In order to treat something, we first must learn to recognize it.[1]

Sir William Osler

“Those who do not feel pain seldom think that it is felt[2].”

Samuel Johnson

What is pain and what are the factors that aggravate it?

Part One

Today, our blog’s focus will be on “pain”, which, it turns out, is the subject of several studies, as it is vital in many different aspects of our lives. Thanks to Assoc. Prof. Dr. Nikolay Yordanov (consultant in anesthesiology and resuscitation, pain treatment and palliative care at Blox Hospice) we will learn more about what pain is, what its role is and how much it “costs” to treat it in different parts of the world.

Why pain?

In recent decades, we have witnessed the incredible development of medical science and technology, which have led to a significant increase in human life expectancy and have caused radical changes in the world’s morbidity. People now live longer, often with more than one chronic illness, and as Cartright writes: “(…) This longer life is accompanied by the experience of more and longer, but always unpleasant sensations” (1).

Several authors, studying the most common symptoms experienced by patients with chronic diseases, found that pain is often one of those symptoms. It is the leading complaint in almost 96% of cancer patients, in more than 80% of AIDS patients (943 patients) and more than 75% of patients with cardiovascular diseases. Pain, as a symptom, is also experienced by more than 2/3 of patients with lung and kidney disease (2).

So what is “pain”?

Pain as an independent feeling, emotion, or experience has been the subject of study and debate by scientists, researchers, philosophers and clergy for many centuries and up until the present day. In the 1970s, the IASP Council of Experts formulated the following definition: “Pain is an unpleasant individual, sensory, and emotional experience associated with actual or potential tissue damage or (a condition) described in the context of such damage.” Therefore, from the above definition, it can be deduced that:

  • Pain is always unpleasant and can significantly increase a patient’s suffering;
  • The amount of pain experienced is always individual and strictly subjective. That is why only the patient can determine whether he feels pain and how strong it is;
  • In addition to sensory pain there is also an emotional component, which, if ignored, can result in its poor control;
  • Another factor especially important – the patient may experience pain even in the absence of objective criteria proving tissue damage.

That is why R. Woodruff writes in his monograph Cancer Pain: Pain is when the patient says,” It hurts me!” “ (3).

Role and significance of pain

Pain is a universal symptom experienced by a person throughout their life – from birth to death. It is a physiological phenomenon essential for the body. Its most important role is to educate the body about the potentially dangerous harmful effects of the environment. Through pain, the body learns to avoid coming in contact with damaging environmental factors, therefore, maintaining its completeness. It is no coincidence that Aristotle claims that “we learn through pain!” and Claude-Bernard writes: “The ability to perceive an irritation as pain is extremely important for everyone’s life.”[1].

The financial cost of pain

The impact of pain on the economies of countries is enormous. The United States estimates that pain had cost American society $ 635 billion in 2010, much more than the cost of all socially significant diseases such as cancer, diabetes, and cardiovascular disease. (4) In China, the incidence of pain in the population over the age of 45 varies between 28.6% and 37.2%, with the cost of treatment increasing from $ 129.9 in 2010 to $ 570.2 per patient in 2015 (5). In the EU, costs (direct and indirect, such as reduced productivity) due to chronic pain, vary between 1.5% and 3% of the gross domestic product between countries (6). For example, the cost per patient with chronic pain in Ireland amounts to € 5,665 per year, which makes the total cost € 5.34 billion per year or 2.86% of the country’s GDP, with costs incurred for patients with chronic pain and clinically advanced depression exceeding twice the cost to patients without depression (7). In the pan-European survey “Pain in Europe”, an international team interviewed 46,394 people over the age of 18 and found that 19% of Europeans surveyed had experienced moderate and strong, i.e. greater than NRS10 ≥5 in pain intensity, for more than six months in the last year.

More than half (59%) of the interviewed patients lived with this pain for a long time (2 to 15 years), and it is no coincidence that 21% of the study’s participants were diagnosed with depression. Due to the pain, 19% of the respondents lost their jobs, and 13% had to change their jobs. Moreover, 60% of them had to seek medical help 2 to 9 times in the last six months. However, only 2% of the respondents visited a specialist for the treatment of pain, and more than 1/3 of the respondents at the time of the interview did not receive any treatment for the pain. The authors also found that in about 40% of the interviewees whose pain was treated found that the treatment was inadequate (8).

Clinical pain

As already mentioned, pain is a psychosomatic phenomenon that accompanies a person from birth to death. It has adaptive and protective functions, but when poorly controlled, it is the symptom that most impairs patients’ quality of life (9).

For pain to be experienced, the information must reach the central nervous system, where a purely physical feeling is added as a psycho-emotional component, which is significantly influenced by the knowledge and experience of the person. Therefore, the perception of an irritation, such as pain, can be modified by many different factors. The most common factors that can modify the perception of pain are:

  • The intensity and nature of the pain itself
  • Knowledge, previous experience and interpretation of the pain felt
  • The presence of concomitant somatic symptoms and complaints
  • Psychological problems, such as anxiety and depression
  • Unresolved social and financial problems and the presence or absence of support
  • Ethnic and cultural factors and differences
  • Religious beliefs, spiritual prejudices and fears

Individual factors can have both a positive effect on pain – i.e. to reduce it, and a negative effect – i.e. to strengthen it (10). Let us consider them separately:

Clinical pain. This is the pain for which the patient seeks help, must be treated and represents the physical pain modified by the factors listed above.

Physical pain (nociception). The intensity of the pain experienced by the patient is the most important factor influencing clinical pain. Severe, uncontrolled pain that limits the patient’s activity and impairs his quality of life significantly exacerbates clinical pain.

Concomitant somatic symptoms. Patients who suffer from poorly controlled somatic symptoms, such as dyspnea, insomnia, constipation, and others, report higher pain levels than those who do not have similar complaints. Therefore, reasonable control of concomitant complaints is a condition without which adequate pain control is impossible (11).

Psycho-emotional problems. These most commonly affect the perception of pain and modulate its intensity. Failure to recognize and untimely treat this pain, leads to an increase in the patient’s general suffering and is often at the base of inadequate pain control. Its timely treatment can significantly improve the effectiveness of ongoing analgesic treatment (12).

Socio-economic problems affecting clinical pain. Often, chronic illness and uncontrolled pain have a devastating effect on the patient’s social life and can cause serious mental and physical distress. In many cases, unresolved social problems directly impact pain, leading to a significant increase in the level of clinical pain (13).

Ethnic and cultural factors. Various ethnic and cultural communities have different attitudes towards suffering, illness and pain, therefore, must be treated with care and respect, and by considering the possible language barriers that may arise when communicating with patients from other ethnic groups (14).

Spiritual problems. Each person has their own unique spirituality. As chronic disease progresses, spiritual problems become more critical to the patient and more difficult to resolve. Neglecting the spiritual factor and its influence on pain perception is often the reason for its poor control (15).

 Pain and suffering

Uncontrolled pain is an essential component of patients’ general suffering in the course of a chronic and potentially incurable disease, such as cancer, diabetes, or rheumatoid arthritis. Apart from the pain, the patient’s suffering is also influenced by various factors – somatic, mental, spiritual, social, cultural and ethnic. The links between these factors are complex, which makes it difficult to account for their impact (16). Such an unresolved social problem can appear as a factor that provokes the appearance of pain and vice versa – and inadequately treated pain can make it impossible to solve an existing social problem.

Uncontrolled suffering in itself can be a source of pain. The term somatization of pain implies the pain caused by uncontrolled mental or spiritual suffering, without an objectively proven somatic cause, which worsens when the patient is alone and is relieved by distracting the patient and not by increasing the dose of opioid analgesics. Often in the medical history of these patients there is evidence of sexual, physical or mental abuse and a history of poor, family experience with terminal illness (18).

[1] Claude Bernard (1813-1878) French physiologist in “Physiologie générale” (1872)

Bibliography:

  1. Cartwright A. Changes in life and care in the year before death 1969-1987. J Public Heal Med. 1991;13(2):81–7.
  2. Solano JP, Gomes B, Higginson IJ. A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease and Renal Disease. J Pain Symptom Manag. 2006;31(1):58–69.
  3. Woodruff R. Cancer pain. European e. Melbourne: Asperula Pty Ltd; 1999. 7–9 p.
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  5. Qiu Y, Li H, Yang Z, Liu Q, Wang K, Li R, et al. The prevalence and economic burden of pain on middle-aged and elderly Chinese people: Results from the China health and retirement longitudinal study. BMC Health Serv Res [Internet]. 2020 Jul 1 [cited 2021 Feb 13];20(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32611450/
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