Misunderstood pain patients | Pain department | Pain

Pain is also a disease

"The pain is really unbearable, I don't know where to look."

Wu Ping has been experiencing stomach pain since July last year. At first, she thought it was a gastrointestinal problem, but she couldn't find anything. Later, she returned to her hometown and was hospitalized. "I had all the tests done from head to toe, and there were no major problems." The test report remained normal, and her pain was also normal. "I am very sad, it hurts every day, it hurts every day." Later, Wu Ping traveled to Shanghai and underwent tests on the appendix, liver, gallbladder, spleen, lumbar spine, and lung CT at different hospitals. However, she still couldn't find the cause of the pain. After being introduced, she finally came to the pain clinic.

At the pain clinic, there are many patients like Wu Ping who come and go, with thick stacks of examination reports and medical records in their hands, intuitively quantifying the path they have taken on the pain relief road.

"There are some chronic pains that continue to persist despite the recovery of the original disease, which also troubles doctors in various departments. Such pain needs to be treated in the pain department," said Fan Yinghui, chief physician of the pain department at Renji Hospital affiliated with Shanghai Jiao Tong University School of Medicine.

Fan Bifa, director of the National Pain Diagnosis and Treatment Research Center and director of the Pain Department of China-Japan Friendship Hospital, once introduced at the press conference in October 2021 that there were more than 300 million chronic pain patients in China, but the public had misconceptions about "pain", and the medical treatment rate was also significantly insufficient. At present, the public's awareness rate of pain related diseases is only 14.3%, and the treatment rate for chronic pain patients is less than 60%.

Acute pain is a warning signal of damage or disease invasion to the human body, and is a common clinical symptom that can disappear as the disease improves. However, chronic pain is an independent disease. According to the definition of modern pain medicine, pain that lasts for more than one month is chronic pain. According to the China Pain Medicine Development Report, there are over 300 million chronic pain patients in China, and they are growing at a rate of 10 to 20 million annually.

Li Xiaomei, 54 years old, walked very slowly when entering the consultation room, with her legs slightly bent and her hands touching the chair before she could sit down. She has been experiencing discomfort, swelling, and difficulty bending in her knee joints since last year. After undergoing blood tests and imaging examinations, the diagnosis was rheumatoid arthritis, and medication to control rheumatic activity was taken. The medication is intermittent, and beyond the knees, shoulder movements are also affected, and finger joints are beginning to deform. "Now I feel pain in every joint of my body. Is this related to rheumatoid arthritis?"

"Of course it does matter. Taking medication is just to control rheumatic activity, but when joint injuries or tendon inflammation occur, pain can still occur," said Fan Yinghui.

The pain in the heart

In addition to the pain caused and sustained by the primary disease on the body, there are also some pains that may come from the heart.

Rural middle-aged and elderly women are a typical group of patients in pain clinics. "This is the time when they feel the strongest sense of powerlessness," said Fan Yinghui. You can see that her two fingernails are black, her joints are thick, and her skin is black, but she often doesn't have anyone to accompany her when seeking medical treatment. This group of people is actually particularly helpless. They are economically disadvantaged and have relatively low cognitive levels, making it easy for them to fall into a dead cycle.

At this point, they are no longer young and strong, and have reached their menopause. Osteoporosis and previous labor injuries begin to slowly manifest in their bodies. When these pains come out, this group of people often come to the clinic and cry while watching.

Facing such patients, relieving their emotions is sometimes more important than prescribing medication for treatment. Fan Yinghui sometimes chats with patients and says, "If he stays here for a while, he will be much better when he goes back.". After feeling relieved, tell the patient not to take medication indiscriminately. Some patients may believe in some methods in pharmacies and in the world. First, they should stop using those that should not be used, and then tell them how to eat and exercise normally, making them realize that it can improve, which is much better.

In fact, about half of the patients who come to the pain clinic have psychological and emotional problems, and the more severe cases can account for one-third. But a small number of patients are unwilling to go to the psychology department. First of all, they need to agree. If they don't agree, they won't accept it. "We dare not easily say the phrase 'you can go to the psychology department to see it' in outpatient clinics."

During the 15 minute outpatient visit, Fan Yinghui did not find any organic lesions on Wu Ping, and the diagnosis given was physical form disorder. This kind of pain is completely devoid of any organ related problems, caused by recurrent pain caused by mental problems. Fan Yinghui said that in the brain, the brain regions that feel pain and the brain regions that sense emotions are very close, and signals can be transmitted to each other. Emotional problems and pain may be mutually causal. Some people experience pain first and then emotional problems, while others experience emotional problems first and then pain.

"If it's understandable, it's right to go to the psychology department," Fan Yinghui said. When the inner pain stops, sometimes the pain that the body once felt also dissipates.

Faced with such "psychological" pain, patients are usually very anxious, have poor sleep, and the treatment effect of various medications is not good. It is better to use some sleeping pills instead. Fan Yinghui said that the pain that people can feel can be divided into two parts, one is physical sensation, and the other is decoding by the brain. At the same time, the brain regions of pain and sleep are very close together, and the quality of sleep and the degree of pain felt will also affect each other.

But in terms of pain relief, these patients are not easy to handle, and the use of medication needs to be more cautious. Psychologists often prescribe some psychiatric drugs, and Wu Ping is currently taking five types of anti anxiety drugs. If painkillers are used casually, there may be some side effects.

Stereotypes

When it comes to pain relief, two treatment methods are often mentioned, such as taking painkillers and getting a blocking injection. However, there are also criticisms and doubts that come with it - "taking painkillers can become a 'drug addict'" and "getting a blocking injection can lead to osteoporosis and endocrine disorders.".

"There is indeed a situation of drug abuse and addiction abroad, which is why it is called the 'opioid crisis' in the United States. However, the control of opioid drugs in China is very strict, and there may be insufficient pain relief. Most patients have been in pain for a long time, so they still say' get rid of it '. Fan Yinghui said that the overall amount of morphine used by Chinese people is low globally, but there is indeed a risk of side effects when taking painkillers.".

As for receiving a closed needle, it is a discourse that has been shelved in doctor-patient communication. Injecting a closed needle, also known as a closed therapy, is when a doctor identifies the patient's pain point and injects medication into the affected area. The closed needle mainly contains two types of drugs: local anesthetic and steroid. Local anesthetic can temporarily block local nerve conduction, while steroid drugs can treat chronic soft tissue injury.

"We dare not mention 'closed needles' now. If we search online casually, it is a problem of femoral head necrosis or damage caused by sealing," said Fan Yinghui. But in fact, most of the condemnation of closed needles stems from unscientific use. The efficacy of closed needles is related to the amount, type, course of treatment of hormones, as well as whether the disinfection during operation is in place and whether the injection is symptomatic. However, there is currently no clear regulation on which type of doctor has the qualification to operate injection sealed needles.

In addition to stereotypes about treatment methods, the positioning of pain departments in hospitals is also somewhat awkward.

Due to the complex causes of pain, it is often necessary to involve knowledge of various subjects in the consultation of pain clinics. "At the beginning, if you are not clear about the disciplinary connotation of pain medicine and do not understand the surgical methods of pain medicine, you are particularly likely to become the role of a triage desk at the entrance. After a patient's consultation, let this go to surgery and that go to orthopedics, and in the end, leave nothing in your department," Fan Yinghui said with a smile.

But as imagined by the outside world, is pain relief treating the symptoms rather than the root cause? In Fan Yinghui's view, pain management has its own technical barriers. "The existence of pain management has actually reduced the number of surgeries that can be avoided," Fan Yinghui admitted. Taking rheumatoid arthritis as an example, some patients may face joint damage and can indeed be repaired through artificial shoulder joint replacement surgery. If there was no choice, surgery would be the only option, but many patients have a condition that falls between conservative treatment and surgical treatment. If immunotherapy is appropriate and function is improved, the degree of shoulder joint damage can be controlled, and surgery can actually be avoided.

The joint that has been replaced at the same time has a usage period of about ten years. After ten years, another surgery is needed for revision, and each revision increases the risk of scar formation, scabbing, and bleeding within the joint, making the next revision more difficult. If young rheumatoid arthritis patients choose joint replacement at the beginning, as they age, the difficulty of surgery and the patient's recovery will become worse and worse. A more ideal situation would be for the rheumatology department to use sufficient immunotherapy to control rheumatoid arthritis, while the pain department is responsible for controlling pain.

For elderly people with knee joint pain and lower back pain, the unique neuroradiofrequency surgery in the pain department can fully alleviate pain without affecting movement, with only a few puncture needles left behind, avoiding premature surgical procedures.

In addition to painkillers and closed needles, pain management has already developed a step-by-step treatment method.

Fan Yinghui suggested that Li Xiaomei first check the degree of joint damage and tendon inflammation through magnetic resonance imaging, and then select appropriate treatment methods for specific sites. If the injury is severe, it is necessary to go to joint surgery for shoulder arthroscopy or other repair surgery. If the injury is minor, conservative treatment can be chosen, such as using shockwave therapy to treat tendons or injecting anti-inflammatory drugs to inflamed areas.

Neuroregulation technology is also a novel analgesic solution. Taking new techniques such as spinal cord electrical stimulation and peripheral electrical stimulation as examples, stimulating a single nerve with electric current can control most of the pain without affecting activity and avoiding the side effects of drugs on the body. "These new developments are what I find most interesting, and only pain doctors are doing this," Fan Yinghui admitted.

Between orthopedics and surgery, which have the advantage of surgery, and internal medicine, which mainly focuses on medication, pain management fills the gap between departments with its unique treatment.

Pain relief is not easy

Compared to other departments, the history of pain management is not particularly long. In 1989, Academician Han Jisheng, the founder of pain medicine in China, advocated and established the Chinese branch of the International Pain Society, marking the official establishment of a professional academic group in the field of pain in China. In 1992, this academic group officially merged into the series of the Chinese Medical Association and established the Pain Branch of the Chinese Medical Association. In 2007, with the joint efforts of academician Han Jisheng and other pain medicine experts, the Ministry of Health of China issued Document No. 227, requiring the establishment of a clinical primary diagnosis and treatment subject - Pain Department - in medical institutions.

However, at the same time, the pain subject is not an independent clinical medicine secondary discipline. Last month, Fan Yinghui gave a lecture to a fifth year medical student at Jiaotong University School of Medicine. Before starting, she introduced herself as "I am a pain doctor". The students below chatted and discussed, but they were unaware of the existence of pain medicine and did not understand what it does.

Due to the lack of corresponding specialized medical education, pain doctors rely more on post employment education and clinical experience for teaching. At the beginning, some doctors in the pain department were diverted from the anesthesia department, which helps to observe changes in the patient's condition and maintain stable circulation and breathing; Regional anesthesia techniques such as nerve block, lumbar anesthesia, and epidural puncture catheterization have also laid the foundation for partial analgesic surgical operations, but these still fall within the scope of local anesthesia and can only ensure that the pain point is no longer painful within two hours.

The chronic pain that is truly classified as a disease is very complex from diagnosis to treatment. Pain can occur in any part of the body, and precise identification of the cause of pain requires a nearly comprehensive knowledge base. In addition to consultation, the daily routine of the pain clinic also includes reading X-rays, reviewing laboratory tests, performing puncture under intraoperative imaging positioning, and mastering a complete set of surgical skills.

The Pain Department of Renji Hospital currently has 7 medical staff with backgrounds in anesthesia, spinal surgery, and neurology. In addition to doctors, there is also a pain specialist nurse responsible for professional pain care. In its latest recruitment announcement, doctors in orthopedics and neurosurgery are still being recruited. Multidisciplinary backgrounds have become the trend.

In daily work, multidisciplinary consultations are also common. "Some patients have low platelets, so can they install an intrathecal pump? This requires consulting a hematologist. For example, when a tumor undergoes bone metastasis, it is often accompanied by severe pain. Radiation therapy can control the progression of some tumors, but some patients cannot meet the position requirements for radiation therapy due to pain. Some patients still feel unbearable pain after radiation therapy and are eager to request the implantation of an analgesic pump. At this time, it is necessary to consider the impact of radiation therapy on the healing of the implanted surgical wound and choose a good surgical opportunity." Fan Yinghui said that sufficient communication is a prerequisite for good cooperation.

In May of this year, the General Office of the National Health Commission issued a notice on the issuance of the list of pilot hospitals for comprehensive pain management. This is a further measure at the national level to improve the comprehensive management ability of pain discipline, following the joint issuance of the "Pilot Work Plan for Comprehensive Pain Management" by the National Health Commission and the National Administration of Traditional Chinese Medicine in February this year. It is also a manifestation of the further attention paid to the need for pain relief.

As pointed out by the International Society for Pain, although few people die from pain, countless people live and even die in pain. Pain relief has long been seen as unnecessary, but painlessness is a right for everyone.