Good Oversight May Assure Safety of Analgesia

Pain is one of the most common reasons why someone goes to the doctor. This is for both acute (sudden) and chronic (long-term) pain. If non-medical treatment doesn't work, such as rest, ice, exercise, for example, the next step is usually to use medications. Analgesics, medications to relieve pain, are among the most widely prescribed medications because of the high number of people who live with pain. Despite all that researchers have learned about pain management, many people are still experiencing moderate to severe pain, somewhere between 20 percent and 40 percent.

When treating rheumatoid arthritis, for example, doctors have available topical agents (creams or ointments), non-steroidal anti-inflammatory drugs (NSAIDs), opioids (controlled drugs, also called narcotics), and many other types of medications. Yet, most people with rheumatoid arthritis still experience a high level of pain. Cancer is another illness that can cause severe pain. It's estimated that half of people with cancer do not receive adequate pain management.

Many studies that have looked into pain treatment and its effectiveness have been relatively short-term studies and, if the improvement is up to 30 percent, this is considered to be significant, or good. That leaves 70 percent without adequate relief. Understanding how pain management works would help doctors and researchers come up with better pain management strategies. The authors of this article looked into the consequences of finding "profoundly" effective pain relieving treatments.

When analgesics are used to relieve pain, the medications work to stop the cause of the pain, for example an anti-inflammatory will reduce inflammation and thus reduce pain, or to interrupt the pain messages to the brain, like opioids do. A local anesthetic, like a topical cream or something injected directly into the area numbs the pain so the sensation isn't transmitted to the brain. The problem with medications is that not all medications work for all types of pain or all people. There are also side effects that can make the medications intolerable for some people.

Sometimes, an illness or syndrome may cause an altered sensation of pain and this has given researchers a different insight. People with these syndromes may not feel the pain as the body normally does. These conditions are rare, but researchers have found that part of the problem is the way the person's body has a gene defect that reduces nerve growth factor signaling. Using this knowledge, researchers are working on medications that do the same thing, interfere with the nerve growth factor signaling.

In one study, done by Cox and colleagues, researchers studied three different families who had a congenital (born with) lack of sensitivity to pain. Although the children in the family were able to feel normal hot, cold, touch and motion, they couldn't feel pain. Nerve tests didn't find any abnormality, it just was as if they just did not feel pain.

Often, in medical reports of people who don't feel pain, there are a lot of negative issues. For example, from birth, they may hurt themselves on purpose (self-mutilation) and have repeated accidents that can lead to severe injuries. But not all people with lack of pain are born that way either. Some come by this situation later on in life. People with diabetic neuropathy, a condition where people with diabetes have problems feeling their feet and toes properly, can develop severe injuries on their feet. They may not know they even have a blister or cut until it becomes infected and they happen to see it. It's also been found that people with diabetes can have what is called silent ischemia. Ischemia is a condition where blood flow to the heart is restricted but usually causes chest pain. Silent ischemia means the person has ischemia, but there isn't any pain. Other people who have altered or no pain sensation are those who have spinal damage that results in paralysis and lack of sensation below the injury.

So far, there hasn't been any research in the psychological impact of children who don't feel pain. Other than self-mutilation, researchers don't know how lack of pain may affect how they see the world and themselves. However, it is thought that this lack of pain could and would lead to social and psychological disturbances.

So, knowing the drawbacks of eliminating pain completely, the whole issue of treating pain often comes down to a single problem, how much pain relief does each individual need? Should the ability to feel pain be eliminated completely? Some patients need or want much more pain relief than some others need. Whether this can lead to abuse of the drug or addiction also depends on many things, such as the level of pain, the patient's pain threshold, the type of pain, and what is causing it, among other issues.

The potential for abusing some pain relievers, such as opioids, is a constant worry for many healthcare providers and for some patients as well. At this point, researchers haven't found that profound analgesia, a deep analgesia, given to someone who isn't in pain causes addiction. They also haven't found that giving it makes people need more. But, there are concerns about some other issues that can come up with using analgesics to numb pain that hasn't been experienced yet. This is the potential for people like athletes who want to play through the pain, perhaps causing more injury that can be more severe or even permanent. There is also a concern that the criminal element could get hold of this type of thing and then not think twice about getting hurt, because he or she wouldn't feel it.

These concerns are all valid and upfront among researchers who are trying to find better and more effective methods of pain relief. In the search for adequate pain relief, should the goal be complete pain relief or elimination of pain? And if that is available, should this be offered to everyone or to a few people with specific types of pain? How would society be affected if all pain were eliminated?

The authors of this study wrote that some of the issues to be considered include the study process. They feel that the fewer patients involved in these studies, the better. Researchers would have to carefully watch for signs of accidental injuries and for self-mutilation. One thing to consider is that perhaps patients of limited time, those with cancer or are in palliative care for example, may be the right candidates for total elimination of pain.

They also wrote that the government would need to be aware of the research and at what level of development the medications are. There will need to be an evaluation as to whether these medications should be considered controlled or restricted medications as are opioids. Once the medications are available to the general public, doctors would need specific guidelines to help them understand which patient groups need this type of treatment and how to go about it.

In conclusion, the authors believe that although the medical community better understands pain, there's still a lot of work that needs to be done. However, as we get closer to medications that may be able to eliminate pain, the ethical issue of who, where, and for what reason, will all need to be addressed.

John David Clark, MD, PhD. The Pitfalls of Profoundly Effective Analgesic Therapies. In Clinical Journal of Pain. November/December 2008. Vol. 24. no. 9. Pp. 825-831.



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