Treatment of Pain

The overwhelming majority of people come to see the doctor for only one reason: to seek treatment of pain. Deep down inside even people without any medical knowledge at all know and realize that pain is not an illness, but just a symptom of a health problem, and compared to other symptoms mostly not even a serious one.

But still: once in the consultation room most patients finally care less for their diagnosis or their health problems revealed in this diagnosis, but for a quick, preferably instant relief of pain. Once the pain is gone, most people readily consider themselves “cured” or even “healthy”. Free of pain the doctor’s advice is frequently repressed and “forgotten”, the treatment of underlying causes rejected. Western culture willingly puts up with multiple handicaps, but pain is not among them. Pain is unacceptable.

So it is hardly surprising that the treatment of pain has a major part in medical and pharmacological research. The development and sale of pain relieving drugs makes for a vast portion of the pill industry, and specialists like anesthesists and neurologists could indeed be called pain doctors.

We can judge this phenomenon as we like, but one thing has too be stated: the relief of pain indeed is a complicated affair that needs much more knowledge, experience, expertise and fine-tuning that most of us would expect.

It may come as a surprise to you, but in the last detail we don’t even know. Pain as a matter of fact is not a definable “something”, but rather the result of several processes happening almost simultaneously.

The actual cause of pain however has hardly anything to do with the pain it finally triggers: we know countless cases of fatal or near fatal injuries and conditions that are not accompanied by pain whereas other actually quite harmless events like an infected root chanel causing excruciating pain. So you can take one thing for granted: there is no reliable, established connection between a certain pain and its cause. Not even an event as massive for the human body as a childbirth is necessarily connected with a specific degree of pain.

At a close look we can certainly state that pain is a genuine “feeling” and as such just as subjective and non-transferable as it goes with the feelings of individuals. Hard to imagine?

Yes. That is why we will explain on the following two pages how the feeling of pain is born.

Nerve does not equal nerve. There are several types of nerves with different functions, structures and properties running through the human body. Only two of them really are assigned to the transmission of pain signals towards the brain. These are the fast transmitting A Delta fibers for signals of sharp pain and the slow transmitting C fibers for signals of dull pain.

Both are unevenly distributed in our body. We find them with a very high density right under or near the skin and rather sparsely deeper inside the body and the inner organs.

This is why we react on noxious impulses, even rather harmless ones, directly on our skin much quicker and more sensitive than on comparable, but matter of fact much more threatening impulses on let us say our liver. The main pain defenses of our body are concentrated on its outer periphery. Thus a torn toe nail is much more alarming for us than a ruptured liver – even when the toe nail is highly dispensable but the liver essential for life.

Nature’s logic behind this system gets obvious when we look at our brain: it has no pain transmitters at all. Once it is damaged, chances for survival are so neglectible that nature did not consider the installation of any alarm system to be warranted.

We know of African tribes where shamans do brain surgery on patients that neither received any drugs nor any other pain management but seemingly do not feel pain. Though there is no definite proof it still is widely accepted that there is no pain felt where there is no pain expected or accepted.

There are many examples for this phenomenom: shamans who take glowing ambers in their hands, tribal girls who give child birth without any assistance and countless tribal initiation rituals that in our eyes must be extremely painful, but which the persons concerned undergo with happy expectation.

We even can find such cases in western society in persons who consider certain painful arrangements as a prerequisite for their sexual arousal.

So even if we do not know what exactly the chemistry in the brain is in these cases, we can argue that cultural and personal perception are among the most pain triggering or painkilling elements to determine an individuals feeling of pain.

The last years have seen a rapid increase in psychological pain management. The most spectacular cases are operations by surgeons and dentists in which the patients are hypnotised. Some of these patients really do not receive any medication, are able to follow the whole procedure with open eyes and concious. Later they will report either no pain at all or just a very remote feeling of pain just as if it had been some other persons pain observed from a distance.

The accepted theory is that under hypnosis the patient gets so “distracted” from the pain feeling that it is finally completely suppressed in the brain: somewhere a gate closes and the pain messengers get no access to deliver their signals.

Although this effect of hypnosis has been well known for a long time, hypnosis itself was demonised for decades as possibly detrimental for a persons mental wellbeing. Recent research however has excluded much of the old prejudice and the fact remains that many people have such a low tolerance for painkilling drugs that hypnosis remains among the few viable options for them.

All the cases described above were about anesthesia – total pain suppression by change or manipulation of a person’s perception of either the whole body or at least parts of it.

But when the headache sets in we usually do not have a far eastern healer with his magic needle around us and even if we had, it would not be very practical if someone was sticking needles into us while we were let us say working at a filling station.

And what work would the cashier at a bank do under hypnosis and how would the customers of the bank like that?

So no matter what impressive techniques have been developed to fight and suppress pain, drugs will remain the standard for this kind of job.

But also if we look at drugs, we will find some elemental differences. There are very strong, anesthetic drugs like opiods that remain reserved for the clinical use.

For our daily use the drugs will most likely be analgesic: they will not primarily affect our central nervous system and will not fog in our conciousness.

Among these drugs we again find different types with rather different properties.

Topical drugs are drugs that do not affect our whole system but just the area where they are needed. This means they are applied externally which reduces their use to such cases where we can exactly localize a pain not deep in the body.

The most common of these drugs are gels containing so called local anesthetics like lidocain. They remain the standard treatment for certain kinds of sport injuries. You just apply them on the skin, the active ingredient is absorbed and sedates the nerves under the skin and in the muscles.

A comparable effect partly based on a different mechanism is achieved with some classic household remedies.

Against tooth aches cloves and clove oil are very efficient when inserted into a dental cavity. Cloves have an ingredient that acts highly sedating especially on the nerves in the mouth.

Essential peppermint oil or cayenne pepper create a feeling of heat on the skin. Locally applied they strongly stimulate blood circulation. This way they “heaten” muscles, tendons, blood vessels, ligaments and nerves and create a stimulus that is pain suppressing.

Aspirin, paracetamol and ibuprofen make up for the overwhelming majority of painkillers sold on the world market. Aspirin, the market leader, sees an estimated consumption of 40.000 metric tons per year.

All three drugs are on the  UN’s World Health Organization list of essential medicines: drugs for which every country on earth should guarantee a sufficient supply at reasonable prices affordable for the whole population and readily available everywhere.

All three drugs belong to the wider group of NSAID’s: non-steroid anti-inflammatory drugs. This term describes drugs that reduce inflammation and do not contain steroids (substances closely related to hormones).

All three drugs to a varying degree also reduce fever.

Besides that however each of these three market leaders in the treatment of pain has very different chemical properties and stems from a very different origin.

Aspirin is an acid synthizised from a salt that originally was discovered centuries ago in the bark of white willows.
Paracetamol is derived from coal tar and the only drug of this type still in use today. It was discovered in the late 19th century.
Ibuprofen is also an acid, but with a chemically more complex structure than aspirin. It was discovered 1960 and is very “modern” compared to its competitors. Unlike aspirin and paracetamol, ibuprofen can also be used topical and is part of many pain relieving gels and cremes today.

It may come as a surprise, but for all three drugs the exact mechanism of activity in the human body is still not known. All three however do block or inhibit certain enzymes that are part of the complicated messenger system for pain transmission described above.

Due to the extremely complicated processes in the transmission of pain signals through the human body some substances have been proven to be highly powerful in the treatment of pain, but again researchers are at a loss to explain what these substances actually effect.

Two of these substances are psychotropic. One is THC, the active ingredient in the cannabis types of hemp. THC recently has been prescribed successfully for many patients who either did not tolerate traditional drugs for pain treatment or who complained that these drugs were not sufficiently effective. THC is widely known to induce mood changes and it is therefore assumed that these mood changes somehow influence the way in which the brain reacts to pain signals. The same applies to several synthetic drugs from the group of antidepressants.

As the most recent alternative in the treatment of pain finally a leaf has to be mentioned. The kratom leaf comes from mitragyna speciosa, a wild growing tree endemic to South East Asia. Kratom has been in use on the Malay peninsula for centuries as a painkiller but just recently draw the interest of modern pharmacologists.

The kratom leaf contains up to 25 chemically very complex alkaloids in different concentrations. Most of these alkaloids are still poorly understood in their activity, but research is going on, especially at universities in Japan and Thailand. Preliminary results just show that some of these alkaloids are extraordinarily effective in the treatment of pain.