MD Šimon Kozák: In algology, nothing works miraculously overnight! It is important to seek advice from specialists

It is said that about 80% of your patients come with back pain and load-bearing joint pain. What factors contribute to chronicization, and how does the so-called mixed type of pain arise?

Free nerve endings are everywhere, meaning around the joints as well, and often patients may experience pains that are of truly mixed etiology. This means that it isn’t only about degenerative damage or chronic inflammation in this area but often there is also neuropathic pain involved. Thus, the medicines we use have various effects and act on different target structures.

Why do some patients experience this “accumulation of pain”?

Patients have different pain thresholds, different coping mechanisms, and capacities. Some are more sensitive, some are more resistant. This is due to upbringing, cultural and social background, but also the patient’s self-confidence and their individual resilience. Thus, the perception of pain can be very different.

To what extent are psychosomatic causes behind chronic pain?

Recently, the proportion of the psychological component in patients has been increasing. It may be due to the stressful periods of recent years. People are experiencing existential uncertainty, and there is subliminal stress. This can lead to higher pain perception and emotions associated with it. In other words, people are more fragile and sensitive to many things, not just pain.

Today, much is said about the role of the vagus nerve in connection with trauma and psychological pain... How do you, as an algologist, perceive methods that “activate” this nerve?

In algology, this is a peripheral matter. Vagus nerve stimulation is an interventional procedure that is done exceptionally. Even in foreign literature, it's not described within standard pain therapy of any kind. It is a nerve that gets stimulated, for example, in the treatment of resistant epilepsies. Thus, if we talk about interventional techniques, they are intended for neurologically ill patients.

What procedures do you use when self-medication isn’t sufficient for the patient?

The problem is that many patients don’t use over-the-counter medications correctly. Either they overdose, or they take ineffective doses out of fear of side effects. Even in the case of these drugs, it is necessary to provide the patient with instructions on how to use them. Algologists have an overview of all types of analgesics, their strengths, dosages, side effects, and especially the mutual combinations and interactions. The spectrum of drugs we use also includes psychotropic drugs and other effective substances indicated by neurologists and psychiatrists. By suitable combinations and optimal dosing, also known as multimodal management, the desired effect can be achieved.

Is it better to start with monotherapy or a combination of analgesics with different mechanisms of action?

When you rely on one approach and expect miracles from it, it usually doesn’t work optimally. In the world of medicine, it doesn’t hold that if two tablets aren’t enough, taking six will work. Our main approach is thus the optimization of pharmacotherapy. With chronic pain, we start with weaker analgesics and gradually proceed to increase the analgesic load or potency of analgesics. At the same time, we also use non-pharmacological methods, such as targeted interventions to affect pain at its origin.

Which medications do you prefer and with which should you be more cautious?

It depends on the origin of the pain. For degenerative musculoskeletal disease, we use those that have good efficacy for joint pains, as these substances are designed to work in joint lining areas. For neuropathic pain, we don’t use non-steroidal anti-inflammatory drugs but substances that act on the nerve membrane level—often these are antidepressants or antiepileptics. The choice of a particular group is based on the diagnosis, clinical examination, and the physician's experience.

Where would you indicate the use of metamizole in musculoskeletal pain?  

Metamizole is a special molecule. Its mechanism of action lies in suppressing inflammatory mediators. The effect is thus similar to anti-inflammatory drugs or paracetamol and works very well in degenerative musculoskeletal disease. Of course, it must not be overused, with a maximum dose of 4 grams per day. Attention should also be paid to possible side effects in the form of allergic or anaphylactic reactions or bone marrow suppression in hematological patients and those with immune disorders. Nevertheless, in the case of musculoskeletal and joint pain, I would see a place for metamizole in all diagnoses. We often use it as an ad hoc or SOS therapy if patients do not have perfect pain relief from chronically used analgesics. It is also suitable as relief therapy during strain.

What is your stance on the use of corticosteroids?

They are effective but potentially very dangerous. We algologists most often apply them directly to the location where the patient suffers from chronic inflammation, chronic edema, or both. It is not suitable to use them in tablet form as chronic therapy.

Is timely pharmacotherapy important in algology? Can it prevent the development of uncontrollable pain?

Definitely yes. Pain is a physiological defense mechanism and should only last as long as the threat exists. If it persists longer, the body creates pathological reactions and becomes sensitized to the pain, which is undesirable. Correct and timely diagnosis and subsequent appropriate treatment represent the best strategy to prevent the chronicity of pain.

When to indicate a patient for surgery, for example, a disc operation? And what needs to be considered?

Back surgery is a major procedure that requires general anesthesia and carries many risks. If there is no absolute indication for neurosurgical intervention or spine surgery, the doctor should be very cautious. It must be remembered that surgical intervention does not always end in full recovery; on the contrary, there is a relatively high probability that the patient will have difficulties or pain even afterward. We have patients who even have worse pain after surgery.

If a patient has loss symptoms, neurosurgical intervention is, of course, necessary. Other problems can be managed by more conservative and gentle methods, and these should always be prioritized. Surgery is the most aggressive form of therapy and is not appropriate to choose as the first method of pain treatment.

However, isn’t preventive surgery sometimes warranted?

Surgical treatment is just one segment of the treatment methods available for painful conditions. It is, however, up to the patient—well informed, to decide. The doctor should definitely not scare the patient with statements like their limbs will become paralyzed if they don’t undergo surgery. These practices belong in the past and, in my view, are incorrect. On the contrary, it is appropriate for the patient to seek a second opinion and then decide which option to choose.

When choosing an algological approach, you stratify patients according to risk. What should be considered for higher-risk patients?

There is a high risk for patients who don’t have very good mechanisms for coping with stressful situations. An algologist determines this during the initial examination. The doctor investigates whether the patient has a psychiatric disorder, whether they are anxious or depressed. These patients could suffer more after unconsidered aggressive procedures than before. For surgical intervention, one must be very well mentally prepared.

How does a patient benefit from a multidisciplinary approach?

I think that anything that is multimodal, multidisciplinary, where experts agree on the optimal strategy, means a benefit for the patient. One states that the patient is poorly managed and should have rehabilitation; another may suggest a nerve block; a psychologist finds that somatic pain is minimal, but the patient recently had a death in the family, suggesting a significant psychogenic component... A large number of such people leave treated, maybe just because their psychological state improves after a good night's sleep. Due to sleep deprivation and chronic stress, a person tolerates painful conditions worse. So we examine and consider factors that don’t cause pain but worsen it. If the other components of the overall state are adjusted, often the pain is significantly reduced as well.

What would you like to tell your colleagues in conclusion?

It’s important that algological care is comprehensive. That the patient doesn’t cling to one method that currently circulates the virtual space and is praised to the heavens. You cannot rely on an immediate effect; nothing ever works miraculously overnight. And it really is important to seek advice from specialists in this field.

MD Andrea Skálová
Editorial Team, Medscope.pro