Living with pain can make life very frustrating. However,being told that there is no option but to bear pain can be very depressing. All of us know someone who often complains of pain in the back,arms,etc. More often than not,family members are the ones bearing excruciating pain day by day,without any known cure. Old people are usually the worst sufferers,but age alone does not preclude the young from the vagaries of chronic pain. The importance of pain is immense in medicine because physiologically,it is one of the most vital indicators that not all is well with the body. To that extent,it is a protective mechanism. So living without pain can also mean living with a latent disease. That is why some hospitals like Indraprastha Apollo have started calling pain the fifth vital sign after temperature,respiratory rate,blood pressure and pulse rate. Patients are asked to rate their pain on a scale of one to ten and treatment is prescribed based on that pain score. In the west,pain relief is regarded as a patient's right. Yet here even in hospitals where there is a pain management facility,doctors rarely refer even cancer patients to us whereas 80 per cent cancer patients experience significant pain at some point. There are no estimates on how many Indians suffer from chronic pain. However,extrapolating from a figure given out by the American Academy of Pain Medicine which found 26 per cent of Americans aged above 20 years have suffered chronic pain,doctors here put the figure at approximately 30 - 35 per cent of the population. That would put the number of Indians suffering from chronic pain anywhere between 36.3 crore and 42.35 crore. Yet,pain remains to this day the most underrated symptom and the superspeciality of pain management is yet to take off in India. Doctors still tell most patients to live with pain. Patients think it is a part of the suffering caused by their disease. Also,there are misgivings about long term use of painkillers. Prolonged use of non-steroidal anti-inflammatory drugs like aspirin and ibuprofen are associated with gastritis because of their action in reducing blood flow to the stomach and also thinning the mucus layer which protects the stomach lining from being damaged by gastric acids. Both actions are associated with the inhibition of prostaglandins. Often in cancer patients,the side-effects of pain medications like morphine are nausea and vomiting,which eclipse even the suffering caused by the disease. The concept of pain management has come a long way even if the facility is available only in a select few institutes. Dr G P Dureja,former professor of the All India Institute of Medical Sciences who started pain management services in the institute in 1986,says just about 10 per cent of medical colleges in the country have pain clinics and opportunities of training in the country are very little. An aspiring pain management professional will almost always have to train abroad. The abysmal levels of awareness have ensured that there is no demand created for this speciality. Dr Dureja,who runs Delhi Pain Management Centre,says only 25 per cent of his patients are referred,the other 75 per cent come through word of mouth and the reason is that many doctors feel referring a patient to a pain management expert would essentially be a statement of his/her medical shortcomings and if the pain is taken care of,the patient may never come back. One reason for this apparent apathy to pain management may simply be the fact that pain is a very subjective feeling,which is difficult to quantify. There are a lot of pain management techniques available beyond painkillers,all of which deal with inactivating some part of the pain pathway. Counselling is also very important, says Dr K J Choudhury,consultant anaesthesiologist at Apollo. The intense mental suffering caused by pain means that even something as mundane as exercising everyday could make a difference because exercise often leads to elevating people's moods. The most common pain-alleviating device used on cancer patients is the intrathecal pump implanted in the area of pain,which keeps releasing small amounts of painkillers. This means that while a patient may be subjected to 300 grams of painkiller orally,through the pump only one gram would suffice. Most other techniques deal with destruction of the nervous pathway which carries the pain sensation to the relevant area of the brain,like the limbic system. These are popular in patients suffering from arthritis,neuralgia or pain related to old accident wounds like phantom pain which afflicts a person who has lost a limb but the pain in that limb does not go away. Dr Dureja says pain management cannot work unless it is holistic. Every little thing has to be taken into account,from posture to lifestyle. Personalised attention is very important because a person in pain also tends to get very frustrated,and anxiety and depression are common. That is why I do not hand the patient over to a physiotherapist,but supervise everything from the exercise to injections myself. Painkillers are not the only way out Intrathecal pumps (Rs 1-1.5 lakh): Planted in the area where the pain is concentrated. It releases minute amounts of painkillers to nullify side effects Radiofrequency ablation (Rs 10,000-15,000): Nerves carrying the sensation of pain are destroyed selectively so as not to affect other sensations Neuromodulation (Rs 5 lakh approx): This seeks to change the frequency of nervous stimulus to turn pain into another less unpleasant sensation. Usually advised only after 5-6 years Deep brain stimulation (Rs 5-6 lakh): It is a stereotactic procedure where electrodes are inserted into the brain and nerve pathways in the brain,which deal with pain are destroyed Cordotomy (Rs 50,000): The spinal cord nerve pathways dealing with pain are destroyed Neurolysis (Rs 5,000-20,000): This involves destruction of neurons in the pain pathway by using chemicals like alcohol and glycol Acupunture (Rs 300-500 per session): This is a fairly well-known option but it is important to go to a trained person
