Pain is the most frequent reason for patients seeing a doctor. A new guide offers an overview of the pharmacological, psychological, surgical and integrative treatments that may provide a benefit for the approximately 20 per cent of the population suffering from chronic pain. The guide’s focus on the strength of evidence for the efficacy of treatments is a new aspect.
31.05.2021 | TINE BAGGER CHRISTIANSEN
Professor Lene Vase, DMSc from the Department of Psychology and Behavioural Sciences at Aarhus BSS, Aarhus University, is part of the group of researchers working on a characterization of chronic pain and pain treatment in the 2020s – a guideline for doctors who are not pain specialists.
"Researchers have agreed for a long time on how to test the effect of pharmacological treatments, but in recent years, more attention has been given to the control groups needed to draw conclusions on the effect of treatments such as psychotherapy, alternative treatment, surgery and deep brain stimulations," says Professor Lene Vase. This knowledge is very important when choosing treatment methods in a treatment system where there is a need to prioritise, directly or indirectly, between different costly treatment methods.
With two medical colleagues, Steven P. Cohen and Michael Hooten from the John Hopkins School of Medicine and the Mayo School of Medicine in the US, respectively, Lene Vase has just published a scientific article in the prestigious medical journal The Lancet.
"Pain is an individual experience. We cannot measure objectively whether or not a person is in pain. Pain is not always associated with neurobiological findings, so we have to take people’s descriptions at face value. That's also one of the reasons why the same treatment doesn’t work for all patients,
Lene Vase, professor, Department of Psychology and Behavioural Sciences, Aarhus BSS
Treatment of chronic pain
To be successful, it is crucial that chronic pain treatment is adapted to the individual patient. This means that there is not one fixed formula for treatment of chronic pain patients.
“Pain is an individual experience. We cannot measure objectively whether or not a person is in pain. Pain is not always associated with neurobiological findings, so we have to take people’s descriptions at face value. That's also one of the reasons why the same treatment doesn’t work for all patients," says Lene Vase.
Today, a number of interdisciplinary treatment methods are available to help patients in pain, and Lene Vase has contributed new knowledge in this area. Among other things, her research focuses on placebo effects and on how to test the efficacy of treatments using experimental and clinical designs.
Strong analgesics are not always the answer
Helping a chronic pain patient is a complex process, and patients respond differently to the help they receive. For example, the mere expectation of treatment can have a positive effect.
One of the problems of pain treatment today is that, generally, many patients only receive pharmacological treatment, even though it does not always relieve pain for all patients. Especially in the US, prescriptions for strong analgesics, such as opioids, represent a problem, as around 6% of patients will stay on this medicine and face the risk of developing abuse or dependence. Furthermore, long-term use of strong analgesics also entails a risk of sleep apnoea, osteoporosis, reduced fertility and sexual problems, as well as a risk of blood clots in the heart.
There is a range of other options for pain relief for individual patients. Physical exercise as well as good sleeping habits play an important role. Some people also have a positive effect from alternative treatments, acupuncture, diet therapy, psychotherapy or music. Another frequently applied treatment method is cognitive behavioural therapy, which focuses on changing patients’ thoughts about their pain. The aim is to improve patients’ quality of life. This is a complex process, but in many cases, achieving better quality of life is more realistic than significant pain reduction.
Using control groups and testing the effectiveness of treatments are important tools to determine which treatments work, whether they have sufficient effect, and why. Lene Vase is an expert on this area.
Testing whether a treatment works is not so easy
Usually, new pharmacological treatments are tested against an inactive placebo (e.g. a calcium tablet), and in order to make their way into the market, new drugs must perform significantly better than placebo. Non-pharmacological treatments, such as surgery and alternative treatments, are not subject to the same requirements., but are often simply started without rigorous testing. If it turns out that they relieve pain, they may be tested against no treatment. But since most interventions are better in the short term than no treatment, it is easy to demonstrate an effect.
Determining whether a treatment is better than a placebo to make sure that the treatment effect is not simply the result of patients’ expectations of treatment is not straightforward. You have to develop an intervention similar to the one you are testing, but without the presumed active ingredient. In recent years, stricter requirements have been introduced for surgery, deep brain stimulation and psychological intervention to show an effect compared with relevant matched control groups.
A placebo is not about fooling the patient
It has been demonstrated that placebo effects play a very important role. Not only as a control when testing new treatments, but also, and just as importantly, because they reveal the extent to which patients’ expectations and perceptions contribute to the overall benefits of treatments.
Historically, the term placebo effects has had a slightly negative ring to it, because placebo has been described as a way of 'fooling’ people into believing that they will recover even though they have just been given a calcium tablet. However, today our knowledge about the factors causing a placebo effect has increased to a level where we can use it actively and ethically responsibly in treatment. The core of placebo effects is that the patient’s experience of a treatment can add to the positive effects.
Or in other words: Patients’ experience of a specific treatment can either work for the treatment, increasing its effect, or it can work against it, preventing the treatment from working optimally.
"When they hear the word ‘placebo’, most people think that it’s about giving inactive medicine, and lying to the patient. But that’s far from the truth. In a modern understanding of placebo effects, the context and expectation play an important role. Practitioners and patients themselves can influence these effects, while administering active medicine, thereby enhancing the overall outcome of the treatment," says Lene Vase, and she continues:
"Fundamental and detailed knowledge about the interactions between psychological and neurobiological processes enables us, as a society and as individuals, to better organise courses of treatment and ensure the best possible treatment outcomes."
"The costs of pain treatment are substantial, and if we want to see changes in this area, we need to look more closely at personalised treatment, while at the same time taking a more interdisciplinary approach," says Lene Vase.
Read the article in The Lancet
Sources
- Chronic Pain: An Update on Burden, Best Practices and Recent Advances, Stephen P. Cohen, Lene Vase, Michael Hooten.
Fact box :Pain is defined as "an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage". Pain is divided into three sub-types:
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