Chronic pain is as real an ailment as any and is characterized by persistence. Defined simply, chronic pain is pain that is ongoing and which lasts longer than 12 weeks. In fact, signals of chronic pain tend to remain active in the nervous system for weeks, months and even years. A major misconception of chronic pain is that it is caused by some unrecognized injury, inflammation or disease, and requires rest for healing and relief. Recent advances, however, suggest that chronic pain is mostly a product of abnormal neural signalling, with biopsychosocial dimensions, and therefore requires a multimodal treatment approach.
Most physicians lack an understanding of treatment options for chronic pain and tend to rely on medication alone, which often results in over-reliance on mostly unproven and often harmful drugs. Added to that is the growing dependence on costly and unproven neuromodulation techniques for treating chronic pain. This over-reliance results from a combination of aggressive drug industry marketing, lack of access to multidisciplinary services like physiotherapy and psychology and also perverse financial incentives for care givers to promote shorter consultations, drug prescriptions and invasive interventions.
Opioids offer a solution in that they are highly effective in treating chronic acute pains, but these are too expensive for most patients in low and middle-income countries. The other challenge with opioids is diversion for recreational use that can cause an ‘opioid crisis’. Patrick Radden Keefe’s Empire of Pain is an excellent exposition of how chronic pain was misused by a US pharmaceutical firm in a marketing campaign for it opioid formulation. Opioids can be devastating, given their high likelihood of abuse and addiction. But due to the malpractices of some companies and the US opioid crisis, they may no longer be easily available even for cancer patients, for whom opioids are scientifically needed.
We must encourage a nuanced discussion on therapeutic options to cure chronic pain that takes a risk-benefit analysis into account. Also, chronic pain must be given a ‘name’ for ease of explanation to patients. Doctors must explain to patients what they are suffering from in language they can understand. Descriptions like “your pain is a product of abnormal neural signalling with biopsychosocial dimensions" could increase patient anxiety. Explanations should be simpler. Such as: “You have nociplastic pain that will be adequately managed by a team of expert caregivers" or “this condition does not require expensive imaging and blood tests".
Another need of the hour is to establish dedicated ‘pain clinics’ at the community level with multidisciplinary teams at their helm. These teams should include physiotherapists, clinical psychologists-psychiatrists, occupational therapists, pain specialists and rheumatologists. Importantly, these specialists should be trained in differentiating nociceptive pain from nociplastic pain.
Another aspect for us to address chronic pain would be to ensure the availability of drugs with proven efficacy in treating nociplastic pains. These include serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine, among others; and other anti-depressants, in lower doses, such as amitriptyline, and gabapentinoids such as gabapentin. Nonsteroidal anti-inflammatory drugs must be avoided as they are not very effective, and their long-term use is fraught with the possibility of serious adverse effects. Likewise, simple painkillers like paracetamol should also be avoided as they are not effective.
Cannabinoids, a class of drugs derived from the cannabis plant, and more commonly used by Ayurvedic physicians in their whole-plant format, may offer an answer as they are strong relievers of nociplastic pain. In several Western countries, cannabis has been taken out of the category of a ‘controlled substance’ and is now being used to treat a host of conditions, while also being misused as a recreational drug.
This class of drugs, however, risks facing the same fate as opioids, waylaying another set of drugs that could be useful if given by experts on the basis of correct indications and all the precautions against misuse. Cannabinoids have a deep-rooted and old India connection. For thousands of years, cannabinoids have been used in Ayurvedic medicines. Their pharmacological properties must be scientifically studied by pharmacologists, especially from the standpoint of controlling nociplastic pains. Cannabinoid receptors are distributed widely in different parts of the central nervous system, including in the brain.
Pharmacologists may like to investigate this ‘Indian’ drug to find out the mechanistic basis of nociplastic pain control, if any. That may open a path for scientifically conducted and strictly controlled trials for its efficacy and adverse effects both over a short period (drug trial) as well as over long periods in phase-IV (post-marketing) surveys.
Chronic pain is real. It deserves to be taken more seriously. The big question is whether cannabinoid medicines could help. The jury is still out on that, as experts will have to submit these medicines to authorities for appropriately conducted, double-blind controlled trials in patients with chronic nociplastic pains. It is critical for these trials that they involve specialists who can correctly and accurately diagnose fibromyalgia (nociplastic) pains. If these drugs prove to be effective and without any short-term or long-term adverse effects, then applications may be submitted to the appropriate authority for their approval for use by practitioners of modern medicine.
Anand N. Malaviya is former head of the department of medicine and chief of clinical immunology and rheumatology services, All-India Institute of Medical Sciences