Treating pain with respect | Mumbai news - Hindustan Times

Treating pain with respect

Aug 21, 2023 12:36 AM IST

The author discusses the issue of pain management and addiction to painkillers, highlighting the opioid crisis caused by the Sackler family's promotion of OxyContin. They also mention the underrecognition and undertreatment of pain in India's healthcare system, particularly in cancer patients. The author calls for specialized doctors in pain therapy and emphasizes the need for a better understanding of patients' needs and suffering.

S has been my patient for years with a condition called chronic pancreatitis. A young man in his 30s, he was diagnosed at the age of 21. It’s a disease which causes inflammation, damages the pancreas and can lead to diabetes and malnutrition. However, its predominant symptom is repeated, excruciating pain in the belly and the back. It devastates a person’s life. It doesn’t let them sleep, eat or work. S went through all possible therapies. Pain killers, nerve blocks, endoscopic procedure and later even surgery. The pain still continued. All treatment methods for chronic pancreatitis have limited success. If we take out his entire pancreas, his pain will stop. But that will make him a severely labile diabetic. Somewhere along the way, S shifted from routine pain killers to narcotics. That helped. At least he could get some sleep. At one stage, I own up to prescribing morphine after all routine pain killers had failed. Later someone prescribed a patch of Fentanyl. S visits me regularly. At the end of every consultation, he looks at me sheepishly and says ‘Doctor can you give the prescription? I only take small doses’. On multiple occasions, I have tried to nudge him to slowly reduce and stop. Have tried giving him all possible alternatives. But he is hopelessly addicted. And yes, I end up prescribing morphine or Fentanyl to him.

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HT Image

I binge watched ‘Painkiller’ on Netflix this weekend. I rarely do that. Of course, I had read about the Sackler family and the Purdue pharma story. But the series still riveted and disturbed me. The roots of the recent opioid crisis in the USA are many, but a big contribution came from the greed of the Sackler family. Through their company Purdue pharma they systematically promoted OxyContin a narcotic addictive pain killer as a panacea for all varieties of pain. They not only did it with inducements to doctors but tried to downplay data about side effects and deaths related to overdose. It soon became a recreational drug with kids snorting it. At one level, the story is one of classic profit-driven pharma and greed. At another, it’s about how prescriptions of doctors can be influenced. But is it only that? Or is it also the nature of severe pain that craves intervention and relief? Is it possible for the patient suffering from excruciating pain to resist swallowing the pill which gives instant relief? When do pain killers become an addiction? Is the patient the driver or a victim?

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There is an unfortunate paradox in India. We may be underrecognizing and under treating pain in the healthcare setting. There were strange constructs almost incorporated into medical teaching and training. I remember being taught by Professors of Gynaecology that the reason epidural analgesia is not routinely used during childbirth is because ‘Indian women tolerate pain’. I recall being told that rural Indians have a higher threshold for pain. That alcoholics do not need local anaesthesia for suturing wounds because they are inebriated. Hopefully these are bygones.

As a surgeon, I deal with post-operative pain daily. We are getting better at it. We now use regional analgesia often with the temporary epidural catheter around the spinal cord. And round the clock narcotics. That’s the only way the recovering patient can sit, walk early. This prevents several infections, especially in the lung. Minimally invasive procedures have reduced post-operative pain. But it’s embarrassing how for years we undertreated it. Our patients lay in bed motionless for days together with the fear of pain. The social distance between us and our patients and an intimidated patient meant that he or she did not complain, which was misinterpreted as tolerance. Hospitals in the developed world now have pain teams. Whose main work is to assess pain and manage it. We are just about beginning to put this into practice in a few hospitals.

An even more disturbing area where we continue to do severe injustice is cancer pain. Especially in its terminal stages. The palliative care community in India has been demanding improved access to a cheap and effective drug like morphine for years. But it is still available with great difficulty. It’s an uphill struggle for the patient and the family to procure appropriate pain killers. Strangely there is a discussion on addiction in someone who is in the last months of life.

Pain is ubiquitous. We all experience it. From the all-pervasive toothache, backache, joint pains to chronic pain syndromes, it’s unfair to dismiss it as a by-product of some disease. Or something that must be endured. For the sufferer it demands immediate attention. Of course, we need to acknowledge the potential of pain killers for side effects and addiction. For example, knee joint pain may be better served with local therapy rather than regular use of anti-inflammatory drugs. A tablet of Diclofenac or Ibuprofen works like magic but can damage the kidneys in the long run. But try telling that to the person who cannot walk. Specialisation in pain therapy is a huge need which awaits identity and recognition. Pain needs more focussed doctors.

One reason the Sackler family’s avarice worked in the early years is because it was serving a felt need. Till it came to be a narcotic which could be sniffed to get a high. The dividing line between pain relief, side effects and addiction is nebulous. Like many situations in an illness, it’s a tightrope walk. And it is another area where it’s impossible for the doctor to actually imagine the patients’ needs and suffering. Pain challenges the quest of science to be objective.

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