PAIN – the single biggest cause of disability in the UK

A discussion on the difficulties surrounding pain – and the best ways to treat one of the most common problems afflicting the UK population – by Dr Roger Henderson

Pain. There’s a lot of it about.

Yet if you asked 100 people how to describe the pain they have, you will receive 100 different answers- a dull ache, a piercing sharp pain or a persistent toothache-type discomfort. Whatever way it is perceived, however, one fact remains. Chronic pain is experienced by almost eight million people in the UK alone and is found more commonly in the elderly population. It is the single biggest cause of disability in the country and my waiting room always seems to be full of people suffering from pain of some degree for various reasons.

So, how should we define pain in its main forms – acute and chronic’?

Acute usually results from disease, injury or inflammations such as may occur after surgery, for example. The cause tends to be apparent and treatable, and the pain is self-limiting, gradually settling with time. However, in some cases this acute pain persists for more than three months and is then labeled as chronic.

Unlike acute pain, which acts as the body’s alarm telling us something is wrong, chronic pain is not a preventative warning but indicates cell damage somewhere in the body. Significantly, it can also be made much worse by environmental and psychological factors such as anxiety, depression, fear, temperature and age. Typical examples of chronic pain include headache, low back pain, arthritis pain and cancer pain.

It should come as no surprise that it can also prove resistant to medical treatment and pose considerable challenges to physicians trying to treat it. One of the reasons for this is that pain is a complicated process involving delicate and complex pathways between chemicals in the brain and the nervous system. Pain receptors in the body trigger electrical impulses that travel to the spinal cord which acts as a relay center where the pain signal can be blocked, enhanced or modified before it is sent to the brain.

To help treat people with chronic pain, it is crucial that they understand its causes and the wide range of steps that can be taken to help. Conventionally, doctors use painkillers as their mainstay of chronic pain treatment, often employing what is known as the World Health Organization analgesic ladder. The strength of painkiller is gradually increased until pain control is hopefully achieved and a `three- rung ladder’ is used:

Step 1:
Simple painkillers such as paracetamol or non-steroidal anti inflammatory tablets (NSAIDs). These help reduce pain and inflammation by moderating the chemicals in the body that cause inflammation, the prostaglandins. Unfortunately these chemicals are also required for processes in the stomach and so NSAIDs may cause side effects, such as stomach ulceration, which are intolerable for some people. There are also some safety fears over the long-term use of some NSAIDs, as it is thought that continuous use may contribute to an increased risk of heart attack and some have even been taken off the market for that reason.

Step 2:
Codeine-based painkillers and weak opioid drugs. Codeine helps relieve pain but may cause problems such as constipation.

Step 3:
Strong opioid drugs such as morphine. These can be in the form of tablets, in liquid form, as skin patches or lozenges or a syringe driver.

Whatever treatment is used, it is always tailored to counter the pain present since relief often needs constant review. Other conventional treatments may be added in with painkillers, which is known as adjuvant therapy. These include antidepressants, steroids and anticonvulsants, all of which can be effective when tailored to the right patient at the right dose.

Natural alternatives to conventional treatments are increasingly popular. Acupuncture was recognised by the Chinese as being an effective painkiller and massage can also be good at reducing not only pain but also high levels of stress, which in turn may be making the original problem worse. (This is almost a reflex response – how many times have you said `Rub it better’ to someone when they have bumped themselves?)

Natural alternatives to NSAIDs are increasingly popular because of the relative lack of side effects and include:

Omega 3 fatty acids help to reduce the production of inflammatory prostaglandins in the body that can worsen pain. Our modern diet tends to contain far more proinflammatory omega 6 than the protective omega 3 fatty acids and so supplementing with omega 3 can be helpful.

Glucosamine is now increasingly suggested by many general practitioners, as this appears to be of benefit in people whose pain is linked to arthritis, especially in joints such as the knees and hips. Some studies suggest its efficacy is similar to that of NSAIDs (but without the harmful side effects) but unlike NSAIDs, studies also suggest that glucosamine may help to repair the damage sustained by arthritic joints.

Chondroitin when taken together with glucosamine is effective in reducing pain and inflammation around joints by promoting cartilage formation.

Bromelain is an enzyme, derived from pineapple stems, that has powerful anti inflammatory properties and has been found to significantly reduce pain and swelling. It can also enhance the absorption of any other nutrients or supplements you may be taking.

MSM (Methyl sulphonyl methane) is crucial in building healthy connective tissue and reducing the inflammation that so often triggers chronic pain. Although it is found in some foods, it is easily destroyed by heating and processing so supplementation is recommended. Other similar supplements that can be used include Devil’s Claw and green-lipped mussel extract.

The ancient Greeks used mint oil to cool joint pain and inflammation and willow bark to help stem chronic pain. Over 2,000 years later, natural supplements still have a vital role to play in the management of the complex condition we call pain.

Dr Roger Henderson

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