Lords of pain, this great unknown in medicine

Incommunicable, variable according to the present feeling and the past of each one, the lords of pain remains for the doctors a mystery. Until now poorly studied at the faculty, sometimes neglected, especially in countries marked by Catholicism, it is today the subject of renewed interest. On the occasion of World Pain Day, October 19, an update on the most current knowledge.

lords of pain

“The word pain, ( lords of pain ) simple as it is, contains a thousand ailments. The formula is from Marin Cureau de La Chambre, one of his (many) doctors in whom Louis XIV perhaps trusted the most. We can suppose that the man of the art knew what he was talking about, so much the Sun King had to suffer from physical insults of all kinds, from one end to the other of his interminable reign: since gonorrhea which had come to him at the age of the first love until the unbearable attacks of gout which transformed his last years of life into the ordeal, passing by the typhoid fever which made him suddenly lose his hair on the eve of his 20 years, more than probable urinary stones, the tearing of all its upper left dentition and the scarring of the palate with “points of fire” …

Without forgetting, of course, the legendary anal fistula of 1686 for which the surgeon Charles-François Félix developed an instrument (the “royal curved” scalpel) that he had the prudence to try on several dozen destitute. picked up at the hospice of Versailles – several of which succumbed – before introducing it, with the sweats of anguish that one guesses, into the first foundation of the kingdom.

One and the same word to designate a thousand different ailments. In writing this sentence, Marin Cureau de La Chambre who, in addition to being a doctor, was also a bit of a philosopher, wanted to put his finger on what still remains today, for many thinkers of pain, ( lords of pain ) one of its essential features: its incommunicability.’

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An experience that cannot be shared ( lords of pain )

If it is “undoubtedly the best shared human experience, with that of death”, as anthropologist David Le Breton writes in his “Anthropologie de la pain”, pain is, at the same time, an inherently indivisible experience, in the sense that no one can get into the body – or the head – of another when that other is in pain and says or shows pain. “You can never live the pain of the other. And this is arguably the most terrible truth about pain: that it is not transferable. Pain, even more than any other effect, reminds us to what extent we are the only ones able to experience what we have to experience, ”writes for her part the philosopher and psychoanalyst Cynthia Fleury, who has worked a lot on the subject since its publication of his essay “Pretium doloris”.

Noting that the patients had difficulty “verbalizing” their pain, ( lords of pain ) and in any case, did not say it insufficiently precise terms to help the doctor in his diagnosis, Marin Cureau de La Chambre, therefore, undertook to research and characterize the pain. universal, non-verbal signs of pain: the face that frowns, the eyebrows that frown, the body that contracts or even retracts, the uncontrollable laughter that breaks out …

Four centuries later, this research continues, with other means. In 2013, parturients underwent a strange experience under the watchful eyes of Inserm researchers. While they were giving birth, a camera aimed at their eyes recorded, from a fraction of a second to fraction of a second, the variations in the size of their pupil: before the onset of contractions, after, before the epidural, after … Film analysis showed that the pupil increased in diameter and, in reaction to light stimulation, contracted more when the pain ( lords of pain ) caused by the contractions was more intense.

In search of a reliable indicator

As bizarre as they may seem, studies like this are far from clinically harmless, if only for all the situations in which it is impossible to tell how badly one has. evil: think of patients in the recovery room after an operation, those in a coma …

Having a reliable indicator, precisely calibrated, of the level of pain, ( lords of pain ) would be of great help for doctors and first and foremost for algologists, these (unfortunately too rare) doctors who have chosen to specialize in the study and the treatment of pain. Doctor Alain Gahagnon is one of them. He teamed up with his colleague Martin Winckler (the author of the bestseller “La Maladie de Sachs”) to publish a veritable sum of more than 500 pages on the subject, “You will understand your pain”.

In their work, the two authors insist on a point that further complicates what was said above about the incommunicability of pain: the perception biases to which it gives rise. Inevitable biases due to the fact that everyone, had he taken an oath to Hippocrates, perceives, tolerates and therefore (if he is a doctor) recognizes and evaluates the pain ( lords of pain ) of others according to his own experience and his a priori. While these biases are inevitable, they happen to penalize women much more than men.

Gender inequality

“It is known, explains Alain Gahagnon, that women’s pain ( lords of pain )tends to be minimized by medical staff, and that they are, therefore, on average, less well relieved than men, even though many studies suggest that, with equal stimuli, they feel more pain than they do. ” Why? “He still drags the idea that women, when they say their pain, would describe it in a less factual, more emotional way, in short, that they would ‘add to it'”, answers the algologist. “She is a child of the medical patriarchy, a remnant of the ‘hysterical woman’ of the nineteenth century”, abounds Cynthia Fleury who specifies that the doctors – men or women – who give in this bias most often do so “in spite of themselves” .th  century ”, abounds Cynthia Fleury who specifies that the doctors – men or women – who give in this bias most often do it“ in spite of themselves ”.

This “double standard” is all the more shocking and unacceptable given that, no doubt for hormonal reasons, women are much more prone than men to chronic pain. Migraine, which affects more than 10% of the population, affects three women for one man. Irritable bowel syndrome (5% of the population), two for one. Fibromyalgia, this chronic disease characterized by diffuse muscle and joint pain and which has long been denied by a large part of the medical profession, for the sole reason that it did not understand the origin, strikes more than 80% of women.

In the case of migraines, the role of hormones has been clearly demonstrated. More generally, estrogens are likely to sensitize more to pain ( lords of pain ) than testosterone: how else to explain that transgender women, who absorb female hormones, suffer from chronic pain more often than before their transition?

According to data collected on the occasion of the publication in 2017 of a “White Paper on Pain”, no less than 12 million French people, men or women – or 18% of the population – suffer from chronic pain ( lords of pain ). And, hardly believable figure, 70% of them would not receive appropriate treatment! A situation completely out of step with the Public Health Code which guarantees for each patient the right to receive “the best possible relief from [his] suffering in the light of proven medical knowledge”: the law-making pain relief a fundamental right The patient goes back to Bernard Kouchner, eighteen years ago …

Lack of training

If the taking into account – and taking charge – of pain ( lords of pain ) by the medical profession, and in particular in hospitals, still leaves a lot to be desired, it is perhaps quite simply because to relieve pain, whatever it is, rarely constitutes a highly technical activity, and therefore potentially profitable for a hospital or clinic. And it is also, even more simply, for the lack of training of doctors. Even if the pain is the first reason for consultation, both in emergencies and general medicine, medical studies still reserve the minimum portion. “Over the entire course, the number of hours of lessons specifically dedicated to pain is only twenty. It is much too little for such a vast subject ”, laments Alain Gahagnon,

However, there would be a lot to teach them, as the “proven medical knowledge” invoked by the Public Health Code has progressed since the time of Marin Cureau of La Chambre. The main turning point dates back to the 1960s, when two neuroscientists from the Massachusetts Institute of Technology, Quebecer Ronald Melzack, and Briton Patrick Wall, gave the brain the central role in this affair: it is in the gray cells, not in the brain. the organ that suffers, that pain ( lords of pain ) is born. Just as it produces sorrow or joy, fear or disgust, the brain, and it alone, produces the painful sensation, without which it would be difficult to understand how it happens in amputees to continue to suffer in their missing limb – the famous phantom limb syndrome. More generally,

The painful signal path

If the distinction between chronic and acute pain ( lords of pain ) is well known, doctors and algologists superimpose another, a more fundamental one: in the eyes of those skilled in the art, pain is either nociceptive or neuropathic. The nociceptive system (from the Latin nocere, to harm, to make harm) triggers what one could call the “pain-sentinel”, this siren which is loudly heard each time our body is attacked from the outside or that some something is malfunctioning inside our body: you accidentally put your hand on a hot cooking plate; immediately, the injured area reacts by manufacturing chemicals, prostaglandins; these activate thermal nociceptors, these sensors located at the ends of the sensory nerves (which bring up the

It is only when the painful signal, having made its way to the head via the spinal cord, reaches the brainstem than the brain, that the pain ( lords of pain ) is actually felt… and that the reckless man quickly withdraws his hand. Ironically, the brain, where everything is played out, is the only one of our organs to be itself devoid of nociceptive sensors: once your skull has been opened, a surgeon could happily butcher your gray matter without causing it in you. least physical inconvenience …

By parentheses, these pain ( lords of pain ) perception pathways are in place and operational by the 25th week of pregnancy, as a result, that infants, contrary to what medical science has long believed, are also sensitive to them. However, this twenty-five-week threshold greatly exceeding the legal deadlines for abortion in all countries of the world, the argument cannot be taken up by anti-abortionists: the embryo does not suffer. e week of pregnancy, which results in infants, contrary to what medical science has long believed, are also sensitive to it. However, this twenty-five-week threshold greatly exceeding the legal deadlines for abortion in all countries of the world, the argument cannot be taken up by anti-abortionists: the embryo does not suffer.

When the alarm system is down

But it also happens that this alarm system (that is to say the nervous system) is itself the subject of a lesion causing its dysfunction: we are then dealing with neuropathic pain ( lords of pain ). Difficult to diagnose, they also have the unfortunate characteristic of being resistant to conventional analgesics, the treatment often revolving around taking antidepressants or antiepileptics. They can affect both the peripheral nervous system, as in the case of postherpetic pain (occurring after shingles), or central, as in multiple sclerosis outbreaks. The causes that can cause them being as numerous as they are varied, neuropathic pain is frequent,

A better understanding of pain ( lords of pain ) and its workings, which we owe to modern medicine and neurology, has an interest that goes far beyond the framework of physiology. Thus, knowing the path followed by the pain signal once it has passed through the brainstem and reached the brain sheds vivid light on the very concept of pain. And allows us, for example, to understand why pain cannot be reduced to a purely perceptual, sensitive experience. After passing through the brainstem, the pain signal passes through the thalamus, the center of production of emotions: it is here that the pain acquires its emotional component. After the thalamus, the signal reaches the neocortex, where the pain is rationalized and contextualized: last step, just as important as the previous one,

It is also in the neocortex that the pain, duly recorded, acquires its memory component: the painful experiences lived in the past are not without consequence on the way in which we will feel those which await us; several studies have shown that the more pain you suffer in your early childhood, the more sensitive you are to pain ( lords of pain ) when you grow up. Memory can also be painful …

The results of neuroscience, therefore, confirm that pain, an experience that is at once perceptual, emotional and memorial, is not, as David Le Breton writes, “a physiological fact, but a fact of existence. It is not the body that suffers but the individual as a whole ”. Cynthia Fleury does not say anything else when she relies on the testimonies of her patients in analysis suffering from chronic pain ( lords of pain ) to underline how much these, far from causing them to suffer in their flesh alone, invalidate them as people. “It is in this sense that I say that chronic pain constitutes a ‘matrix’, even if it is a negative matrix. Between two crises, two peaks, there is the anguish born from the anticipation of the next one, and this anguish is, too, disabling: the subject no longer trusting himself, not wanting to put himself in a situation of bankruptcy, deprives himself, adopts an avoidance strategy, which puts him in the background. Which weakens him in his social, professional, and emotional life, ”she explains.

To each his own tolerance threshold

A “spiral of vulnerability” which is further aggravated by the months, even the years of diagnostic wandering, when these chronic pains do not find an obvious explanation, when all the medical examinations return to normal … and the pain ( lords of pain ) nevertheless persists, like this is the case with fibromyalgia. “I hear patients who tell me: ‘I don’t know if I’m telling it to myself’, or: ‘I may be settling into this identity of a patient. I tell them that sickness does not constitute an identity, ”says the psychoanalyst.

lords of pain

We are not equal in the face of pain, if only because of our genetic makeup which predetermines the number of nociceptive sensors in our body. For the same person, the pain ( lords of pain ) tolerance threshold is also not constant throughout life and can fluctuate greatly depending on the circumstances. It will decrease in the event of depression or, simply, of personal or socio-professional difficulties; conversely, it will increase in certain extreme situations: marathon runners wanting to finish their race at all costs do not feel pain as they would otherwise, because then their brain, which has several pain control and modulation mechanisms , massively releases this natural morphine that are endorphins.

Religion gets involved

But, if the tolerance threshold varies from person to person (and, for the same person, from one situation to another), it also oscillates from one society and from one era to another. . An intimate fact (and even one could not be more intimate), pain ( lords of pain ) is also, at the same time, a social fact, with which culture, education, moral values ​​, and religion interfere. Catholicism is an eminently “sorrowful” religion: to understand by this that it values, even glorifies pain, ( lords of pain ) starting with that of Our Lord and Redeemer Jesus Christ. In the societies of the past, padlocked by the Church, “pain ( lords of pain ) was a powerful factor of order: if you suffered, it was because you had committed a sin and that God, who knows everything, was punishing you in your flesh. », Analyzes Cynthia Fleury.

It is by no means a coincidence that the paradigm shift occurred in countries with a Protestant tradition, with liberal thinkers, imbued with what sociologist Max Weber would later call “the ethics of Protestantism”. “In this ethic, the Creator expects people to produce more and more, for the good of all. And, of course, we are more productive if we are well than if we are in pain. The pain ( lords of pain ) then lost its raison d’être; therefore, it had to be fought by all means ”, continues the philosopher.

Even the old Latin countries like France have more or less converted to this new vision of things. But with delay and mezzo voice. Bernanos’ beautiful phrase – “He who seeks the truth of man must seize his pain” ( lords of pain ) – perhaps could not have been written in the country of Adam Smith or that of Henry Ford. And France is still looking at this powerful analgesic that is morphine with prevention that England or the United States do not have – even if it is true that, in the latter country, the absence of safeguards on opioids was the source of what will undoubtedly go down in history as one of its most serious public health crises.

Without denying the risks of dependence that may result, if their intake is not strictly supervised by the medical profession, not only morphine but also other less powerful opioids (called “level 2” according to the scale of the World Health Organization, such as tramadol or codeine), Alain Gahagnon regrets the “stubborn prejudices” which surround these molecules and explain their underuse, in France, in the fight against pain ( lords of pain ), in particular, that of cancer patients.

Our country’s shortcomings in pain ( lords of pain ) management are not limited to this issue of opioids. Despite the pioneering work, in the 1990s, of great doctors like François Bureau at Saint-Antoine hospital or Jean Bruxelles in Cochin, despite also the three Pain ( lords of pain ) Plans which followed one another at the turn of the 1990s and 2000s, this load remains far from optimal and far below requirements. But the tide may be turning.

In this regard, the past few months have been revealing. On October 21, 2019, the date of World Pain Day, 47 associations had stepped up to the plate to request “urgent recognition and efficient management of pain ( lords of pain ) as well as the psychological suffering associated with it” and call the public authorities “to make pain ( lords of pain ) a real priority in public health policies”. Four days later, on October 25, the National Assembly voted to experiment with therapeutic cannabis. wanted by LREM deputy Olivier Véran, who has since become Minister of Health – it will last two years and will concern some 3,000 patients. With this green light, France is only catching up: 17 countries of the European Union have already authorized treatments based on medical cannabis. On this subject as on others, Louis XIV would perhaps not have supported France to find itself at the back of the pack.

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