An understanding of the phenomenon of pain ought to accommodate the following points:
• Pain can occur without tissue injury or evident disease and can persist after injury has healed.
• Serious tissue injury can occur without pain.
• Emotion (anxiety, fear, depression) is an inseparable concomitant of pain and can modify both its intensity and the victim's behavioural response.
• There is important processing of afferent nociceptive (see below) and other impulses in the spinal cord and brain.
Appreciation that pain is both a sensory and an emotional (affective) experience has allowed clinicians to realise that to meet a complaint of pain automatically with a prescription alone is not an
4 Tricyclic antidepressants may reduce morphine requirement in palliative care without noticeably altering mood.
appropriate response, for 'There is always more to analgesia than analgesics'.5 Pain that is not the subject of an analysis by the clinician (and explanation to the patient) may be inadequately relieved because of lack of understanding. It is a justified and shaming criticism if doctors do not provide adequate relief of severe pain (postsurgical, palliative care of advanced cancer) by bad choice and by overusing and, also important, underusing drugs, and by defective relations with their patients.
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