“Better pain relief also includes accompanying the patient as a whole”
Three questions for Xavier du Crest, a palliative care doctor, on pain relief concerning the advances achieved and the challenges still to be confronted.
What is the present situation regarding pain relief and can we now expect new improvements ?
Pain relief is a fundamental aspect of the care of patients; it has even been registered in law and in the missions afforded to care establishments. From my own point of view, things are moving in the right direction. Many advances have already been achieved in three directions:
- Medicinal techniques as such.
- The dissemination of information on such techniques for medical staff.
- Understanding by medical staff of the pain felt by the patient.
Which techniques do you consider to be the most promising in terms of pain relief?
- The use of a morphine pump, with the possibility for the patient to self-administer a dose according to the level of pain (the so-called PCA – Patient-Controlled Analgesia pump is widely available yet inadequately used.
- The intrathecal pump is a technique used in cases of resistant pain. Implanted surgically, the pump releases medicine doses continuously via a catheter, the tip of which is positioned in the spinal chord. Its advantage is that it demands much smaller doses of medicine in order to achieve the desired analgesic effect and reduces certain undesirable side-effects.
- Ketamine, initially used in psychiatry to treat depression, is also used against chronic pain, and in palliative care.
- Endometriosis is an example of a disease identified some time ago, but for which pain relief has been recognised more recently. For that particular pathology, implanted neuro-stimulation may be used. This innovative technique uses low voltage electric currents to modulate the activity of the central nervous system.
- Conventionally, a distinction is made between so-called “nociceptive” pain felt in the event of a fracture, or inflammation, and neuropathic pain, associated with nervous system lesions. They may appear as a result of chemotherapy, a painful post-operation syndrome or may be present in certain diseases (CVA, diabetes…). For those pains, one should mention the use of rTMS (repetitive Transcranial Magnetic Stimulation), a method using magnetic pulses to modulate cerebral activity.
In this table of advances, a particular point has to be underlined. Considerable efforts remain to be made concerning the access to healthcare: there is a shortage of pain relief centres in France and those which exist must be expanded.
Could you speak to us about the treatment and the time necessary for the patient to feel relief ?
Pain seizes patients throughout their persona: their body, their psyche, with possible repercussions socially, spiritually… Cicely Saunders, a pioneer doctor in palliative care spoke of “Total pain” with four dimensions: physiological, psychic, social and spiritual.
The first stage of the treatment is crucial, it is for patients to be listened to and understood about their pain, without being judged. I can quote a concrete example. To treat certain types of chronic pain, it can be recommended for the patient to lose weight. An overweight situation in fact adds strain on the body and can therefore generate pain. In such situations, the way to explain and accompany the patient is essential for him/her to understand how that can have an impact on his/her pain (and hence its treatment).
For severe or chronic pain, it is important to get away from the cycle “I am in pain therefore I take a medicine”. The treatment will be a combination of medicinal, functional (physiotherapy, ergotherapy…), psychological and other approaches. When a patient is suffering from a sprain, a combination of a splint-cold treatment-analgesics eventually becomes inadequate. Physiotherapy is needed. In the case of back pain, re-education with physiotherapy is essential, and it must be sustained over time. Finally, I have to tell you that it is important to understand that our body has a “memory” of pain. The management of a painful event has an impact on any future events.
Do you see any scope for non-medicinal procedures for pain relief, and which ones do you consider to be promising ?
De facto we are experiencing a proliferation of non-medicinal therapeutic proposals. The difficulty is to identify those which will provide true benefit. The initial reflex to have, in my opinion, is to talk about it with your doctor. Corporal type approaches (such as the pilate method, fasciatherapy..) may be beneficial for working without violence on muscles. There are also interesting approaches based on hypnosis and virtual reality. It is advisable to maintain a critical approach to all these proposals. It would be utopian and dangerous to believe that there is a “miracle solution” applicable to everyone for all types of pain.
In my opinion, one must keep in mind the multi-disciplinary aspect for the relief of pain since it has been described as such. It is not merely a physical sensation. The emotional, psychic context also has an impact. The brain can modulate pain according to stress, or fatigue… those are some of the approaches for multi-disciplinary treatments combining medicinal and non-medicinal therapies.
New treatments and new strategies have emerged in recent years to better accompany patients. A major challenge for the coming years will be access to healthcare.
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