About ten percent of the Swiss population suffers from chronic pain. Monika Jaquenod-Linder, MD, has been a pain therapist in Zurich for about twenty years. At the Spine and Pain Clinic in Zurich, she treats patients who have a long history of suffering.
Dr. Jaquenod, pain therapy always reaches its limits. What are the main problems when you think of your specialty consultation?
Dr. Jaquenod:
One of the big problems is that pain is multidimensional, that psychosocial factors interact in addition to the purely biological dimension. And we can often only insufficiently influence these. Chronic pain patients with a long history of pain are particularly problematic in this regard. In tumor pain patients, for example, the pain can often be significantly better adjusted, and the biological component predominates. These patients are concerned with other goals, pain relief is paramount, and potent opioids are administered in high doses, which is not possible in non-tumor pain patients.
Then eminence over evidence still applies to pain therapy in the sense that the therapist is required as a human being?
Yes, I am convinced of that. Leadership of the chronic pain patient is quite essential. This is about experience and a sense of what a patient needs and what might help them. In twenty years I have learned a lot and I am still learning, which makes it exciting.
Are pain patients referred to specialists too infrequently (along the lines of “I can handle it”) or do you often see patients where you wish you had consulted them sooner?
This certainly happens, especially if they are diagnoses that require specialized expertise. In other cases, a primary care physician who has interest, time and patience for chronic pain patients is of great importance. However, primary care physicians cannot always devote the time such a patient needs.
Second opinions can be useful for both the patient and a primary care physician. I, too, am sometimes happy to discuss complex cases as part of a team; this way, there are always suggestions and new interesting views.
What guidelines should a primary care physician follow, where do you look for yourself?
Crucial knowledge comes from my 20 years of experience. I try to read the latest articles on specific topics. For example, my area of interest is opioids. The individualization of the chronic pain patient is crucial. It seems important to me to always start from the patient, the type of pain, his pre-existing conditions, age, etc. The WHO staging scheme is outdated. It shows only three groups of pain medications, making it too simple. However, it illustrates how little medication we actually have available: three levels, that’s not much. It is also interesting that in the lowest tier, that of non-steroidal anti-inflammatory drugs (NSAID), are those drugs with the most serious side effects on organs. The step scheme does not say anything about dosages and useful combinations.
What is also always important to me are the long-term perspectives. For example, one should not immediately increase the dose of opioids steadily with enthusiasm, and in five years one has reached a dose limit that no longer permits any increase or return. Again and again, further alternatives should be critically evaluated.
They noted in a presentation to Zurich Internists that coxibs are underprescribed compared with classic NSAIDs. Why is that?
If we give drugs from a certain “class” that have side effects, we should use those that are less dangerous. So the ones with fewer gastrointestinal or cardiac side effects, for example. I am reluctant to use non-steroidal anti-inflammatory drugs on principle, with the risk profile they must have quite good and long-term efficacy. They are “weak”, lowest WHO level, and one automatically thinks that they are therefore harmless. But it is not so. I am convinced that the indication must be just as correct as for the opioids. Long-term use should be subject to the same criteria and efficacy for pain must be proven.
When do you use these medications?
If an inflammatory component plays a role, then the drugs are appropriate. I constantly check the dose and intake, it should never become a no-brainer. Does the patient need it daily and what is the success? What else can he do? This includes improving the daily structure, finding the sleeping and waking rhythm again and increasing activity. The goal is to get back to normal a bit, and the medications only support that. Patients need to see and strengthen more of their healthy parts in the body. For example, if patients have pain in the lower extremities, they can exercise the upper body without restriction, but often it is forgotten. It is essential to avoid deconditioning. A good body image is important for each of us, and pain patients have often lost that.
What else would you like to have in your medication treasure box?
I would like to have a new class that attacks completely different receptor systems. It would also be nice to have a long-lasting local anesthetic that works for three to four months – a kind of Botox for the pain pathways. The latest good market launch is the Qutenza™ pain patch: with one patch, applied over one hour, significant pain relief can be achieved for up to three months if well indicated. I am also curious to see whether a cannabis preparation will one day come onto the market that can be used with good success.
Interview: Susanne Schelosky, M.D.
HAUSARZT PRAXIS 2014; 9(5): 8
