient for some patients. discharge. Continuous infusion allows for better pain relief The continuous peripheral techniques most but does not adequately cover the peaks of pain the commonly used for postoperative pain relief are the patient may experience. interscalene block for shoulder surgery, infraclavicular
2012 MÈTODE Annual Review 133 monograph pain shows tis face peaks of pain the patient may experience. may patient the ofpain peaks cover the adequately not does but control, pain better for allows infusion Continuous techniques. management pain several are There patches contain a reservoir of areservoir opioids gelpatches contain in form, latest management. The pain chronic in forward amajor been has step diffuse, can which drug the thoracotomy, surgery). or vascular herniorrhaphy (especiallyor postoperative after neuropathies myalgia) (headaches, disturbances nerves, functional of injuries traumatic (types II), I and regional pain zoster...), toherpes secondary (trigeminal, complex surgery, post-laminectomy syndrome), neuralgia back failed degenerative after pain spondylarthrosis, (spinal are: back pain units stenosis, pain chronic analgesiccontrol and ef invasive provide pain that better techniques pain-relief delivery, new of forms drug of plus administration, changed signi 134 Annual Review MÈTODE 2012 MÈTODE Review Annual 134 ■ surgeryknee and sciatic block for foot surgery. block for elbow surgery, the femoral nerve block for DEALING WITH CHRONIC PAIN CHRONIC WITH DEALING The use of devices, attached to the skin, through through skin, useof tothe devices,The attached pathologies in The most treated frequently haveAnalgesic pain chronic options for treating Þ cantly in recent years, with years, new recent cantly in routes Þ cacy.
© Fernando Morant facilitate recovery.facilitate to and wellbeing patient for both pain this to control important confi hospital is It during nement. pain postoperative suffer surgery major undergoing patients 85% hospitalized of About
© Fernando Morant as well as a diffusion-limiting membrane which lets electrodes implanted in the epidural space. It is mainly a fairly steady ß ow through for 48-72 hours. This used to treat neuropathic and ischemic pain and can procedure allows for greater patient comfort by also be used for chest pain (angina). reducing the multiple daily doses of painkillers. So, we can see from this review of the main In addition, new analgesic administration formats techniques and approaches to controlling acute and allow patients to quickly and adequately control their chronic pain that, nowadays, we are able to offer most pain, which is especially useful in cases of cancer patients a better quality of life. As long as techniques breakthrough pain, in which relief is achieved within a are applied appropriately, pain becomes tolerable, few minutes and lasts a predictable time. irrespective of its origin. On the other hand, regarding interventional In the eighties, the view that the French health techniques in chronic pain management, multiple authorities held on the treatment of pain changed invasive techniques can be used in patients with chronic totally. The reason was that a relative of the Minister pain, from simple nerve blocks and in Þ ltration to more of Health at the time was suffering from a pain that sophisticated techniques that include radio frequency was dif Þ cult to control, and could not Þ nd quality lesioning, spinal infusion or spinal cord stimulation. care at one of the most dif Þ cult times in life. From pain shows face tis All these techniques may be that moment on, an active policy used on different targets. However, began. Pain-management and sometimes it is essential to verify «PAIN IS ONE OF THE MAIN palliative-care units were set up, or perform diagnoses before using training programmes were run SYMPTOMS CAUSING the more sophisticated techniques for health professionals as well as the source of the pain may not PATIENTS TO SEEK as public awareness campaigns be clear and the exact source of MEDICAL CARE. NOWADAYS and research into new therapies pain must be located Þ rst. Blocking WE HAVE BOTH THE was promoted. All this led to an can be employed to temporarily PHARMACOLOGICAL TOOLS improvement in the quality of life reduce pain or to allow patients to for French citizens. carry out rehabilitation which they AND INTERVENTIONAL Pain is one of the main would not be able to if they were TECHNIQUES TO TACKLE IT symptoms causing patients to seek in pain. TOGETHER» medical care. Nowadays we have These techniques are usually both the pharmacological tools monograph performed in sterile rooms and interventional techniques to preferably surgical areas and to carry them out, tackle it together and, so doing, we can improve the different localization support methods are required. quality of life of patients suffering pain. Practitioners may use nerve stimulation, ultrasonography, computed tomography and even magnetic resonance BIBLIOGRAPHY imaging, all with the sole aim of reaching the target area ALIAGA , L. et al ., 2009. Tratamiento del dolor. Teoría y práctica . 3rd edition. Publicaciones Permanyer. Barcelona. more accurately. ALIAGA , L. et al. , 2006. Anestesia regional Hoy . 3rd edition. Publicaciones Radio frequency uses electrical currents exceeding Permanyer. Barcelona. 500,000 Hz to produce well-de Þ ned lesions, BREIVIK , H. et al. , 2006. «Survey of Chronic Pain in Europe: Prevalence, Impact on Daily Life, and Treatment». European Journal of Pain , 10: 287-333. which can be predicted by controlling electrical BREIVIK , H. et al ., 2009 «Cancer-related Pain: a Pan-European Survey of parameters, temperature and electrode measurement. Prevalence, Treatment, and Patient Attitudes». Annals of Oncology , 20: The therapeutic effect is achieved by the heat and 14201433. CATALÀ , E. et al. , 2002. «Prevalence of Pain in the Spanish Population: electromagnetic changes generated. Conventional Telephone Survey in 5,000 Homes». European Journal of Pain , 6: 133-140. radiofrequency can also be used, typically reaching LEE , A. et al. , 2007. «Economic Evaluations of Acute Pain Service Programs: temperatures of 80 °C, or pulsed radiofrequency, which a Systematic Review». The Clinical Journal of Pain , 23: 726-733. MACRAE , W. A., 2001. «Chronic Pain After Surgery». British Journal of reaches temperatures of 42-45 °C with a pulsed rather Anaesthesia , 87: 88-98. than a continuous current. MCMAHON , S. B. & M. K OLTZENBURG , 2006. Wall & Melzack. Tratado del Radiofrequency is mainly recommended for spinal dolor . Elsevier. Madrid. VALLANO , A. et al. , 2007. «Estudio multicéntrico de la evaluación del dolor pains but is also being applied to peripheral joints en el medio hospitalario». Revista Española Anestesiología, Reanimación (shoulder, knee...), peripheral nerves (greater occipital y Terapéutica del Dolor , 54: 140-146. nerve, sural nerve...), and the like. Carlos Tornero Tornero . Coordinator of the Acute and Chronic Pain Spinal cord stimulation is a neuromodulation Management Unit. Department of Anaesthesiology, Valencia University technique that modulates pain transmission using Clinic Hospital.
2012 MÈTODE Annual Review 135
CHILDREN IN PAIN
HOW TO MEASURE AND TREAT PAIN IN LITTLE ONES
Cristina Morales
Children experience pain just like adults, since nerve pathways develop during pregnancy. Pain in infants has particular connotations because it is diffi cult to assess, but there are validated methods to detect it and, above all, there are procedures and medicines to treat pain effectively in children. pain shows face tis Why should we devote an article to pain in children? reasons, it is especially important to recognise and Does this context differ from adults? Based on the avoid unnecessary pain in children, pain that can and de Þ nition of pain as an unpleasant sensory and should be avoided with the proper treatment. emotional experience , it seems logical that children are equally prone to suffering it as adults. For many ■ UNDERSTANDING PAIN IN CHILDREN years we were under the misconception that children had a lower perception of pain due to the immaturity Assessing pain in children is a dif Þ cult task, since of their nervous system. Nothing is further from the it is a symptom and is, therefore, subjective. To this truth. Indeed, it has been shown that between the we must add the fact that how pain is perceived, second and third trimesters of pregnancy the neural interpreted, lived and, above all, expressed varies pathways for pain develop. depending on the patients What is true about pain in age. Children under two have children is that it has special «PAIN IN CHILDREN HAS no concept of time, and have connotations, on the one hand SPECIAL CONNOTATIONS dif Þ culty understanding pain: due to the dif Þ culty children have what is it and how long it will monograph DUE TO THE DIFFICULTY in understanding what it is and in last. Therefore pain is invasive expressing themselves and, on the CHILDREN HAVE IN and it scares them. From two to other, the dif Þ culty adults have UNDERSTANDING WHAT seven years of age, kids have an in interpreting and, therefore, IT IS AND IN EXPRESSING egocentric view of the world, they preventing or treating pain. THEMSELVES, AND THE believe someone is responsible Painful experiences in for their pain but do not know childhood, even when they are DIFFICULTY ADULTS HAVE IN how to locate it. Seven to eleven not remembered, will change INTERPRETING THEM» year olds have developed logical the childs perception and thought, so they can explain, attitude to pain later in life. locate and quantify the intensity Studies of preterm infants that undergo extensive of pain. And Þ nally, over elevens can understand testing or painful techniques (multiple blood that they can do something to modulate pain, and so extractions, intubation...) from birth indicate they they need information about pain and how to treat it. have a lower tolerance to pain and are more fearful All these aspects must be taken into account when of potentially painful situations in later life. It has assessing and treating pain in children. been demonstrated that children who suffer from Despite the dif Þ culties in assessing pain in pain in neonatal units fare worse because they have children, there are numerous approved methods and lower oxygen concentration, increased cardiovascular scales enabling objective measurement. To assess pain instability and higher intracranial pressure; moreover, in children under three years of age, signs derived their neurological development is slower. For all these from their stress response can help us, such as heart
On the left, Greta Alfaro. Life 2 , 2011. Digital collage, 21 x 28 cm.
2012 MÈTODE Annual Review 137 monograph pain shows tis face 138 Annual Review MÈTODE 2012 MÈTODE Review Annual 138 orcolour, of orverbaldegrees pain, scales. numerical drawingsmore with facial expressing useful, varying pain». However, may scales be graphic for children or«excruciatingend-points representing «no pain» a position alongbetween two acontinuous line leveltheir of toastatement by agreement indicating model most respondents used the commonly specify for used tothose adults. In similar used, be can scales excessivethrough calm. and stillness may which express pain in children their pain, of cases chronic in especially orirritability, crying (withdrawal re movements body and expressions, crying screaming, signs behavioural such other facial as are There bloodorsweaty high pressure palms. breathing, rate, situation before and after treatment. after and before situation the tocompare us allows which 0, 1or scored are they present, are image the in shown elements various the If pain. to assess us help can three) (under children young of expression facial The assess itsassess ef to treatment after then and pain initial the to assess adults, such As in own should used scales be pain. which asked then their one ismostThey are like right. far on the upending with excruciating pain feel right pain, on intense the increasingly children lefton shows the the and someone who no pain has face told the that are Children Catalan. and Spanish for numerous languages, including usein instructions with assessment for children in pain recognised expressionswith different isinternationally and Spaffords over children In of years six age, analogue visual Þ cacy. Faces Scale Pain ß exes). should One not always expect consists of faces six Opened mouth: mouth: Opened Nasolabial furrow Furrowed brow: brow: Furrowed YES: 1, NO: 0 NO: 1, YES: 0 NO: 1, YES: 0 NO: 1, YES: 0 NO: 1, YES: tightening: tightening: deepened: Eyelid Eyelid
© M ÈTODE can be found at:
© IASP
© De La Ribera University Hospital, Alzira There is a lot of information about one particular For most drugs used in paediatric medicine, clinical non-pharmacological method, which concerns the use trials are not conducted using children and therefore of oral sucrose. Studies show that children between two the results must be extrapolated from trials in adults. and four months of age given 0.6 ml/kg of 24% sucrose This means that the dosage is calculated from the solution during immunisation experienced less pain usual dose in adults, either in terms of weight or than children of a similar age who were given water. body surface area (BSA) or age range. Painkillers Some paediatricians have proposed the systematic use are no exception, and limited clinical research in of this procedure during the vaccination process. children means the authorisation to use drugs in this Parents play an important role in implementing age group and the conditions of use do not coincide non-pharmacological methods to avoid unnecessary in different countries. A recent Italian study shows pain, and to help them in this task they should be that acetaminophen among other drugs, which is properly informed by health professionals. approved and widely used for children, has different Analgesics are used to treat pain usage conditions in Italy, France and the UK. In Italy, pharmacologically. Although there are many dosage is adjusted to the childs weight while in the
different drugs, few receive paediatric approval: United Kingdom it goes by age group and in France by pain face shows tis acetaminophen, ibuprofen, metamizol and codeine. the two methods combined. What is remarkable is that The latter, however, despite being a proven pain the doses do not coincide. Does it make sense that a reliever can also be associated with acetaminophen, child of equal age and weight receives a different dose and is sold in Spain only as a cough medicine. of acetaminophen based on that fact he/she is French, Until the eighties, aspirin was the analgesic English or Italian? The public should not be alarmed,
ÈTODE of choice in paediatrics. However, it is currently the differences may not be that important, but an effort
© M contraindicated in patients under sixteen years of age should be made to harmonise the authorisation and because its use to treat fever in some viral infections, conditions of use of different drugs in the international such as chickenpox, has been associated with a severe arena. In fact, the European Medicines Agency is and potentially fatal condition called Reye syndrome. promoting the study of drugs in children, including What is more, there are now alternatives with a better analgesics, and harmonisation of information and legal safety pro Þ le, such as acetaminophen or ibuprofen. conditions of use. Children can experience pain from the moment they are born and this is of importance as early monograph painful experiences may in ß uence later development. Therefore, it is necessary as far as possible to prevent and relieve pain in children, and parents can play a key role in this task.
BIBLIOGRAPHY EUROPEAN M EDICINES A GENCY . Paediatric Medicine Development. European Medicines Agency. Available at:
2012 MÈTODE Annual Review 139
THE RIGHT NOT TO FEEL PAIN
ETHICAL IMPLICATIONS OF PAIN RELIEF
Enrique Soler
Pain can have far-reaching effects on people’s quality of life. Improper treatment is a serious healthcare issue and an ethical problem of the fi rst degree, directly affecting people and potentially undermining their dignity. The absence of adequate pain assessment and management violates the basic ethical principles of autonomy, welfare, nonmalefi cence and justice. pain shows face tis
Ethics is a philosophical discipline dealing with between knowledge and practical applications. This moral issues, that is, our behaviour actions, habits is true for both chronic and acute pain. The causes and life in general from the viewpoint of what is are multiple: culture, attitudes, education, economic good, dutiful or valuable, qualifying behaviour as capacity and health policies. good or bad , right or wrong , valuable or devoid Furthermore, there is enough research to support of moral value. When it comes to pain, an ethical the statement that inadequate pain relief, as well approximation is also suitable, and when referring to as diminishing the overall quality of the affected the ethical aspects of pain we are doing nothing more patients life, also decreases their life expectancy. than asking ourselves within this Although there are situations topic area «What is right?» and for which there are no valid «What is wrong?». That is, what therapeutic alternatives at should and should not be done «PAIN IS AN UNPLEASANT present, unnecessary pain is a
with respect to this healthcare EXPERIENCE THAT AFFECTS serious healthcare problem. This monograph issue? ALL HUMAN BEINGS AT SOME can be de Þ ned as persistent pain, due to inadequate treatment POINT IN THEIR LIVES AND, PAIN CONTROL AND or absence of any therapeutic ■ DESPITE HIGHLY DEVELOPED DIGNITY measure, despite availability of KNOWLEDGE REGARDING effective therapies. Pain is an unpleasant experience THIS AILMENT, TODAY IT Even today millions of people that affects all human beings IS STILL INADEQUATELY suffer different types of pain at some point in their lives that can be avoided. This lack of and, despite highly developed TREATED» consideration for others pain by knowledge regarding this health professionals is an ethical ailment, today it is still problem of the Þ rst degree, inadequately treated. Pain can have far-reaching directly affecting people and undermining their dignity. effects on peoples quality of life, with important Numerous studies, conducted in recent years, consequences in personal, family and social circles. indicate that even in cases where pain is treated, the It is a major public health problem given the large treatment is inadequate or insuf Þ cient. B. Ferrell talks socioeconomic impact it has, due to the consequent about the triple whammy effect: the doctor prescribes use of health services, the loss of productivity in the quantities below what is necessary, nurses administer work ambit and disability subsidies to be paid. less than that prescribed and patients do not report Despite the progress made both in the their pain fully. understanding of mechanisms involved in pain After many years of neglect, in August 1999, the processes and treatment thereof, there is a huge gap Joint Commission on Accreditation of Healthcare
On the left, Marusela Granell. Eternal Night , 2011. Photograph, variable dimensions.
2012 MÈTODE Annual Review 141 monograph pain shows tis face 142 Annual Review MÈTODE 2012 MÈTODE Review Annual 142 we reach. If donot have within they are necessary the knowledge available torelieve whether ornot pain, tools and the who suffer, all ustomake encourage and with those for solidarity call attitudes Truly ethical ■ considered as should and be rights of fundamental infringement exist it alleviate to prevent or it entirely an is right. human fundamental relief consider a as pain Organisation Health WorldAssociation for the Study and of the Pain of problem, the International magnitude the the with physical or psychological violence. to Due violatesact that peoples dignity, occur might as without it pain, considered being an unnecessary breathing. pulse, bloodand pressure way temperature, body as asimilar monitored in consideredbe the was to for aim pain The standards. their control in (JCAHO)Organisations problem. health public amajor is it Currently circles. social and family personal, in consequences important with oflife, quality people’s on effects have far-reaching can Pain ETHICAL CONSIDERATIONS ETHICAL To when means the allow tosuffer pain aperson It isdif Þ cult to justify continued suffering of suffering continued cult tojustify ß agrant malpractice.agrant Þ fth vital sign therefore and vital be fth Þ nally included pain includednally pain their body,their is not body psychophysical only the the beings exist human through Although determination. place for the as physiological clinically is taken the which dichotomised dualism, of Cartesian remnant beings. of human dignity and sense of beforedeep awe well-being the humility and more A compassion forbearance. and they deserve, should view and someones with death well-being esteem and respect wishes withand the patients the They suffering. shouldand grant values, more toways attention patients of the mitigating pain paid policymakers society, health if and clinicians adigni to right debate on the of current the bitterness intensity and without and by excessive family intervention. The surrounded to dying withoutis associated pain, all professionalsall involved patient care. in professional obligation not only of but of doctors, also Avoiding isthe suffering and pain we referskills, patient who the tothose have them. dif The absence of adequate pain relief a tobe seems pain of absence adequate The For most people, concept of the a «digni Þ cult de to physical and the the and Þ ne but easy to detect, and awakens and ne but easy todetect, a Þ ed death would diminish considerably would death ed diminish mental , and where body , and the Þ rst moral and and rst moral good death is death Þ ed death» death» ed
© De La Ribera University Hospital, Alzira pain shows face tis © De La Ribera University Hospital, Alzira Truly ethical attitudes call for solidarity with those who suffer, and encourage us to make all the tools and knowledge available to relieve pain.
place where disease acts, but the persons dimension they have to assess and treat the pain and suffering of monograph where suffering is experienced and the person as a each and every one of their patients. Failure to do so whole is affected. The corporeal is not something a implies an unful Þ lled responsibility, that is, they can be person has but something that the person is . held accountable to patients and to society as a whole. Suffering involves the The welfare state which has individuals values and been achieved, in European well-being, as well as the «THERE IS ENOUGH countries especially, promotes underlying physical causes. the worship of beauty, of what is RESEARCH TO SUPPORT Thus, in addressing pain the young, the desperate search for psychological, social and THE STATEMENT THAT happiness, understood as a kind of spiritual aspects of analgesic INADEQUATE PAIN RELIEF, AS permanent nirvana of continuous therapy are not ornaments WELL AS DIMINISHING THE and inexhaustible pleasure, where but essential components of OVERALL QUALITY OF THE there is no place for the sick, good pain management. This the weak, the bad or the ugly. In dichotomy has led physicians AFFECTED PATIENT’S LIFE, this context, however, we should to assume responsibility solely ALSO DECREASES THEIR LIFE not be tempted to identify the for the treatment of physical and EXPECTANCY» rejection of unnecessary pain biological aspects of disease, and unnecessary suffering with a while they leave suffering to be hedonistic attitude. treated by psychologists, priests and social workers. Proper pain relief is a priority in the care of all ■ PRINCIPLISM AND ETHICAL ANALYSIS patients, and is deeply rooted in the origins of the medical profession. Physicians have the responsibility With the birth of bioethics, a number of models to treat both the patient and the person, which means or ethical paradigms have been put forward to
2012 MÈTODE Annual Review 143 monograph pain shows tis face 144 Annual Review MÈTODE 2012 MÈTODE Review Annual 144 and popular in the biomedical biomedical the in popular and widespread most The new discipline. the approach is, autonomy entitled protection. to are autonomous people with diminished that entity and convictions: everyone that an as should treated be principles.ethical assessment management and violates basic these pain of absence each case. adequate The individual for should established between them hierarchy be equally, respected but be to when con in four would, principles for (autonomy)respect persons justice. and These never excuse an as used be defence, oras lack the and avoided considered thus is and couldbe action that isaharmful This suffering. and possible,as such istoactin away toin as far as of surgery prevent trauma and pain orreduce to necessary means touseall failure cases, these In tests. diagnostic invasiveness certain and of surgery impossible toavoid patient, given tothe trauma the situations where of are it intervention.risks There is avoid in with associated recovery.prognosis facilitates and relief improvesown pain morbidity adequate while of bene prevent to means it, violates principle openly the withoutpatient providing to suffer pain, necessary the whatseek for isgood patient the above Allowing a all. autonomy. of principle bene The oreven relief in helpstoadecline leads perpetuate pain inadequate more dependent;them furthermore, considerably autonomy,and their reduces making recovery. favours and by caused pain speedy anxiety reduce preferences their helps patient respecting to the and informing Properly plan witha pain-relief them. design and pain alternatives available their totreat of them the inform they manifest, believe pain the in ofthe principles famous the took Childress, and Beauchamp founders, Its moral principles:moral bene patients, shouldgovernedand be tofour according workers relationships between all healthcare general ofprinciplism. point starting the as ofbioethics letter foundational In the present case, to respect patient present case, autonomy respect the to In Respect for two implies aperson ethical The principle of principle nonmaleThe By we destroys contrast, know pain aperson This model advocates that medical practice, and in in and practice, model advocates medical that This Þ rstly, toinvolve to treatment, their patient the in Þ ß cence. Moreover, itself its produces pain icting harm on the patient, minimising the the patient, on minimising the harm icting primum non nocere non primum Þ prima facie, facie, prima cence, nonmale Belmont Report Belmont Þ cence, traditionally cence, traditionally Þ wrong eld is principlism. principlism. eldis Þ cence requires usto requires cence be principles principles be , requires us to to us requires , . Ignorance can can . Ignorance Þ cence, ß ict the ict the true true ß ict pain ict pain pain or excessive external intervention. external excessive or pain without todying ofa«dignifi concept associated is The death» ed TOOLS ANDKNOWLEDGEAVAILABLE TO AND ENCOURAGEUSTOMAKEALLTHE SOLIDARITY WITHTHOSEWHOSUFFER, «TRULY ETHICAL ATTITUDES CALLFOR RELIEVE PAIN» sufferer. Even before any ethical analysis, it is necessary to determine the technical correctness of the procedure. The principle of nonmale Þ cence also requires us to weigh the bene Þ t versus risk of each analgesic intervention, and to know the side-effects of drugs and analgesic techniques. It obliges us to choose those with better therapeutic and safety pro Þ les, taking into account the patients clinical situation and characteristics. Health professionals, as moral agents, have an ethical responsibility to treat our patients so as to maximise the bene Þ ts and minimise the harm. The principle of justice demands equality in the medical treatment received by each patient, and this is violated when some receive proper pain relief but pain shows face tis others do not, depending on the professionals or institutions they are assisted by. Justice dictates that similar medical conditions should be treated similarly. All patients are entitled to have their pain assessed and treated adequately. Ignorance or the unequal distribution of healthcare resources is no excuse or defence in a society that guarantees the universality and equity in access to healthcare. Finally, with respect to resource availability and distribution, although there are many high- cost techniques, analgesic treatment is generally speaking easily affordable. Indeed, there is a wide © Fernando Morant range of powerful low-cost drugs available and
If death was looked upon with more compassion, respecting the analgesic therapy is an essential component of good monograph patient’s values, well-being and wishes, the debate over the right pain management. to a dignifi ed death would stir up less controversy.
of proper training or knowledge leads directly to malpractice. «FAILURE TO USE Both physicians and other AVAILABLE RESOURCES TO
professionals working in patient ALLEVIATE PAIN SHOULD BIBLIOGRAPHY care have the responsibility to BEACHAMP , T. L. & J. F. C HILDRESS , 1999. BE CONSIDERED AN ACT OF be appropriately quali Þ ed and Principios de ética biomédica . Masson. PROFESSIONAL NEGLIGENCE» Barcelona. to posses up-to-date knowledge CLARK , P., 2002. «Ethical Implications of on drugs and other techniques Pain Management. Can a Formalized Policy that bene Þ t patients. If, for Help?». Health Progress , July-August: some reason, this is not possible then they have the 19-28. © Fernando Morant GÓMEZ S ANCHO , M. & M. O JEDA M ARTÍN , 1997. «El problema del dolor. responsibility and ethical duty to consult professionals Historia y análisis de un escándalo». Medicina Paliativa , 4: 20-34. who are properly trained to handle pain. Defending RICH , B., 2000. «An Ethical Analysis of the Barriers to Effective Pain Management». Cambridge Quartely of Healthcare Ethics , 9: 54-70. ignorance is to violate the goals of medicine and to MACPHERSON , C., 2009. «Undertreating Pain Violates Ethical Principles». breach doctors basic duty towards their patients. Journal of Medical Ethics , 35: 603-606. Gomez and Ojeda tell us: «Inadequate pain relief SOLER C OMPANY , E. & M. C. M ONTANER A BASOLO , 2003-2004. «Consideraciones bioéticas en el tratamiento del dolor». Persona y is the most outrageous and persistent medical Bioética , 20-21: 49-63. malpractice». TORRES , L. M., 2005. «El tratamiento del dolor como un derecho de todos». Failure to use available resources to alleviate Revista de la Sociedad Española del Dolor , 12: 399-400.
pain should be considered an act of professional Enrique Soler Company. Head of the Pharmacy Unit at the Arnau de negligence, as it causes unjusti Þ ed harm to the Vilanova Hospital. Valencia.
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