Pain is very much a personal experience, writes Charles Gauci, who argues that what is severe pain to one individual may not necessarily be as severe to another.

Pain is caused by an event which has either damaged the body, such as chronic arthritis, or which has the potential to damage the body if left unheeded, such as acute appendicitis. In some cases pain is described in imaginary terms; hence, patients may describe their pain as being ‘stabbing’ or like ‘walking on broken glass’ even though they may never have actually experienced such events.

A paper in the British Medical Journal (2016) showed that pain affects between one-third and a half of the population of the UK (just under 28 million adults) and that this figure is likely to increase further in line with an ageing population.

A ‘Pain in Europe’ survey (2004) interviewed over 46,000 people and reported that a third admitted to suffering continuous chronic pain. An American study (2014/2015) revealed that 11.9 per cent of all chronic pain was due to cancer. No accurate local figures are yet available.

One has to distinguish between acute and chronic pain.

Acute pain, which is sudden and immediate, acts as an alarm; it’s the body’s natural response to actual or potential physical harm. It can sometimes be life-saving as in the case of abdominal pain which warns of acute appendicitis. Acute pain is, therefore, definitely a useful pain.

Chronic pain, which is pain lasting for longer than three months, such as the continual pain generated by, say, arthritis serves no useful function whatsoever. It merely reflects the fact that changes have occurred within the body. Its value as an alarm signal having passed, chronic pain is, consequently, a non-useful pain, which simply demoralises the patient and puts a strain on the patient’s family and on the nation’s health resources.

Pain which persists after all signs of the original cause have disappeared or where curative treatment of that cause is not possible must be regarded as a disease in its own right which demands specific treatment.

Pain is very much an individual personal experience, thus what is severe pain to one individual may not necessarily be as severe to another. There are no definite tests to prove that pain exists and it is impossible to measure pain objectively.

The same condition may cause different types of pain in different individuals. Pain, apart from being an unpleasant sensation, often also generates an unpleasant emotional experience (suffering). Pain does not always arise at the site at which it is experienced; hence, pain in one part of the body may indicate a problem at another site (referred pain). The brain is capable of both reducing and increasing the level of pain being felt and emotions can play a large part in pain perception. Chronic pain is more common in women. 

There are essentially, three kinds of pain.

When pain arises in the presence of an undamaged nervous system, it is referred to as nociceptive pain. Such pain is very common and often arises from the musculoskeletal system.

There are no definite tests to prove that pain exists and it is impossible to measure pain objectively

When pain arises from a damaged nervous system, it is referred to as neuropathic pain; this is a particularly vicious form of pain which is often difficult to treat. Nerves can be damaged by trauma, toxic chemicals and metabolic illnesses such as diabetes. They can be invaded or squeezed by tumours, trapped by scar tissue or suffer infection; an example of the latter is chronic pain which may follow an attack of shingles.

‘The epidemiology of chronic pain’, by Gary J. Macfarlane, from online journal Pain.

When there is no obvious cause for it, pain must be regarded as being functional or psychosomatic. Chronic pain can appear as a result of mental illness such as anxiety and depression as well as in severe stress; here we talk of the stress becoming somatised.

It is extremely important to identify which type of pain is present as the treatment of each is fundamentally different. More than one form of pain can sometimes be present in the same patient.

Many patients attending pain clinics, quite understandably, become upset if the doctor suggests referral to a psychologist or psychiatrist as they think that the doctor does not believe that their pain is genuine. They are mistaken. Such pain is indeed genuine but is due to problems with the function as opposed to the structure of the body and consequently requires treatment by the correct specialist.

Self-help is fundamental. Patients must help themselves, especially when suffering from musculoskeletal pain. An obese patient with low back pain must lose weight. A patient with an arthritic spine must avoid heavy lifting; here pain can be considerably improved by a daily routine of simple back exercises. In a number of cases the family doctor may decide to refer the patient to the relevant specialist; the latter may then  decide to refer the patient to the pain clinic. In other cases, it may be felt that direct referral to the pain clinic by the family doctor is indicated.

Pain clinics will only deal with chronic pain and the pain specialist may insist on a prior consultation with an appropriate colleague to rule out any curable conditions. Patients with musculoskeletal pain should always be initially assessed by a physiotherapist before referral to the pain clinic.

Pain clinics have a lot to offer patients but it must be understood that interventional procedures (‘injections’) only come at the end of a long road and are not always successful.

In general, very strong opioids such as morphine should be reserved for cases of cancer pain, due to the real risks of addiction. Most strong painkilling drugs (analgesics) are opioid-related and often cause constipation. Anti-inflammatory drugs must only be used in short courses and with caution because of the possibility of serious side-effects.

In neuropathic pain, the over-activity of damaged nerves can often be reduced by antidepressants and/or antiepileptic drugs, so patients should not infer any sinister motive from their use by the doctor.

There is very little hard scientific evidence that medical cannabis is of any long-term use in chronic pain. The adverse effects of its prolonged use, including any possible effects on pregnancy, have not yet been properly evaluated.

There are many diverse drugs, which when used judiciously can help to control pain, but it is important to ensure that the drug dosage is increased, if necessary. Naturally, all doctors should be totally familiar with the risks and benefits of any drugs they employ.

Sometimes, it is not possible to remove the patient’s pain. In some hospitals a structured pain management programme exists to teach such patients how to cope and live with their pain. 

Chronic pain is indeed a major problem but in this day and age no one should be told by their doctor to live with it unless they have been comprehensively treated, if necessary in a pain clinic.

Charles Gauci is a consultant in pain medicine at  Mater Dei Hospital and at Gozo General Hospital and lectures on human anatomy at the University of Malta.