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Pain has NO use
- Nicholas B Scott (14 April 2005)
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What pain is for.
- David W. Yates (6 February 2005)
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Nicholas B Scott, consultant anaesthetist
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Editor, I enjoyed Dr Nash's editorial "What use is pain" (1) very much and I would be interested to hear his thoughts and those of your readers on the following observations and conclusions. Firstly, in any film where the "goodies" are being chased by the "Forces of Evil" at some stage inevitably one of them succumbs to an injury, whether it be a broken leg, bullet wound etc. The situation is the same in real life. The net effect is to slow that person down and the whole group. If pain served any benefit it would surely galvanise the injured party into a sub 4-minute mile leaving all the others to catch up! Secondly, when we are confronted suddenly by an on-coming car or horse or train the next few seconds result in either a "rabbit in front of the headlights" situation or a sudden surge of strength and heightened reflexes and thus the ability to get out of the way. The victim does NOT experience pain as part of the "flight, fight or fright" process. It is the individual's ability to suppress the pain that determines their fate. Sportsmen and women who experience sudden pain on the field or track very often CANNOT continue in contrast to the prevalent view that in these situations the body completely suppresses pain by releasing endogenous opioids. The greater the damage the greater the pain, which limits the individual's ability to suppress it and there are many examples captured on television and screen of Leriche's opinion that "the pain has only made more distressing and more sad, a situation already lost." Likewise the individual reactions to angina, toothache and headache and minor limb trauma determine a person's ability to continue to perform their daily activities. Over the last 20 years there has been an increasing belief that pain serves no true beneficial purpose when recovering from surgery where the "danger" has already passed before the pain is appreciated. There is also great interest in pre-emptive analgesia and the need to get your analgesia on board before the trauma occurs which mimics the philosophy of the 1971 British Lions coach Carwyn James of "getting your retaliation in first". Furthermore the effects of clinical pain are inseparable from the effects of increased sympathetic activity.In the setting of modern elective surgery the only benefit of both is to maintain blood pressure in the presence of moderate to severe haemorrhage, the incidence of which should be very low in this country. Thus we are left with the realisation that neither pain nor sympathetic activity are desirable in the perioperative period. Various studies and meta-analyses attest to the beneficial effects of the PERI-operative use of beta-blockers, alpha-agonists and regional anaesthesia. Thus there are two major issues in moving these ideas forwards. Firstly that pain cannot be treated as a separate phenomonen independent of sympathetic discharge and other body responses to trauma such as immunosuppression and hypercoagulability. Secondly, perhaps more importantly,the maxim for the treatment of and the teaching of postoperative pain should be, as with all other branches of medicine, that prophylaxis is better than cure. NB Scott, Dept of Perioperative Medicine Golden Jubilee National Hospital Clydebank. 1 T. P. Nash Editorial II: What use is pain? Br. J. Anaesth. 2005; 94: 146-149 Conflict of Interest:None declared |
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David W. Yates Kent & Sussex Hospital, Tunbridge Wells, Kent
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Editor-In his Editorial Nash asks what pain is for and shows that the question has vexed philosophers from Plato onwards. While the 2500 years since Plato sounds a long time, it is a very short time in the evolutionary timescale which may be more appropriate when considering basic conditioned reflexes that we share with many animals. Our behaviour is strongly conditioned by our memories, in which we make associations between events that occur at around the same time. When I was young I overindulged in a platter of seafood and became ill. For a few years after I was unable to think of eating shellfish without feeling nauseous. Although it may have been the quantity of food that was my downfall rather than its nature, or even an entirely coincidental viral infection, my brain had made the association and was warning me of danger. Any stimulus which we associate with pain or illness is likely to be avoided. This is not an intellectual process and the fact that people can train themselves to overcome their conditioning to walk on hot coals, for example, does not make it any less valid. Nor does the fact that intense emotion or distraction can cause pain to be ignored. These are special and unusual circumstances and should be considered in the same way as the ability of some people to control their pulse and blood pressure; we recognize the phenomenon but it does not make us doubt the usefulness of the normal mechanisms of autoregulation. In our sophisticated world these reflexes can sometimes be counterproductive. For example we consider postoperative pain to serve little useful function and even to be dangerous by inhibiting respiration and coughing. Similarly the stress response is a nuisance which interferes with fluid management. However, from the body's point of view there is little difference between an operation performed by a skillful surgeon and any other traumatic injury. Thinking teleologically it is clear that for a Palaeolithic hunter-gatherer who has fallen and broken a limb, the pain and stress response prevent further damage and promote conservation and effective use of the body's resources. Dr.Nash has evidently spent his career treating patients with chronic pain, which is commonly related to conditions causing long-term damage to the body. In the era of our hunter-gatherer ancestor such conditions would not be associated with long-term survival. It is the increased life expectancy that has really shown up the shortcomings of systems that are concerned with the avoidance of immediately threatening problems. For the basic requirements of fighting infections, avoiding toxins and injury and recovering from trauma we are fortunate to inhabit a machine which may be an old design, but which still works pretty well to allow us to make the most of our lives. The simplistic medical student, trainee anaesthetist and patient are correct - pain is protective and provides warning. David Yates Conflict of Interest:None declared |
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