Better chronic pain treatment needs a multifaceted approach, more preventive medicine, says doctor

According to Dr. Abdul-Ghaaliq Lalkhen, medical science has let its patients down for centuries where pain management is concerned, and it's scarcely doing better today.

"What you really want is a reassuring doctor who can explain the problem and give you an understanding of what you're going through and what needs to happen," he told The Sunday Magazine's Piya Chattopadhyay.

Lalkhen has worked in anesthesiology and pain management for two decades and is a visiting professor at Manchester Metropolitan University in England. His latest book, An Anatomy of Pain: How the Body and the Mind Experience and Endure Physical Suffering.

"You can watch somebody grimace or groan. They may use a stick or they may limp, but nobody can feel the pain of another individual. It's quite an ephemeral experience to grasp."

A broken alarm system

Usually, most pain from a minor physical injury fades after time. Lalkhen likened it to an alarm switching off. Chronic pain, however, is different.

"Sometimes, despite all of those injuries healing, the pain persists," he said, as though it were a car alarm that continued to blare even if no one is trying to break into the vehicle.

Lalkhen explained that chronic pain can be challenging to communicate the feelings related to it, especially when the damage can't be seen.

"It can be very lonely and isolating because a lot of people don't believe individuals who express that they have pain when there is no damage to be demonstrated by our current technology," he said.

Any long-term condition — heart failure, diabetes or chronic obstructive airways — requires a holistic or biopsychosocial approach, Lalkhen said — and chronic pain is no different.

"It's a disease. It's now being classified in the ICD 11, which is the International Classification of Diseases, which is used by many hospitals as a coding system for conditions, as a separate disease rather than a symptom," he added. "Managing that disease requires a holistic approach to understand that you can modify the loudness of the alarm."

It's a struggle because people see their bodies as machines and they see doctors as individuals who have the ability to fix those machines.- Abdul-Ghaaliq Lalkhen

The need for a holistic approach

According to Lalkhen, chronic pain can be treated with medication or interventional procedures (minimally invasive diagnostic, therapeutic or biopsy procedures). Different psychological and physical therapy techniques can also be used to help people adapt and live with chronic pain.

"The difficulty with our current therapies is that they can also damage other parts of the nervous system that we don't intend to modify," he explained.

"Opioids are a great example of a kind of a drug which we use to try and turn the loudness of the alarm down. But the reality is we dampen everything down and affect the body in ways that we hadn't intended."

He added that the problem often arises when there's a purely medical approach to managing chronic pain because that inevitably leads to a reliance on opioid therapy or interventions that turn the patient into a very passive recipient.

He likened it to treating diabetic patients with insulin and tablets without providing dietary advice to help manage their condition. Without that multifaceted approach, patients' quality of life often deteriorates, he said.

But when doctors do take a holistic approach over solely prescribing medication, Lalkhen said that patients generally react "badly."

"It's a struggle because people see their bodies as machines and they see doctors as individuals who have the ability to fix those machines," he said.

We don't really understand the complexity of the system. Therefore, much of the medications and interventions we have are fairly rudimentary.- Lalkhen

Pain mechanisms are complex

According to Lalkhen, when the "quick fix solution" — such as a joint replacement — doesn't relieve chronic pain, patients will sometimes seek him out  for a tablet or an injection that will switch off their pain.

"The first thing they think when you talk about alarm systems and nerves is — 'do you think I'm saying that I'm imagining it?' So people generally believe that you think that their pain is psychological," he said.

"A lot of doctors believe that if a patient doesn't present with a proportional amount of pain to a particular injury in that doctor's experience, then they're labelled distressed, histrionic or neurotic."

But multiple studies and MRI scans of the spine and knee have shown that there's very little correlation between the changes seen on the scan and the amount of pain somebody experiences.

While there's a lot of ongoing research around pain mechanisms, Lalkhen added, "we don't really understand the complexity of the system. Therefore, much of the medications and interventions we have are fairly rudimentary."

Unintended consequences

According to Lalkhen, treating chronic pain by borrowing drugs prescribed for other conditions is quite common.

Gabapentin and pregabalin, for example, are often prescribed for epilepsy and neuropathic pain, which is due to disease or damage of a nerve

"We'll use those drugs for nerve pain and then will go, well, if we use it for nerve pain, we can use it for all sorts of chronic pain because it's the same, isn't it?" But he explained that this can result in unintended consequences such as depression.

"The same is true of opioids, because we don't always measure the impact of what we're doing. It's a challenging area because we don't understand the mechanisms," he added.

That's why there needs to be a very transparent conversation between a doctor and the patient about the risks and benefits of any treatment, he added.

"It's not about holding anybody specifically responsible. I think the way out of it is information," he said.

Prioritizing preventative medicine

Currently, most chronic pain treatment focuses on secondary care — hospitals and doctors, explained Lalkhen.

"Preventative medicine has to achieve a much bigger part of how we manage health care" and focus more on well-being, he said.

That would include lifestyle improvements like better diet and sleep habits, meditation and mindfulness, and more exercise.

"It's not easy, but I do feel sometimes we measure much more how much health care we deliver than how much disease we try to prevent."

Interview produced by Chris Wodskou.