Physical pain is an unpleasant sensation which can disrupt daily activities. It accounts for one of the top five reasons for medical consultation.
Relief of pain maintains the quality and dignity of life. Pain physicians are medical doctors who specialise in the diagnosis, treatment and management of pain, particularly chronic pain.
It is unfortunate that there is a lack of awareness regarding pain physicians in the society. They treat pain as a disease irrespective of the origin
Specialists like orthopedicians, rheumatologists, oncologists or neurologists treat the disease effectively with an intention of cure or palliation.
However they may not have the specialised training to provide pain relief as pain physicians.
A patient suffering from chronic pain said: “The pain is there day and night and disrupts everything l do. It is unpredictable and l am always uncertain about what I can do. I am totally dependent on my family and feel helpless because I can do nothing in return.”
A pain physician is trained to assess, evaluate and treat pain. They take a multidisciplinary approach and perform interventional or invasive procedures when necessary.
Most specialists do not involve the pain physicians and treat pain themselves.
Pain that persists beyond three months is chronic pain. The most common are low backache, joint pains, headache or fibromyalgia.
Inadequate control of pain leads to frustration and non-compliance to treatment. Self-medication can be dangerous and lead to drug dependence and abuse.
Various studies indicate the lack of awareness regarding pain physicians both among doctors and common people.
Rovenstine, an anaesthesiologist, set up the first pain clinic in New York in 1936. He treated patients suffering from pain not relieved by conventional methods.
Pain assessment is done by various methods. The commonest in use is the numerical rating scales (NRS). The intensity of pain is measured on a scale of 1 to 10.
Higher the number more intense is the pain. Another way of assessment is the visual analogue scale (VAS). A picture or facial expression is selected matching the pain level. Proper pain assessment improves communication and understanding of pain.
In 1986 the World Health Organisation formulated the “analgesic ladder” which was mainly used for cancer pain. It underwent many modifications and is presently used to manage chronic pain also. It was intended to create a global network to reduce pain related morbidity.
The original ladder consisted of three steps
First step-mild pain. Non opioid and anti inflammatory analgesics are used like paracetamol or ibuprofen.
Second step-moderate pain. Weak opioids like tramadol or codeine are used along with supportive drugs.
Third step-severe and persistent pain. It is managed with potent opioids like morphine and fentanyl. Unfortunately, oral morphine is not easily available for pain relief. This affects many cancer patients with severe pain.
Later on, a fourth step was added to the ladder. Various interventional and minimally invasive procedures were recommended like epidural analgesia, nerve blocks and intrathecal pumps.
Palliative radiation in cancer patients is used to provide relief in painful bony metastasis.
In addition to analgesics, various adjuvant drugs are also used. Adjuvants are medications used for conditions other than pain but can be helpful in pain management. Some antidepressants, anticonvulsants, topical anaesthetics and steroids are used in combination.
Trans-dermal analgesic patches are also used.
There are three main principles of the analgesic ladder:
By the clock: Medications need to be taken regularly at proper intervals and not only on demand.
By the mouth: Oral medications whenever possible.
By the ladder: Step wise medications according to the ladder.
A personalised approach and regular assessment is recommended.
There are various training programmes in pain medicine. The West Bengal Medical Council has recognised a one year full-time course at the ESI Institute of Pain Management. All MBBS graduates are eligible to apply. There is also a Fellowship of the National Board (FNB) in pain medicine which is a two year course.
A three year DM degree course in pain medicine has been started in some institutions like AIIMS, Rishikesh.
Surprisingly only anaesthesiologists are eligible for the course. In Bengal, doctors of all disciplines are eligible for the one year fellowship course.
However, there is no DM degree course in Bengal for pain medicine. Dedicated pain medicine departments are few and the students mostly work in anaesthesia departments.
With increasing awareness pain physicians have excellent career opportunities.
At present, the corporate hospitals in Calcutta employ pain specialists only as visiting consultants which is unfortunate.
They should be appointed as full time consultants with a fixed salary. In this way awareness will increase and patients will be benefitted.
With the increase in life expectancy the geriatric population has increased. They along with the entire population need support of the pain specialists.
A structured system is essential and every person deserves a life free of physical pain.
Surgical Oncologist trained at the Tata Memorial Hospital, Mumbai. Presently Clinical Lead, Department of Surgical Oncology, Narayana Health Cancer Institute