Won't somebody please think of the pain patients?

Pain has an element of blank;

It cannot recollect

When it began, or if there were

A day when it was not.

It has no future but itself,

Its infinite realms contain

Its past, enlightened to perceive

New periods of pain.

?

When Emily Dickinson in her poem (circa 1896) described pain and its grip on the human life, she attempted to express how all-consuming and “infinite” the experience of pain really is.

As she brilliantly articulated, pain is a complex phenomenon. We have not yet developed a reliable way to objectively quantify pain, despite all the efforts of modern medicine in investigating pain-related areas of possible biomarkers, such as systemic inflammation, oxidative stress, neurotransmitter turnover, micronutrient status,[1] gene expression,[2] or brain images.[3] Pain reporting and assessing remain a subjective, patient-driven exercise, which relies on the use of the visual analogue scale (VAS) and numeric rating scale (NRS). Pragmatically, the resulting score is a mix of physical, psychological, and emotional factors that we are not able to separate or weigh against one another, leading to scarce accuracy, questionable validity and reliability of the data we collect.[4]

Yet, researchers world-wide are dependent on these scores, and any new (or established) pain treatment is to be evaluated by the magnitude of the decrease it generates in these self-reported VAS/NRS scales. By asking patients to compress their convoluted pain experience into a single-dimensional score, we scientists are simplifying our research and at the same time losing information, an intrinsic phenomenon of every data compression.

One solution might be adding more self-reported scales (i.e., on health-related quality of life, anxiety, depression, treatment satisfaction, etc.) and evaluate their scores together. Or perhaps we could assess the outcomes of a given pain treatment by the overall benefit it brings to the life of the patients, measured against their initial expectations.

What does a patient really want? Is it a 50% reduction of the pain intensity? Or, say, a 99% reduction? What do they expect at the end of the care journey?

Patients are not uniform, and different patients are going to have different medical histories, psychological profiles, life experience, and expectations that do influence the outcomes of care.[5] So, while researchers continue their work in finding ways to objectively capture and describe the pain experience, we may want to define a pain treatment as ‘successful’ not (only) if it led to a pre-defined standard threshold score on the self-reported measurement scale(s) we administered, but if the patient eventually reached whatever realistic goal they had in mind at the beginning of their pain journey.

And even if they missed their VAS/NRS score threshold to be considered a “clinical success”, the pain treatment might have helped them to crawl out of the “element of blank” by allowing them to stand more, run after their grandchildren, or be finally able to go out for a stroll around the block on a wonderful, sunny day in April.

And how can we not see this other than a big success?

- Francesco

Reference List

1. ???????????Gunn J, Hill MM, Cotten BM, Deer TR. An Analysis of Biomarkers in Patients with Chronic Pain. Pain Physician. 2020;23(1):E41-E49.

2. ???????????Niculescu AB, Le-Niculescu H, Levey DF, et al. Towards precision medicine for pain: diagnostic biomarkers and repurposed drugs. Mol Psychiatry. 2019;24(4):501-522.

3. ???????????Mackey S, Greely HT, Martucci KT. Neuroimaging-based pain biomarkers: definitions, clinical and research applications, and evaluation frameworks to achieve personalized pain medicine. Pain Rep. 2019;4(4):e762.

4. ???????????Osterweis M, Kleinman A, Mechanic D, eds. Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. 1987.

5. ???????????Eklund A, De Carvalho D, Page I, et al. Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial. Eur J Pain. 2019;23(7):1378-1389.