The price of pain

Chronic pain and the search for effective treatment

Managing pain has always been central to medical practice. For individuals living with chronic pain, the effects can be severe and far-reaching, significantly diminishing quality of life. It is no exaggeration to say people in chronic pain suffer. Consequently, the search for the ideal pain reliever continues.

Despite advances in medical science, progress has not been as dramatic as many might expect. Although personalised medicine is often discussed as the future of effective pain management – and it likely holds significant promise – it is not a solution that will become widely available in the immediate future. For now, we must rely on the treatments currently at our disposal.

Paracetamol: The world’s most widely used painkiller

Most people will have taken paracetamol at some point. It is an inexpensive and effective pain reliever that has existed since around 1900, although it did not become widely available in pharmacies until the 1950s. Since then, it has become one of the most commonly used medications worldwide.

Spain is somewhat unusual in that over-the-counter medicines can only be purchased in pharmacies. In many other countries, products such as paracetamol can be bought in motorway service stations, convenience stores, or supermarkets, often as store-brand equivalents.

This level of availability can sometimes create the impression that such medicines are little different from everyday products like cough sweets. In reality, the difference is substantial.

How doctors determine safe medication dosages

Drug manufacturers face a particular challenge when producing medications intended for widespread use.

For example, tranquillising an elephant requires a significantly larger dose than tranquillising a small dog. Veterinarians deal with this issue regularly, adjusting dosages based on both the species and the weight of the animal.

When a medication such as paracetamol is marketed as a broadly suitable product for the general population, manufacturers must adopt a middle-ground approach. Standard dosages are typically based on a “typical” adult weighing around 70 kilograms.

However, individuals who weigh less than this should not worry about inadvertently overdosing when taking recommended doses. Over-the-counter medications are designed with a considerable safety margin.

Is paracetamol safe? Understanding the risks

Paracetamol is so familiar that it is often taken for granted. Nevertheless, in rare cases it can cause serious damage to the liver and kidneys, which may be fatal.

For this reason, many countries limit the maximum number of tablets that can be purchased in a single transaction. Retail systems that use barcode-based stock control will often automatically prevent customers from exceeding these limits at checkout.

While this does not prevent someone from visiting another shop to purchase more, the alternative would be to remove the medication from over-the-counter sale altogether.

Intravenous paracetamol in hospitals

Paracetamol is also commonly used in hospitals.

Although it is frequently administered in tablet form, it may also be given intravenously when faster pain relief is required.

When administered intravenously, the dosage is carefully calculated according to the patient’s body weight – much like veterinary dosing – ensuring that the medication effectively relieves pain while minimising the risk of harm to vital organs.

Medical errors and the culture of blame in healthcare

Several years ago, a patient with a rare medical condition that resulted in an abnormally low body weight was admitted to hospital and treated with intravenous paracetamol.

For reasons that have never been fully clarified, the patient was reportedly given a standard adult dose rather than a weight-adjusted one. This resulted in fatal organ failure.

Incidents of this nature are extremely rare. However, the greater concern appears to have been the subsequent attempts by multiple individuals to conceal the error. The fear of litigation can sometimes take precedence over transparency, creating a culture in which the truth is difficult to uncover.

What healthcare can learn from aviation safety

The aviation industry, in contrast, is often cited as a model for how organisations should respond when things go wrong.

Rather than focusing solely on assigning blame, there is a structured and well-established process designed to identify the root cause of an incident.

Even when pilot error is involved, investigators examine whether factors such as control layout or confusing warning systems may have contributed to the mistake. Any findings that could improve safety are disseminated across the industry.

Genuine mistakes are inevitable in any complex field. However, when a culture of blame dominates – as it often does in healthcare – identifying the truth and learning from errors becomes far more difficult.

The Opioid Crisis and the Sackler Family

The Sackler family has once again been in the news following controversy surrounding a substantial donation accepted by the charity associated with Chelsea and Westminster Hospital NHS Foundation Trust in the UK.

The criticism relates to the family’s former ownership of the pharmaceutical company that developed and marketed the opioid pain medication OxyContin.

When OxyContin was introduced, it was aggressively promoted as a “silver bullet” for pain management – offering powerful pain relief without the addictive properties traditionally associated with opioid medications.

Unfortunately, the reality proved very different. The drug became widely prescribed, and hundreds of thousands of people developed dependencies.

In many cases, addiction ultimately led to fatal overdoses, creating one of the most serious public health crises in recent American history.

Why opioid painkillers are strictly controlled

Opioids are tightly controlled medications precisely because of their high potential for addiction.

They are not available over the counter, and when prescribed medically they are typically subject to strict monitoring.

In the United States, problems emerged when new drugs were heavily promoted to doctors and general practitioners through financial incentives, luxury hospitality, and other benefits.

Further controversy arose when the pharmaceutical company was accused of adjusting or misrepresenting data from clinical safety trials.

Can alternative therapies help relieve pain?

Beyond pharmaceutical approaches, are there alternative methods for pain relief?

Personally, I had always been highly sceptical of anything outside conventional medicine. However, after developing a condition that required pain management, medication began to dominate my life, prompting me to explore other options.

I attended a clinic run by a medically trained practitioner who also practiced traditional Chinese acupuncture.

Initially, I was extremely doubtful. Yet within minutes of having small, completely painless needles applied at specific points, I unexpectedly fell asleep. After a brief series of sessions, my pain was significantly reduced.

Processing pain

Pain is a complex phenomenon – it is ultimately processed in the brain.

In some cases, the discomfort we perceive in one area may actually originate elsewhere in the body, a phenomenon known as referred pain.

This neural processing explains why pain is such a subjective experience, varying considerably from person to person.

As a famous Buddhist saying goes: “Pain is inevitable. Suffering is optional.”

The information provided in this column is for educational and informational purposes only, and does not constitute medical advice. It is not a substitute for a professional medical consultation, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health provider with any questions you may have regarding a medical condition.

Dr Marcus Stephan