Maxims, Axioms and Chronic Pain

There is a maxim that has evolved in western, orthodox medicine that goes something like this: Pain has a cause, the cause can be found, eliminate the cause to eliminate the pain. Coupled with the unearned and undeserved faith that modern medicine always has the technology to search and destroy the cause of pain, this has become deeply embedded into our health belief systems.

On the whole, it is an ideology that serves us well – whether you have sat on a drawing pin, suffered a heart attack or developed appendicitis, there is a cause for your pain and it can be successfully diagnosed and treated, with complete resolution of pain as the expected result. The problem is when a maxim (something that is generally true) starts to gain the status of an axiom (something that is so scientifically self-evident that it is true by definition), and this subtle shift has happened in the popular perception of pain, leaving a trail of confused chronic pain sufferers in its wake.

When pain first develops doctors will try their best to diagnose and treat it. Usually, either because of these attempts or despite them, the pain will resolve in a relatively short space of time. When it persists this usually results in more tests, scratching of heads, experiments with treatment (every prescription is an experiment) and referrals to clever doctors in specialist hospitals for…more tests and more experiments. Often, this too will result in the cause being found and a successful treatment – but what about when it doesn’t? What about a patient who has chronic regional pain syndrome – where all the tests are normal and there is no prospect of a magic bullet to target the cause of the pain? Or severe abdominal adhesions, where the cause is all too evident, but there is no treatment? Patients with these conditions, and many others like them, are not only left in chronic pain, but also confused and bewildered by a medical mindset that promised more than it could deliver, that seems to work for everyone else, but not for them.

Thankfully, in recent years there have been great advances in the understanding of the mechanisms underlying chronic pain, and pain management has begun to get the attention it deserves. Any changes in the attitude to pain, however, take a long time to trickle down into public consciousness. In the meantime there is a significant need to provide readable, supportive information for chronic pain sufferers so that they can move beyond popular perceptions into a greater understanding of their condition.

The world of Twitter is a great way of discovering new resources, and I have just come across two websites that are well worth a look at. The first is the Pain Toolkit which is a very user-friendly site that encourages people to take control of their situation with pain, and work with health professionals rather than rely on them. The second is an excellent self-help leaflet on chronic pain produced by Moodjuice. The Moodjuice website itself is worth a look at as well, as it covers other aspects of emotional health, and is full of very readable self-help leaflets.

Where is the Evidence?

I had one of my increasingly rare encounters with a representative from the pharmaceutical industry this afternoon. As usual, it left me wondering when our society will have the courage to stand up to the giants of the industry, and insist that they show some real evidence before they are allowed to market their products.

The drug in question is a new form of pain-killer called Tapentadol. I was quite interested to hear about this product since I had only come across it for the first time three days earlier, and it seemed worthwhile finding out a bit more. The drug is a morphine-like pain-killer, and the major selling point is that it has a novel, dual mode of action. Pain can be classed as nociceptive (standard, hit your thumb with a hammer type pain) and neuropathic (pain caused by over sensitive pain nerves, as occurs for instance after a bout of shingles). We already have drugs that can work on each type of pain, and these include Oxycodone (which is similar to morphine and good for your broken thumb), and Duloxetine, which works on neuropathic pain. ‘All the power of Oxycodone and Duloxetine wrapped up in one molecule!’ the Rep proudly informed me.

Well, if it has the combined strength of two drugs, is it not reasonable to expect it to be more effective than one of those drugs on its own? Apparently not. The best data she could show me was that Tapentadol was no less effective than Oxycodone.

‘I thought you said it was more effective?’ I asked her.

‘Oh it is, it has a dual mode of action.’ she replied.

‘But this just shows it’s no worse.’

‘But we know it is more effective.’

‘And how do we know this?’

‘The consultants at St George’s are using it.’

Well, much as I am sure I respect the consultants at St George’s, this is not what I would call evidence-based medicine.

When a Drug Rep shows you data you can be sure of one thing – it is the best data they have in favour of their drug. What you have to worry about is the data out there that they are not showing you. If this was the best she had in terms of efficacy, then this drug is not yet ready to convince me about its novel new dual mode of action.

It’s at times like this that I am glad of organisations like NICE which will look at whether these new agents really are what they claim to be – and even the PCT which gives increasingly tight guidance on what should usually be prescribed on the grounds of cost-effectiveness. Whilst we might not like being told what we can and cannot do, these organisations stop doctors jumping on the latest bandwagon and are some of our best defences against being hoodwinked by the pharmaceutical industry.

Hmmm, I seem to have strayed into politics. Well, sometimes you just have to do these things. Rant over.