“There are deaths due to fentanyl, but they are masked or not recorded.”

BarcelonaWhen you enter the pain unit of the Hospital Clinic, run by Christian Dorsteler (Madrid, 1971), you do not have the impression that you are in a hospital, or at least not the one we are used to seeing. The walls display pictures of the sea or sky and the light is warm. This is known as neuroengineering and has been designed to impart well-being to people who access this unit, which is the largest in Catalonia for the treatment of pain. A disease that affects between 20 and 30% of the population.

Can pain be measured?

—We have no biological marker, it has never been measured, and until the 20th century it was a fairly unknown topic. In fact, premature babies were operated on without anesthesia or punctured without any painkillers because it was believed that because their nervous systems were immature, they did not experience pain. In fact, when we talk about pain, we are talking about neuroscience, we are talking about the brain, which is less known in medicine. What is clear is that pain must have an imprint on memory.

What does it mean?

– Mammals must remember it. A little boy sees a flame for the first time and wants to touch it, but when it burns out, he won’t touch it anymore. This is mediated by the limbic system, which communicates emotions, and for this reason it is subjective. Two people with the same injury might rate their pain as 3 out of 10 or 7 out of 10.

How was it treated traditionally?

– With home remedies. Since the 1950s, we have become accustomed to anti-inflammatories. Today we do this with derivatives of aspirin, opioids, and some medications such as paracetamol. We treat pain the same way we did 100 years ago.

Shouldn’t that worry us?

— It’s bad news, we haven’t achieved the pharmaceutical advances that other specialties have. Pharmaceutical companies don’t invest much in developing new molecules, they don’t need to because they have old molecules.

Can you give an example?

— In the 2000s, they took a molecule, fentanyl, and put it in a patch. It’s a molecule from the 1960s, off patent, so it’s worth a few cents. There has been a very strong campaign to promote this type of treatment for people with non-cancer pain. They offered it at a high price. And now we’ve been giving fentanyl to people with osteoporosis or back pain for 20 years. In 2004, the company that marketed it achieved a profit of $2,000 million annually. If you treat patients with drugs that cost you next to nothing and sell them for gold, why develop new molecules?

So what do we prescribe today?

– Morphine, oxycodone, but the most commonly used is fentanyl.

Do you see strange effects?

– every day. Serious side effects, especially cognitive in the elderly. Recurrent forgetfulness and primary dementia that accelerates and declines.

Can it be linked to medications?

– Absolutely. We see tolerance to opioids. The body gets used to the medication and needs increasingly stronger doses.

Weren’t they known 20 years ago about the effects it could generate?

– No, I just started, and there was brutal pressure from the industry, which still exists. But they have made widespread breakthrough with opioids in non-cancer pain. 80% of the population with chronic pain has been treated at some point with strong opioids. This should be a major concern for us. We also have data on opioid prescriptions from family physicians.

What are they referring to?

— 12% of patients were taking a medication that should only be prescribed to someone with cancer who is in severe pain. That’s what we call it Fentanyl is rapidly absorbed. It carried 12%. It’s crazy.

Who is to blame?

– All of them. It’s not just the industry’s fault. We doctors believed that we should treat patients this way, and patients asked us to do so as well. Sometimes society doesn’t understand pain as something inherent to aging.

How should pain be treated if not with opioid analgesics?

– This is the problem we saw in the United States. Painkiller addiction was treated like a pandemic, and highly restrictive guidelines were removed, so overnight doctors stopped giving patients opioids. They left them without medicine and without an alternative. So some developed withdrawal, others went to the black market, and there were even people who committed suicide.

How should this be done?

— With integrated care programs for chronic pain patients. Talking with patients, therapeutic education, psychological support groups, relaxation techniques, guided physical exercises. We do it here, which is the largest pain unit in Catalonia. There are modules divided by levels, because it is clear that the techniques differ if we stop oncological pain.

We continue to administer fentanyl here.

– Yes, but we don’t have the problem in the United States, where there is a problem of addiction and people getting fentanyl without a prescription. Here, fentanyl is not prescribed outside centers. We do not have a clear epidemic of deaths, although there are certainly deaths, but they are masked or unrecorded. What we have is an epidemic of over-prescription, which is sure to have an impact on society that has not yet been measured.

In what form?

— Cognitive disorder, hormonal disorder causing hypogonadism, severe intestinal disorder, respiratory problems. And we describe it here, because we saw during COVID-19 that people who took opioids and ended up in the ICU had a much worse progression.

You said that there were deaths that were not recorded.

– Because it is not mandatory, it is not a death that can be declared like tuberculosis. Of course, the diagnosis was not reached. If an acute respiratory syndrome patient dies in bed one morning, the death will likely not be related to a rescue dose of fentanyl the night before.

What if we made the decision that was made in the United States?

– Well, we’re going to have a very serious problem. certainly.

Are you thinking about how to reduce this dependence on fentanyl?

– A very intensive campaign carried out by the Ministry of Health. We worked with them on data collection tasks, which helped, for example, figure out how the use of fentanyl, as well as other molecules, increased from 2013 to 2017. Tapentadol – an opioid painkiller – rose in 5 years by 300%. It is a drug that has not been proven to be better than any other opioid and the pharmaceutical pressure has cost us from half a million euros in 2013 to more than two million in 2017. We are all paying for it through CatSalut.

What does “pharmacological pressure” mean?

– Industry wants, first and foremost, to generate need, then create or manufacture evidence and then develop the means for doctors to prescribe it. And the media is a very important commercial pressure. In this country a doctor receives a very low salary compared to other European countries. And pharmaceutical companies offer to pay for conferences and conferences and writers and things like that. Almost all of us have done that, and it’s a conflict of interest you can’t get out of anymore.

Are you telling me there’s money behind this?

The history of pain and the pharmaceutical industry’s pain is a history of greed.

Now how are we?

— There is a very important withdrawal policy for these medications. I want to believe we are past the era of opioids in pain. I want to believe it, but I don’t have them all. It will be decades before we can cut down on these rampant prescriptions, especially since we have no other solution to pain. We can’t cure it. I hope that new therapeutic targets and new treatments will emerge, but at the moment we are not treating it, the pain.

Are you studying?

— Yes, but it costs a lot because it is the central nervous system. Until the second half of the twentieth century, cardiovascular disease was studied because what killed was a heart attack. Then he moved on to cancer, where there was a brutal progression. Now we are in the age of the brain, and serious investment has begun in diseases such as Alzheimer’s. The pain disappears in this package, but it has a decades-long journey ahead of it.

What percentage of the population suffers from pain?

– Between 20 and 30%. This is a very high percentage, and it is the most common health problem in Western society. It is more common than all types of cancer, all cardiovascular diseases, and all types of diabetes combined.

So it has economic implications, right?

-The effect is brutal. Low back pain alone generates 1,200 years of life with disability per 100,000 inhabitants in Spain. We are the country in Europe with the lowest number. It is believed that pain, all pain, costs us 2.2% of the annual GDP, of the wealth that the country accumulates. It’s a lot.

Why do we feel less pain?

– It was always said that this was the diet. Now there are investigations that say this is the geographical situation, latitude 40 (Barcelona is located at latitude 41). If you follow the parallel, which goes through Sardinia, some of the Greek islands, some of the Japanese islands, the longest-living people in the world live there. In the Southern Hemisphere, latitude 40 south, exactly the same thing happens.

What makes us all so good against pain?

– Social Media. Pain tends to isolate a person a lot. Because seeing the other person suffer makes you suffer, and separates you both. Social communication is beneficial for pain. a lot.

What is the most common profile you deal with?

— She is usually a woman around 70 years old, between 65 and 75 years old, of very low socioeconomic status. Women experience more pain than men. Women with a lower socioeconomic status suffer more than women with a more advantaged socioeconomic status.

Is there any explanation why it affects women more?

– not clear. It can be a hormonal problem, but it can also be a neurobiological problem. In other words, women have a different threshold for perceiving pain. We think it’s a protection mechanism, because nature protects the female more than the male. But it is not clear.