No Pain, No Gain

Pain is a topic that has always interested me, possibly because I have always felt like a bit of an outsider in my views on analgesia (pain killers). My family are a bit unusual in the way we manage pain. My parents have always argued that pain is good for us, it lets us know there is a problem and we should listen to our body and not mask this pain. As such my siblings and I would not be given pain killers but instead advised to exercise through a painful muscle, or chew on a clove for toothache or use a hot water bottle for tummy ache. Even to this day I will rarely use any pain killers. My Father’s tolerance of pain is particularly high – in the last few years he refused any analgesia after both his knee replacement operations or during a colonoscopy. In fact I can’t say that I have ever seen him take a painkiller. Most people are shocked if I tell them this, as society generally has a very negative view of pain, in fact the use of paracetamol, NSAIDS and other over the counter analgesia is very high in the UK. We are taught to dose our children up with these drugs from an early age to protect them from pain, and to carry analgesia around with us in case we develop an ache or a pain while at work or away from home.

Pharmaceutical companies advertise over the counter analgesia on prime time TV and these drugs are easy to buy and socially acceptable to take.

I recall after giving birth being handed a bag full of paracetamol and ibuprofen without even being asked if I wished any pain relief – this was despite not taking any analgesia other than entonox during the birth or immediately after. When I politely declined, I was informed that I had to take them as they could not be dispensed to anyone else. My parents had similar experiences after their joint operations.

With all these prescription pain killers being dished out so readily its no great surprise that the Faculty of Pain Medicine reports 5.4% of 16-59yr olds have misused prescription analgesia not belonging to them. In addition a staggering one third to one half of the UK population complain of chronic pain in a 2016 BMJ article ¹. Whilst this may seem shocking, most people- including many clinicians – do not consider the use of regular analgesia that concerning. Pain can be stressful for our body and mind, it can affect our quality of life and our mood. Living without pain is generally considered to be much better for us even if this pain is dulled by drugs.

However, pain can be useful too, it tells us not to overuse an injured limb or eat something that doesn’t agree with us, and protects us from further injury. Pain also triggers inflammation to be targeted to the area to aid healing. We also know that analgesia can slow wound healing and affect bone mending so there is a fine balance to be struck with these medicines.

This week an article published in Cell ² made me consider the benefits of pain further. In this paper researchers discovered that pain-triggered neuropeptides directly interact with goblet cells in the intestine. Goblet cells are stimulated by these neuropeptides into producing mucous which lines the gut. But why should mucous production during pain be useful? Our gut microbiome is teeming with microorganisms which perform many important functions for us from vitamin and hormone production to immune function, metabolism of important nutrients and signalling between the gut and end organs. Without a healthy balanced gut microbiome our health suffers greatly.

The integrity of the mucous membrane of the gut is key to this function . Without this integrity the gut wall would become permeable (so called leaky gut) which allows harmful bacteria into our blood stream causing inflammation and disease. So it seems that our body is rather cleverly protecting us from the harmful effect of pain by strengthening our defences and bolstering our immune system in the gut. In this mouse study neuropeptides were blocked in mice with inflammatory bowel disease (a condition which causes inflammation and pain in the gut), these mice were found to have a significant thinning of their mucous layer in the gut and worsening of their colitis in comparison with mice whose pain signaling pathways were not blocked. In other words pain blocking drugs worsened their condition.
The implications of this study are far reaching. We now recognise the importance of maintaining a healthy gut microbiome to prevent disease. it would therefore seem prudent that we consider this additional risk to our gut microbiome when we take pain blocking medication.

Fortunately the NICE guidelines 2021 on chronic pain are already in support of a non drug based approach to pain and most clinicians are now aware of the lack of evidence for analgesia use in chronic pain patients. This study cements this advise and should make us consider alternative ways of managing acute pain too. My family and I have always managed pain without analgesia and I believe this approach can be taught. For example, when I tore my ligaments in my knee I walked more and got up to stretch my knee as often as I could and used cold compresses. If I have a pain I generally do breathing exercises. The way we look at pain makes a huge difference – if we see it as a way for our bodies to tell us something or heal it is no longer frightening or negative and we can manage it better.
BSLM is also championing this approach through innovative practices such as “free from pain” by George Ampat, coaching patients to lifestyle change and recognising the role that diet can have in improving pain. It’s time we changed our narrative on pain management, after all, no pain, no gain!

View the NICE Guidelines Here

References

1. Prevalence of chronic pain in the UK: a systematic review and meta analysis of population studies. A. Fayaz et al; BMJ open 2016;6:e010364

2. Nociceptor neurones direct goblet cells via a CGRP-RAMP1 axis to drive mucous production and gut barrier protection. Daping Yang et al; Cell Oct 27 2022; Article 1; vol 185; Iss 22; p4190-4205