Pain management is an oft neglected, yet significant facet of treatment that impacts nearly every aspect of a patient’s recovery. Pain is also an extremely personal experience, varying significantly based on each individual’s physical condition and even their beliefs.
Oftentimes, patients are typically referred to pain specialists only after going through simple painkillers with gastroenterologists, neurologists, surgeons, and other health providers. It is important for pain doctors to review patient history while weighing various medical perspectives to find the most appropriate course of action for treating, diagnosing, and managing pain.
We hear from pain management specialist Dr. Daniel Phang as he delves deeper into the various aspects of pain management and what you should take note of.
Pain is a highly personal and unpleasant sensation that happens when pain receptors transmit signals informing your brain that a part of your body is injured or in danger of getting injured. Everybody experiences pain differently, even if the reason for their pain is similar.
Pain can range from feeling mild to severe, and feelings of pain can include tingling, pricking, stinging, burning, shooting, aching or electric sensations. Pain is vital in alerting us to harmful changes to our body, such as cancer, or our environment, such as when you are touching a hot stove or iron.
Pain that persists for more than three months is known as chronic pain and can happen without a known cause or persist even after an injury is healed. Chronic pain can affect one’s mood, relationships and aspects of their daily life, making it difficult to do necessary tasks or enjoy activities.
According to Dr. Phang, pain management can be categorised into four broad categories:
Many patients are concerned about pain medication’s side effects, especially in Asia where there’s a strong culture of medical avoidance. Of course, these concerns are not unfounded. Anti-inflammatory medicines such as Arcoxia, for example, can cause gastric side effects as well as increased risk of heart attacks and stroke. Doctors must therefore assess patient suitability and communicate the risks involved before issuing prescriptions.
Dr. Phang reassures that specialists do not freely prescribe pain medication in their practice prior to a discussion with the patient, “A discussion on the side effects of pain medication as well as its benefits need to be discussed with the patient before we prescribe anything. For example, if the patient is young and healthy like you, I will briefly mention that opioids is a group of medication that I will not touch and I will not prescribe them to you.”
Other side effects that patients may need to look out for include anti-inflammatory medication which may have adverse effects on those with kidney or cardiovascular health problems.
Stronger medications such as opioids are reserved to alleviate cancer patient suffering, and therefore restricted from younger and healthier patients who otherwise have a strong chance of recovering. As every opioid exhibits different properties, doctors use the WHO letter of analgesia framework to decide tailor pain medication to a patient’s condition.
Even then, opioids are only issued in low doses in the beginning, and only after patients have signed off on which opioids they consent to being treated with to achieve a specific goal. Non-opioid analgesics such as nonsteroidal anti-inflammatory drugs are used for mild pain, followed by weak opioids like hydrocodone or tramadol. Only the most potent opioids (morphine, methadone, oxycodone, etc.) are issued to patients with severe and persistent pain.
Aside from recommending pain medication for palliative care, pain management specliaists like Dr. Phang also help with interventional pain management.
“For example, if some of these palliative care patients require certain catheters to be put in the spinal cord to relieve pain in a more effective manner, I'm there to talk to the patients about it.” Dr. Phang elaborates. “Things like nerve blocks, that's where we come in.”
Pain intervention methods involve needles that are inserted into the patient’s body, such as the aforementioned catheters placed in the spinal cord for pain relief.
Interventions are considered to be minimally invasive and can be a way to avoid major surgery. Even then, some patients can get nervous about intervention out of fear of hospital admission, anaesthesia, or needles, and will require counselling from their doctors or physicians. Sedation may also be delivered to improve the patient’s comfort. Common targets are pain generators such as slipped discs, facet joints, and compressed nerves.
“What is injected through these needles will be discussed with the patient first, it need not necessarily be just steroids or something to dull the pain away,” Dr. Phang adds.
Dr. Phang encourages patients to go for physiotherapy, especially if they’re experiencing sports injury or musculoskeletal problems such as chronic back pain. It’s important for patients to discuss physical therapy regimens with their doctors as alternative treatments and even medical products on the market may not be evidence based and therefore require careful research before being recommended to patients.
In most cases, patients would have had medication resistances and allergies picked up by family doctors before being referred to pain specialists. While it is possible for patients to develop new reactions to medication, tolerance and dependence generally does not develop unless they are placed on opioids. Milder medications such as Panadol have not been found to produce similar effects. Often, patients who experience a decrease in Panadol’s effectiveness are actually developing more severe pain symptoms instead.
Nevertheless, if a patient feels strongly about not wanting to take pain medication or develop strong allergic reactions, Dr. Phang states that pain doctors may decide to take them off prescriptions and recommend physiotherapy as a baseline preventative measure. Topical medication may also be offered in lieu of oral medication.
There is a possibility of a patient’s pain medication reacting with their other medication. As such, it is important for doctors to look out for antidepressants and anticonvulsants in a patient’s medical history, as their drowsiness effect may be amplified with pain medication, as is the case with anti-neuropathics such as Gabapentin and Lyrica.
Another common concern for pain management specialists is the risk of patient’s taking pain medication alongside supplements. Although in most cases, vitamins and additives such as glucosamine are not harmful to the body, and can be a good complement to pain medication.
Pain medication may possibly worsen a patient’s liver, heart, and kidney problems. As such, liver failure patients should be kept away from paracetamol, as are heart and kidney patients discouraged from anti-inflammatories such as Arcoxia, Voltaren, and Diclofenac.
For these patient cases, Dr. Phang emphasises the importance of patient-doctor communication for an effective and personalised treatment.
