Chronic pain has become a significant crisis in India, affecting over 19% of adults and soaring to 25% among women. Yet, awareness about palliative care and specialized pain management remains abysmally low. Dr. Vandana Prakash, a clinical psychologist, and Dr. Mary Abraham, a renowned figure in neuro-anesthesia and pain medicine, are leading efforts to change this narrative with their multi-modal approach. Their latest publication, “Managing Chronic Pain,” is the result of years of collaboration. Drawing on their extensive expertise, the authors delve into the complex interplay of physical, psychological, and social factors influencing pain perception and management.

Here are excerpts from the interview:

HoA: What misconceptions about pain prevail in our culture?

Dr. Vandana Prakash:  Patients often harbor misconceptions and biases about pain, perpetuating myths such as the belief that pain is perpetual or indicative of irreversible bodily damage. Some may even view pain as a form of punishment for past transgressions. These distorted perceptions fall under the category of catastrophic thinking, exacerbating anxiety and autonomic symptoms. Additionally, pain can manifest as a symptom of underlying psychological conditions like depression, where individuals may experience pervasive bodily discomfort. Even in disorders such as schizophrenia, patients may develop delusions of pain. Addressing these cognitive distortions is essential for comprehensive pain management.

HoA: When does pain transition into a disorder?

Dr. Mary Abraham: Pain is classified into acute and chronic categories based on duration. Acute pain typically lasts less than three months and arises from injuries, surgeries, or internal organ inflammation. It’s a protective response and usually responds well to treatment. However, when pain persists beyond three months, it becomes chronic. Chronic pain requires a different approach as it often involves nerve-related issues and may not respond to standard anti-inflammatory drugs alone. Over time, chronic pain can become a disease itself, leading to disability, insomnia, mood changes, and other complications. For instance, chronic post-surgical pain can develop when surgical pain isn’t adequately managed. While this occurs in a small percentage of patients, it highlights the importance of addressing pain promptly and comprehensively.

HoA: Can you clarify how referrals to pain specialists work and whether patients are aware of alternative treatments for managing pain?

Dr. Vandana Prakash: Unfortunately, awareness of pain management options in our country is abysmally low, prompting us to author educational materials. Patients often endure a frustrating journey from one doctor to another without finding relief. Many end up in my care after other specialists fail to resolve their issues. Patients typically turn to neurologists, neurosurgeons, or orthopedic doctors for pain issues and resort to self-treatment. They only consider pain specialists as a last resort.

HoA: Pain management often involves prescribing painkillers. The US is going through an opioid crisis. What’s the situation in India? 

Dr. Mary Abraham: Fortunately, India has stringent regulations regarding narcotics, primarily prescribing strong opioids for cancer pain following the WHO ladder established in 1986. We rarely prescribe strong opioids for chronic non-cancer pain, a practice that distinguishes us from the situation in the U.S., where indiscriminate prescribing has led to alarming death rates. Due to strict regulations, prescriptions must be issued through registered medical institutions authorized by drug controllers, helping us avoid similar crises. However, for severe cancer pain, we prescribe strong opioids, ensuring they’re used responsibly for a specific period and stored securely. The WHO ladder allows for oral administration at home by caregivers, facilitating domiciliary palliative care.

Dr. Vandana Prakash: But such precautions are only confined to medical practitioners. In rural areas and small towns, people often resort to various substances to alleviate pain, leading to uncontrolled drug addiction. Many patients I encounter have multiple drug addictions stemming from attempts to relieve pain without awareness of specialized care available in hospitals or from doctors.

HoA: What are the psychological causes of pain? 

Dr. Vandana: Psychologically, individuals with chronic pain commonly experience depression, which exacerbates their condition. Unresolved psychological issues can manifest as physical pain, with bottled-up emotions and stress contributing to various physical ailments. Chronic pain sufferers often experience muscle tension and related problems such as shoulder and low back pain due to underlying stress and anxiety. Anxiety disorders are closely linked to pain, particularly in areas like the neck, shoulders, and stomach, while stress-related conditions like irritable bowel syndrome further underscore the intricate relationship between mental and physical health.

HoA: What advice do you offer to primary caregivers of individuals coping with chronic pain?

Dr. Vandana: Caregivers play a vital role in providing support and encouragement to patients. They should maintain a positive environment, avoid negative expressions, and appreciate even small efforts towards improvement. Distracting patients from pain and focusing on other aspects of life can significantly enhance the family’s overall mood.

HoA: How do you engage with cancer patients? Is pain management readily available for cancer patients in India? 

Managing Chronic Pain has been published by HarperCollins

Dr. Vandana:  While palliative care hasn’t reached every corner of India, models like Kerala’s neighborhood palliative care network exemplify its integration into primary healthcare. Hospitals should establish pain clinics and palliative care units to broaden access, extending beyond specialized cancer hospitals to grassroots levels.

Dr. Mary: The COVID-19 pandemic prompted a shift to online palliative care sessions, potentially expanding reach. Integrating palliative care into mainstream healthcare is essential for wider accessibility and better pain management.

HoA: How can chronic pain be effectively managed in old age?

Dr. Vandana: Managing pain in old age requires a multi-modal approach, including medications, physical therapy, social engagement, and lifestyle adjustments. Surgery may be considered for some conditions, but non-invasive methods and alternative therapies like yoga and acupuncture can also be beneficial. Encouraging older adults to remain socially active and mentally stimulated contributes to improved quality of life and pain management.

HoA: There’s skepticism surrounding alternative therapies. What’s your take on their efficacy?

Dr. Mary Abraham: Alternative therapies, alongside pharmacology, can be effective in managing painIntegrating complementary and alternative medicine into mainstream treatment can offer additional avenues for pain management.  I recently encountered a patient suffering from severe sciatica who was regularly practicing yoga. Curious about the exercises prescribed by his yoga teacher, he asked me to meet with them to ensure the exercises were suitable for his condition. Upon meeting the yoga teacher, we collaborated to tailor exercises specifically beneficial for his spine. This illustrates the potential benefits of yoga in pain management.

Dr Vandana Prakash: Integrating complementary therapies like yoga into mainstream treatment can be beneficial, provided they’re supervised by experienced practitioners. Psychological therapies such as dance therapy and music therapy can also alleviate pain and stress. Practices like maintaining a diary or engaging in meditation and yoga are particularly effective in managing anxiety disorders.