In search of a solution for the pains that were believed to be invented

Until very recently, pain was just a symptom, a warning sign of a disease, that we had put our hand too close to the fire or that we had hurt ourselves lifting the grandchild and we had to stop so that the body could repair the injury.

But in 2020, the International Association for the Study of Pain changed the definition to include the subjective nature of the painful experience and describe it as an "unpleasant sensory and emotional experience, associated with, or similar to that associated with, actual or potential injury or described in terms of that damage.

In that same document it is stated that "a person's account of an experience such as pain should be respected."

Many people who suffer pain whose origin cannot be traced to physical damage, who had felt that their suffering was judged as something made up,

Pain is now, in many cases, a disease in itself, which can no longer be eliminated by attacking its origin and which must be faced bearing in mind that it is a personal experience in which, in addition to biological factors, other factors influence psychological and social.

It is a subjective experience and no less real for that.

In Spain, a report from the Ministry of Health estimated that one in six people suffer from chronic pain, and yet, from the professionals who treat patients with physical or psychological interventions to the scientists who try to unravel the secrets of pain, there are a common point: few resources are dedicated to understanding and treating such an important problem.

Despite the prejudice that one may have in a society where when there is pain one looks for pills, the first line of attack against many persistent pains is not pharmacological.

In 2018, an article in

recommended initial non-drug treatment for chronic back pain, with a “biopsychosocial” framework that included pain education, help adjusting expectations, and resuming normal activities and exercise, taking into account the environment of the patient and include psychological support programs for people with persistent symptoms.

As Beatriz Rodríguez Vega, head of Psychiatry, Clinical Psychology and Mental Health at the La Paz University Hospital in Madrid, recalls, “in 2016, the Center for Disease Control and Prevention of the United States (CDC) recognized the use of

(full attention ) as a recommendable alternative to pharmacological and opioid pain treatment”.

compassion-based therapies

The psychiatrist states that, "despite the recommendations and support from scientific evidence and usual clinical practice" of the value of "third generation therapies based on mindfulness and compassion" they are not used regularly and widely.

“Training in these practices is complex and lengthy, and standardized protocols are used for research in which training is also required.

These programs are psychoeducational and could be implemented from primary school in a first step of intervention.

There is a lack of dissemination of knowledge, training in these practices and time to put them into operation ”, she affirms.

Researchers from the chronic pain care program coordinated by Ángela Palao in La Paz published

a clinical trial in the

, in English terminology) to deal with pain versus a cognitive behavioral therapy program, the psychotherapeutic intervention with the most evidence to treat the problem.

After two months of weekly two-and-a-half-hour sessions, patients did better on pain acceptance or anxiety levels with the compassion program than with cognitive behavioral therapy.

Given the subjective nature of pain, expectations are essential for all types of treatment.

Alfonso Vidal, head of pain at Hospital La Luz, Sur de Alcorcón and Valle del Henares de Torrejón, explains that when he receives his patients, he tells them that "practically all the patients who go to the pain units improve, but practically none are cured." .

It's something that can be controlled, like high blood pressure, but it's not going to go away,” he adds.

And this happens with pharmacological treatments, with psychological ones and with those that combine approaches.

Carlos Goicoechea, professor of pharmacology at the Rey Juan Carlos University of Madrid, recalls that this is the reason why some treatments without any type of scientific proof can work momentarily.

placebo psychology

"In a clinical trial, the placebo effect can have an analgesic effect of up to 20% and the drug 40%," he points out.

But like all treatments for chronic pain, the therapeutic effect expires and a treatment without a base can produce an emotional rebound effect.

“There are unscrupulous people who propose marvelous solutions, which do not last long, and then the patient loses hope regarding that treatment and also regarding others”, she explains.

"Maintaining emotion in a chronic patient, who on average is a 65-year-old woman who has been in pain for 8 years, is very difficult," she says.

In this regard, she recommends a pragmatic approach to the use of pain medication.

“The pharmacological approach must be maintained if it works.

Am I going to be taking pills all my life?

If they help you and do not harm your body,

Along with the interest in psychological interventions, there are other physical ones that already offer good results, although they are sometimes difficult to finance.

Vidal comments that there are treatments, such as radiofrequency stimulation, which modulates nerve function by applying temperature changes, or spinal stimulators, devices similar to a pacemaker that transmit electrical signals to the spinal cord to treat pain, which are useful for pain treatments. back, but given their cost they are not covered by the health system.

"Afterwards, sometimes, a person with a back problem is sent to a neurosurgeon, who can have the same cost, 15 or 20,000 euros and is more invasive, and is not questioned," he compares.

To improve treatments for the painful experience, researchers are trying to understand the processes that get out of control so that pain becomes chronic and the brain perceives a signal of damage that no longer serves as protection.

Elvira de la Peña, a researcher at the Institute of Neurosciences of Alicante (IN, Miguel Hernandez University-CSIC), explains that pain is studied at different levels, from the periphery, the point where the cause of pain is, "when you prick a finger or undergo surgery", to the central nervous system, the spinal cord, and ends in the cerebral cortex, where the perception of pain occurs.

"Therapies that act on the cerebral cortex are the most efficient, like drugs that inhibit the response to pain, but they also have more side effects," she continues.

“It also acts in the medulla,

but it is difficult to access, and at a peripheral level, anesthesia is used, for example”, he adds.

But, he acknowledges, "it is not yet known why the cause of pain disappears and the pain continues, whether it is a failure at the most external level or in the brain."

New target against pain

At the IN, De la Peña and Félix Viana have applied their knowledge to test a drug from the pharmaceutical company Esteve to prevent neuropathic pain, generated by an uncontrolled pain signal produced by chemotherapy against colon cancer.

In these patients, the suffering is caused by tactile and thermal hypersensitivity due to alterations in a type of receptor, known as the TRPA1 ion channel, necessary to feel pain under normal conditions and avoid it.

His experiments with mice indicate that the application of a drug that blocks the sigma 1 protein modulates the functioning of TRPA1 and normalizes the response to painful stimuli.

By acting at the peripheral level, the side effects are not important.

Ion channels, which account for sensations of hot and cold or pressure on the skin,

For the future, there are many lines of research to better explain pain, something that is also very useful for managing it with patients, and generating new treatments.

Optopharmacology, which would make it possible to release drugs with light stimuli at a precise point where pain is triggered, or immunotherapies, which have already shown their efficacy in cancer or rheumatic diseases, could be used to modulate the expression of pain.

Also, according to Vidal, "there are good expectations with transcranial magnetic stimulation, which consists of applying a magnetic field and focusing it on certain structures of the brain."

In a field closer to science fiction, Goicoechea points out, "gene editing is being applied in mice to block sodium channels [that communicate pain to the brain]."

These channels have been found to be altered in some families, such as that of a Pakistani adolescent who did not suffer from pain due to a mutation in the SCN9A gene.

The young man, who saw his syndrome reflected in an article published in the journal

in 2006, he made a living as a fakir and ended up dying at the age of 13 when he jumped from a rooftop.

One last example of the difficult balance between the necessary pain and the one that can be ruled out.

As a general recommendation, experts advise approaching pain units as soon as possible, because the sooner the pain is treated, the greater the chances of alleviating the suffering.

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