Some pains warn us of danger, and are like a key which opens the door to a cure. Others are chronic pains, and over six million people in Spain suffer from these. The most common are in the back, joints, head and shoulders. These can disturb sleep and cause anxiety, insomnia and depression. "Chronic pain affects between 10 and 30 per cent of the adult population, and women aged between 40 and 60 are the most affected. This pain is usually related to emotional problems and is the cause of 80 per cent of visits to pain clinics," explains Dr Jordi Montero, the leader of the Neuropathic Pain study group of the Spanish Neurological Society. This doctor has written a book called 'Permiso para quejarse' (Permission to complain), which has been published by Ariel and which refers to all types of pain: those which are just an alarm and are learned in childhood, those which are relieved by medication and those for which there is no treatment and continue to distress those who suffer from them.
In your book you say: "Pain is a wonderful invention." What is so wonderful about it?
When I say that, I am referring to pain as a sensory experience which serves as a defence mechanism. If we didn't have that acute pain we wouldn't be able to survive. In fact there is a very rare condition called congenital insensitivity, which is hereditary, where people who suffer from it lack specific nerve fibres and can't feel pain; they receive blows, fractures and infections without even noticing. They tend to die from complications fromself-inflicted injuries. Only those whose symptoms are slight manage to overcome the illness. That's why pain is a wonderful invention. It is an alarm which tells us where the fire is, such as when we get appendicitis, for example. Nowadays, thanks to the properties of substances with an opiate action which even the Romans used, modern science has developed analgesic medications for acute pain and they are really powerful, capable of boosting the networks which stop the sensation of injury occurring. We are lucky because we don't have to suffer pain, not even when dying.
Even so, some pains seem to remain and there is no remedy for them.
That is chronic pain. It is very common and millions of people suffer from it. It lasts a long time - more than six months - but there is no sign of damage. There is no pharmaceutical treatment for it and until recently people were told there was nothing wrong with them, or they were being hysterical. That was pure ignorance on the part of the medical profession, because these people do have pain and that's why they want permission to complain, because of their pain. This is something we have discovered in this century through new cognitive neuroscientific techniques, which have enabled us to observe how the brain functions. Most of the ideas in the world about philosophy and psychology have a physical and scientific basis. We have been able to see what happens with fear, where the neuronal networks which signify fear, horror and attachment are located. We have also been able to see what happens in the brain when pain occurs, so we know that patients who suffer from chronic pain really are experiencing it.
But if there is no damage, what causes that pain?
This type of pain is produced by a memory, a sensitivity. In many cases it occurs in people who have suffered very intense pain in the past and it is recorded in their minds. A simple touch, or smell, anything which evokes that past pain, can produce the same feeling. It isn't that the pain (or the cause) actually exists, but its representation in the brain is experienced as something real. It only stops when the people sleep, because when they are unconscious the memory can't appear. Also in some cases of Alzheimer or patients with neuronal damage which causes amnesia, the pain can disappear if someone doesn't have a very vivid memory of it.
Do you always ask patients whether the pain wakes them up at night?
Yes, because if the pain is due to damage, a trigeminal neuralgia, for example, it would wake them up. But if the pain is constructed by our conviction, by our consciousness, even without us being aware of that, it cannot appear when we are sleeping. That is important to know. In the same way, we can see that chronic pain is worse when the patient is anxious, when they worry about their pain, or when they join an association of patients who suffer from the same thing.
So in that case it isn't a good idea to mix with other patients who have the same thing, as people do with some illnesses.
In cases of chronic pain, definitely not. It would be like an association of poker players who try to give it up but meet up and have a game. In a case like that, wouldn't it be better to mix with people who play chess?
Is the pain real which we feel when someone we love is ill, or we believe we have inherited it but according to your book it is learned?
This is a disturbing subject. We learn and understand through imitation. For example, when Messi shoots a goal the motor neurones of the people who are watching order the quadriceps to move and they imagine themselves doing the same thing. In order to know the significance of something, like that movement, we have to do it in our imagination. We learn through imitation. You have the same smile that your mother would have right now, and you learned it when you were four and a half months old and copied it. And our family all speak with the same accent, and we have the same gestures, because we learn by copying.
So how do we learn when the pain is acute?
Just like anything else. A child copies his or her models. Very obese parents have obese children. It is true that there is also a factor called the imprint, which means that not everybody copies at the same time. That also depends on the brain, and we see this in twins whose behaviour is different. In general, though, their behaviour will be very similar. So, children who see their mother suffer a lot of pain end up suffering from a similar pain later. There are pains which are not transmitted through genes, but through simple observation. In general, what we copy are emotions, because it is they that govern, not reason. They are the reason we usually choose certain food in a restaurant, or the clothes we wear, or why we love one person instead of another. Pain is moved by emotions, so for pain to appear the emotions are very busy. Our conscience has a limited control over our feelings and can produce imaginary pains without us realising it.
Is that difficult to cure?
GPs aren't given enough time, or paid enough, to be humanist in the way they deal with all this. They send people for tests and write prescriptions. If a GP sees six people with headaches in half an hour, asks for six resonance scans and writes thirty prescriptions, he is a good doctor but he won't cure any of them. But if a doctor only sees one, doesn't ask for any tests and doesn't give a prescription but the patient is cured, as far as the health service economists are concerned he is a bad doctor. Doctors nowadays are stopped from being humanists, and this type of problem isn't dealt with from an empathetic view, putting yourself in the patient's place, understanding them, talking to them, spending hours with them sometimes. That would be impossible. Patients need a friendly gesture, affection, without a desk in-between. But the culture, our culture, plays a very important role. In the case of chronic pain you have to move away from this way of doing things, change everyone's attitude and it is very important for patients with this pain, which is causing them so many problems, to know what is happening to them, not to be ignored, and for their pain to be understood. We should explain to patients why they have the pain.
We don't have a pain culture...
No, and we all want to be really happy, although we don't really know what that means. Nobody wants to suffer, and as we have the concept of acute pain which is treatable, we think chronic pain must be the same: "Oh, they can give me something for it." And it's a business, and they are given something for it, but it isn't very effective. The benefits of treatments which combine motivation, physiotherapy and caresses, generally in the form of massages, are increasingly obvious although there are many other types of physical contact, emotional care . we are living at a time in which huge lights are beginning to shine on the medicine of the 21st century, because we now know who is the enemy. From a pharmaceutical point of view we are going to be able to be more effective. It is very probable that the modification of certain neuronal receivers can intervene in the alterations of the networks which signify pain in our brain. On the other hand, there are great hopes and projects about electric stimulation of the nervous system, in what has come to be called neuromodulation through stimulation, which is already being applied to patients with Parkinsons.
In your book you talk about the case of a patient with chronic pain who doesn't feel pain when he is playing a role in a theatre. Are you doing research around alteration of conscience?
That was something I experienced which taught me a great deal and I should send it to scientific magazines because I believe it is something to think about. I remember something a patient said to me: "Doing something isn't the same as being seen to be doing it." In this case, he forgot the pain. We don't feel it when we are pretending to be somebody else because, obviously, that person doesn't have the same memory and therefore the pain which is recorded in it doesn't occur. This is very interesting. As you say, perhaps it could be a way of carrying out treatments, but it is something far beyond my ability. Maybe the psychologists of this century who study neuroscience will consider this to be material to work with.
Does complaining help us to overcome pain?
Sometimes a complaint has a sense of grievance, and that is a neurological phenomenon, and it is a type of demand. It helps us because as the pain can't be measured we need to listen to the patient, and he has the right to express his complaint. Through the complaint we can understand what is happening, and more about their emotional world, I have to know things from the patients' pasts because they could be the cause of their chronic pain. You have to look at this in depth and we need specialists who can do that, people who are professionals in emotions.