Posted in Psychology & Medicine

Analgesic Ladder

Quite possibly the most common condition that a physician needs to treat is pain. Being the main way for the body to communicate that there is something wrong, pain can take various forms to make us suffer physically. The best way to make this pain go away is to treat the underlying cause, but often the cause is unclear and we need to manage the symptoms first.

Just as there are many kinds of pain, there are numerous different types of analgesics, or painkillers. Doctors and nurses take into account various factors to decide which analgesia to use, how much to give and how often to give it. For example, opioids (e.g. morphine) are one of the most effective pain-reliefs, but it comes with many adverse effects such as vomiting, constipation, drowsiness, slowing of breathing and potentially death. To facilitate this, the World Health Organisation created the concept of the “Analgesic Ladder”, establishing some simple rules to guide appropriate analgesia administration.

The ladder has been adapted to accommodate for new research and advancing pain-relief methods, but the general principle remains the same.

First, simple non-opioid medications should be given orally and regularly. Almost always, the first-line analgesia is paracetamol (acetaminophen in USA). It is an effective pain-relief, especially when it is taken regularly four times a day, while being extremely safe as long as it is not taken above the maximum dosage (4 grams/day). As effective as it is, people often neglect to take it regularly as directed, or take it too late when the pain has progressed to a severe level, hence the common misunderstanding that it is weak.

The next step of non-opioid medications are non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen or diclofenac. These medications work particularly well for musculoskeletal pain, muscle aches from viral illnesses and simple headaches. However, they are prone to causing stomach upsets, ulcers and kidney dysfunction. They can also exacerbate asthma in some patients. It should be taken in conjunction with paracetamol as they have a synergistic effect. Because of its gastrointestinal side effects, it is recommended to be taken after meals.

When paracetamol and NSAIDs are ineffective at easing the pain, a weak, oral opioid such as codeine or tramadol is added in. These medications are powerful, but often have undesirable side effects such as nausea and vomiting, constipation, confusion and agitation.

As we step up the ladder, we introduce stronger opioids. This includes oral options such as sevredol and oxycodone, to intravenous options such as IV morphine and fentanyl. As effective as these medicines are, they must be used with caution given the significant adverse effects such as opioid narcosis, where a patient can stop breathing or enter a coma.

Other than opioids, there are various other options of pain relief that may be explored as adjuncts. Neuropathic pain from nerve damage is notorious for being opioid-resistant, so medications such as gabapentin or tricyclic acids (traditionally an antidepressant) may be used. Ketamine is sometimes used as it has analgesic properties. A PCA (patient-controlled analgesia) pump with morphine or fentanyl may be more effective to optimise the timing of doses. Long-acting opioids such as methadone may be considered. Lastly, nerve blocks with local anaesthesia, such as epidurals, are often used in conjunction to reduce the need for opioids.

Pain is an extremely useful evolutionary tool as it allows as us to avoid harm, but it can create just as many problems. The analgesic ladder helps health professionals better manage pain so that patients do not have to suffer as much while they are being investigated and treated.

Posted in Psychology & Medicine

Placebo Effect

A strange phenomenon found in medicine is the placebo effect, where a patient’s symptoms improve after being given a completely inert substance (like a sugar pill) under the guise of a medication. The placebo effect is not only limited to pills, but any procedure that is intended for a therapeutic purpose (but does not have any actual therapeutic value). It is believed that the placebo effect is a strong component in many forms of alternative medicine such as homeopathy and faith healing. The placebo effect has been proven to be effective in improving or even curing the symptoms of some diseases such as allergies, asthma, headaches, abdominal pains and even severe illnesses such as heart attacks and cancer. Placebos are particularly effective for psychological symptoms.

There has been much research to determine how the placebo effect works. The leading theories so far are that placebos act to relieve anxiety and condition the patient into a more positive mindset, reducing stress and boosting the body’s natural healing process. This would also explain why placebos are effective in pain relief as perceived pain is amplified by negative emotions. Cognitive dissonance may also play a role, where the patient’s mind believes that since it is receiving treatment, it must be getting “better”, producing a beneficial psychosomatic reaction. Essentially, fooling the mind to believe and expect that it will get better makes the patient actually feel better.

Research into the placebo effect has also revealed some bizarre characteristics of the effect. For example, it has been found that the placebo effect is stronger if there are more pills, the pill is larger, branded or generally looks fancier. Even colour plays a role, with blue pills acting better as depressants (“downers”) and red pills acting better as stimulants (“uppers”). Telling a patient that a placebo will have a certain effect boosts that effect. Human factors such as the doctor’s credibility and confidence or the patient’s expectations and culture are known to drastically change the efficacy of a placebo. What is weirder is that studies have shown that telling a patient that they are being prescribed a placebo will not affect its efficacy, as long as they are told that “it could help them”.

The placebo effect is a great example of how much influence our mind, beliefs and expectations have on our health and our lives. The more positive thoughts and beliefs we have, the healthier we become. The more negative we are, the less effective treatments become. In fact, the same pill that gives people the placebo effect can be used to increase pain and symptoms if it is described in a certain way. This is known as the nocebo effect – the opposite of the placebo effect.