Pain stayed so long, I said to him today

“I will not have you with me any more.”
I stamped my foot and said, “Be on your way,”
And paused there,
Startled at the look he wore.
“I, who have been your friend,” he said to me.
“I, who have been your teacher,
All you know of understanding love,
Of sympathy and patience I have taught you.
Shall I go?”   

Author unknown

Pain is a friendly messenger, carrying news from the frontiers of the body to the command center of the brain. Like the messages traveling across telephone wires, pain is just a series of electrical impulses traveling up nerves. The brain sorts the electrical impulses and presents them to you, the conscious mind inside, as a coherent story about what’s going on down below. Sometimes the message triggers an immediate reflex action, like pulling a hand away from a hot stove, even before your mind grasps the problem.

How is pain relieved?

Relief from pain depends on stopping the electrical impulses carrying the pain message or on altering the way the brain puts the message together. Every drug or procedure used in pain treatment works on either the simple electrical message, or on its complex interpretation by the brain. Ultimate relief comes when the conscious mind disappears into sleep, which is of course the great achievement of general anesthesia. Consciousness is the barrier to complete relief of severe pain.

Most pain, however, is not the severe unremitting variety that requires treading the fine line between consciousness and oblivion. Most pain comes in an acute form that gets us to the doctor for treatment of a sudden illness, or in a chronic form related to our heads or our skeletons. Thousands of years ago Cicero made the distinction: “All pain is either severe or slight; if slight, it is easily endured; if severe, it will without doubt be brief.”

Willow bark – the first pain medicine

Time and chemistry have given us surgery, anesthetics, antibiotics and narcotics – life-savers for diseases heralded by severe pain. They have also given us lesser drugs for lesser pains, a long process beginning in the 5th century BC when Hippocrates recommended chewing the bark of the willow tree to relieve pain and reduce fever. A long line of chemical derivatives of the willow bark’s salicilin culminated in a stable powder patented and marketed in 1899 as aspirin, the world’s first synthetic drug. Aspirin launched the world’s pharmaceutical industries.

Anti-inflammation and pain

Inflammation causes pain and the purpose of the pain is to get you to attend to whatever is causing the inflammation. Pain relief from aspirin is best understood in terms of its anti-inflammatory effects, but the drug has multiple other biochemical properties, many still being discovered. One effect, on an enzyme involved in the production of chemicals that produce inflammation, led to the development of ibuprofen and its cousin naproxen. These newer drugs, non-steroidal anti-inflammatory drugs (NSAIDS), are mainstays in the treatment of the aches and pains of daily life.  Anti-inflammatory steroids like prednisone are far more potent and used only when their risks are balanced by the seriousness of the problem under treatment.

Tylenol is not an anti-inflammatory drug

Tylenol, or acetaminophen, is commonly thought to be just like aspirin, but it is chemically unrelated, has no anti-inflammatory effects, produces no gastric upset and doesn’t affect blood clotting. It reduces fever by a direct action on the brain, but no one knows how it reduces pain. The pain-relieving properties of aspirin and the NSAIDS, apart from their anti-inflammatory effects, are also poorly understood. It is possible that they decrease pain perception in the mind, but if so, no one understands how.  They are most effective after an acute injury, after simple surgical procedures, or with infrequent headaches (relief here is also of unknown mechanism).

Frequent analgesic use can increase pain problems

But what about pain of chronic conditions like osteoarthritis and frequent “tension” headaches, in which inflammation plays a lesser role? Much arthritic pain is from tightness and muscle imbalance. Gradual activity warms up joints and removes some of the discomfort. Exercise, heat, ice, massage, weight loss, stretching, Pilates, and yoga help minimize drug use in these chronic conditions. Frequent use of analgesics for headaches (more than once a week) actually lowers the threshold for headache triggers (like lack of sleep, alcohol, lack of exercise, stress, etc.)  and for pain perception, and often leads to a cycle of increasing drug use producing increasing numbers of headaches. This phenomenon is known as rebound headache and it highlights the importance of other methods of headache prevention and relief (adequate sleep, stress management, attention to diet and exercise, etc.).

Selling pain relief like candy

Since 1915, when aspirin became available without a doctor’s prescription, the sale of over-the-counter (OTC) pain relief has achieved the heights late Merck chief Henry Gadsden aspired to when he wished aloud 30 years ago that he could sell drugs to healthy people just like Wrigley’s sells candy and gum. These days, OTC pain medicines are so readily available that they seem as harmless as the candy next to them on the shelf.

Side effects

Unlike candy, OTC pain relievers have to be processed by the liver and kidneys. Chronic use can produce liver and kidney impairment, even failure of these organs. Chronic analgesic use damages hearing. Aspirin and other NSAIDS may erode the stomach lining; all but Tylenol impair blood clotting. Recent statistical studies resulted in withdrawal of two newer NSAIDS from the market because people taking them had more heart attacks than those on placebos. The problem also appears in statistical analysis of those on high doses of the older NSAIDS.

Don’t kill the messenger – heed it

Because no drugs are risk-free and pain is just messenger telling you about a problem, try to reserve the pill option for pain that interferes with sleep or truly inhibits you from carrying out the activities that are important to you. Attend to the causes of the message in as many non-pharmaceutical ways as possible. And remember that an analgesic “virgin” or infrequent user gets more out of a painkiller than an analgesic veteran.