At the IASP 2021 Virtual World Congress on Pain, to take place June 9-11 and June 16-18, the International Association for the Study of Pain (IASP) will present awards to honor the achievements of up-and-coming as well as more established investigators (these awards were originally to be presented at the 2020 World Congress on Pain in Amsterdam, which was canceled due to the COVID-19 pandemic). In advance of the meeting, PRF spoke with each of the winners. In this interview, we chat with Ashok Kumar Saxena, MD, DA, one of the two winners of the IASP Award for Excellence in Pain Research and Management in Developing Countries (see interview with Ana Vieira, PhD, the other winner of this award, here). This award honors an individual or team that has achieved an outstanding level of excellence in programs of basic science research in pain or pain management, clinical research or practice, and/or policy changes in pain management in the developing world.
Saxena is a professor and head of the Department of Pain Medicine and Anesthesiology at the University College of Medical Sciences, University of Delhi, India. He has spent the past three decades investigating neuropathic pain and pain genetics as well as pioneering the use of pain assessments and outcome measures in India, including their translation into the local Hindi language, and their validation. Here, Saxena speaks with freelance writer Kayt Sukel to discuss pain management in India, how the Indian government could help to advance it, and why, even after 30 years of research, there are still many questions he wants to pursue. The following is an edited transcript of the conversation.
What first interested you in the study of pain?
My passion and interest in pain management started way back in 1985. I came across many patients who were experiencing chronic pain. They were suffering to varying degrees, but, in certain cases, the pain was intolerable and excruciating. We had only one or two therapies, maybe, that we could use. That inspired me to do something proactively.
At that time, the specialty of pain management was in its infancy; it was just developing here in India as well as in other developing nations. Western countries had better pain medications and pain management strategies. So my mentor and myself decided that we must establish a pain clinic, and by the grace of God Almighty, we established it in October of 1987. We wanted to come up with better pain management strategies, so we started to carefully document the type of pain, how many months or years the patient had been suffering from it, and what had been done before to treat it.
Until that time, we were not very clear about different types of pain. We just thought it was all the same – pain was pain. But as we documented more of the details for each patient, we started to understand that there were different types of pain – nociceptive, neuropathic, and mixed pain. And we used drugs like paracetamol and other medications available at that time, as well as electro-acupuncture, massage, and transcutaneous electrical stimulation techniques. But these provided only very transient pain relief.
As much as we tried to tell those whom we were treating to be calm and patient, that the pain would settle down in time, we soon realized that nothing really helped until the doctors actually listened to their problems. We listened more closely about where they experienced the pain, whether they experienced tingling, numbness, or other sensations, so that we could pinpoint what kind of pain was being experienced. That’s how we learned that many of these cases involved neuropathic pain.
How does the state of pain management in India compare to the rest of the world?
Pain management in India right now is not a separate specialty in medical school. While trainees can learn about pain medicine at a pain clinic, they do not get detailed education.
A few of the medical schools and corporate hospitals in India do occasionally have a pain clinic, and a few of my colleagues practice pain management in their own personal pain clinics. However, to receive private care requires a lot of money, so there are government-funded pain clinics. But there are not enough doctors who know how to help patients manage their pain.
What could be done to improve pain management in India?
To start, the government could make pain medicine a separate specialty in all medical schools, on a uniform basis. We have very poor people who live in our country who do not have health insurance, which only covers a maximum of 10% of the country’s population. With more government funding, these people could at least get access to pain management in medical schools and district hospitals. I hope that, one day, the government of India will take the initiative and take bold steps in helping to promote pain management across all the hospitals.
It is also important for the government to take the initiative to set up in-depth research and analytics to help us better understand the genesis of pain, to develop and test new pain management techniques, and to find ways to bring more pain management options to people. Right now, only a selected few can afford the treatments that might help them.
Tell me more about your research.
My focus is on neuropathic pain. Initially, we did not know how many different types of pain there were. Then, around the year 2000, we finally understood that there is a special entity known as “neuropathic pain.” I’ve spent the last two decades focused on uncovering the peripheral and central mechanisms of this type of pain, as well as creating evidence-based, step-by-step guidelines to better manage it. I’ve also been focused on molecular mechanisms of pain, including the genetics of neuropathic pain. There are about 20% to 30% of patients whose pain will not resolve.
I have been exploring messenger RNA expression and microRNA levels of different pain genes, and also looking at cytokine genes, all of which make significant contributions to the development of pain. Currently, we are focusing on the modulation of messenger RNA expression of the autophagy-associated genes interleukin-1 beta and interleukin-8 in post-herpetic neuralgia.
We have also published our research on chronic persistent postsurgical pain following staging laparotomy for ovarian carcinoma and its relationship to signal transduction genes. Another area of our research is cross-sectional analysis of the mediating effect of fear, anxiety, pain-related catastrophic thinking, and depression on pain-related disability in post-herpetic neuralgia patients. We have also recently published our research on pulsed radio-frequency lesioning of intercostal nerves in post-herpetic neuralgia patients and the modulation of brain-derived neurotrophic factor levels.
You’ve championed the use of pain outcome measures in India. Historically, how were pain outcomes tracked, and why was it important to change that?
Of course pain is a subjective sensation, and we want to decrease the intensity of that pain. If a patient says their pain intensity is a 9 out of 10, which is very severe, excruciating, and unimaginable pain, and I can bring it down to a 4 out of 10, it seems like that should be satisfactory pain relief and that you’ve had good success in pain management.
But in the past, we did not talk much about secondary outcome measures, like quality of life. If we were able to bring down the pain intensity, we said we were successful. But many of our patients had difficulty in attaining a good night’s sleep for a number of months, were unable to engage in routine activities, or were experiencing other issues that greatly impacted their day-to-day lives. So finding ways to track these secondary outcomes is just as important as tracking the primary outcome to make sure we are really bringing holistic pain relief to the community of pain sufferers.
You’ve also worked on developing country-specific guidelines for the treatment of neuropathic pain. What has that been like?
When developing these guidelines, we have followed the international guidelines to a large extent. But it can be difficult sometimes to follow them completely because of our patients’ genetic predisposition. The efficacy of certain drugs will be on the lower side if you have a particular genetic profile, so you may not get as much pain relief. There are times when, given the genetic make-up of Indian patients, we must modify the guidelines according to our needs and requirements.
Were you surprised to receive the IASP Award for Excellence in Pain Research and Management in Developing Countries?
I was shocked, humbled, and honored at being selected for the award. I am also overwhelmed with infinite joy. I’ve been working on pain for more than three decades, but I know that there are so many others who work just as hard as I do. It’s tough competition! So many of my friends, all over the globe, are tirelessly working to help to alleviate the pain and suffering of mankind.
I am so grateful to the International Association for the Study of Pain, to the committee members, to my many colleagues, and to my patients, who have all helped me, in many ways, to conduct my research, to make my own kind of difference, and to become worthy of the award.
What are you planning to investigate next?
Right now, I’m working on a few projects on pain genetics and neuropathic pain. There is still much to learn about pain and pain management. I’m trying to do a head-to-head comparison of one drug like pregabalin to pregabalin plus duloxetine for the management of diabetic peripheral neuropathy. I am also starting some projects on osteoarthritis of the knee joints, especially in elderly patients, to test the efficacy of platelet-rich plasma. These projects, in addition to my continued work on epidemiology and pain management in India, should keep me busy for a few years to come.
What have you learned about how patients with chronic pain should be treated?
First and foremost, you must be a good listener; you must listen to what patients experiencing chronic pain say about their perception of pain, and the subsequent suffering and its relevant consequences. It is of vital importance to do a detailed assessment.
We also now understand that chronic pain is a biopsychosocial phenomenon. So many patients are not just experiencing pain, but also suffering from depression, hypervigilance, severe anxiety, and kinesiophobia – fear of pain due to movement – and other problems. So we must do a holistic assessment so we can minimize the biological, social, and psychological factors that influence pain by using drugs, cognitive behavioral therapy, relaxation techniques, counseling, and other non-pharmacological methods.
We must take a modern, sympathetic, and multipronged approach to treating chronic pain patients so that nothing is missed and we help our patients feel better and better. The ultimate aim is to provide optimum pain relief and a good night’s sleep following adequate rehabilitation, with freedom from depression and anxiety.
Kayt Sukel is a freelance writer based outside Houston, Texas.