Pain destroys the brain. Pain medicine doctor: “I see human dramas”

Katarzyna Pinkosz, Wprost: Is shingles a disease that we have within us? As if we were sitting on a bomb that could explode at any moment because the virus is lurking in the body?

Dr. Magdalena Kocot-Kępska: Shingles is an infectious disease manifested by the reactivation of latent infection with the varicella virus – Varicella zoster. After suffering from chickenpox, the virus “dormant” in our body and may become active at some point. 99 percent of the Polish population (taking into account adults) had contact with the varicella virus. After illness, it is not eliminated from the body.

Since the virus is dormant in the body, is there a chance that it will never reactivate?

It's true, it may never reactivate, we may not get sick.

This is how most of us think…

Most people still think that chickenpox is a mild disease, that shingles is also a minor illness that has nothing to do with chickenpox. We do not realize that we have this virus inside us and that it can become active when, for example, we are sick, weakened, or have cancer. It can then get out of control of our immune system and cause symptoms of shingles.

Why can pain persist after having shingles?

The varicella-zoster virus destroys neurons; as if it was eating them, making holes in the myelin sheaths of neurons when we suffer from shingles. The nervous system does not like being damaged, touched or cut, which is why it reacts so excessively to this damage.

It is understandable why pain accompanies the disease. But why does the pain persist in some people even though the virus itself is defeated by the body?

The virus is not defeated. Even after recovering from the disease, the virus is still dormant and the immune system keeps it under control again. We have many viruses that lie dormant in us, such as the herpes virus. Almost all of us have had herpes (caused by a virus from the same family as the virus that causes chickenpox and shingles); it comes back from time to time – not because we get infected again, but because the virus lies dormant in the immune system and reactivates when our immune system is weakened or we are simply older.

Does this mean that you can also get shingles again?

Unfortunately, yes, especially in the case of weakened immunity.

You have been dealing with pain management for many years. What is so characteristic about postherpetic pain, the so-called postherpetic neuralgia?

The pain is localized in the place where there were skin lesions during shingles. It is not just pain, it may also be hypersensitivity to touch. Patients must be careful with clothes, women are irritated by bras and underwear. The pain usually worsens on cloudy, rainy days. It is also made worse by stress.

However, it is not only pain, there is also often hypersensitivity to temperature, tingling, itching, numbness – these are symptoms of damage to the nervous system.

You have a patient whom you have been treating for 30 years for pain after shingles.

She contracted shingles when she was 60 and is now 90. She has been coming to the pain clinic for 30 years – not because she is being given the wrong medications or not taking them. I treat her in accordance with the guidelines and with all the methods available in modern medicine. But it is very difficult to treat pain that results from damage to the nervous system.

We don't know why this happens – there are probably many mechanisms of neuropathic pain that we are unable to identify or we do not have a drug that would act on such a mechanism. We use, among others: antiepileptic drugs, antidepressants – are effective in one in three-four patients, i.e. in 25-30%. people. Even if we use the correct medications, as recommended, in the correct doses, the chance that we will reduce the pain is approximately 30-50%. Please note: we will reduce the pain, not cure it.

What about typical painkillers, such as paracetamol, ibuprofen, ketoprofen?

They won't work at all. Lidocaline patches may be effective in postherpetic neuralgia. But unfortunately, they are effective in only one in four patients. In some patients, despite the use of all drugs and methods available in world medicine, the pain cannot be eliminated or even reduced.

If patients coming to your clinic suffering from postherpetic neuralgia were aware of this disease, would they decide to get vaccinated against shingles today?

Over 80 percent says yes and would recommend vaccination to other people. These are very suffering patients.

However, the problem is costs…

Today, the vaccine is 50% reimbursed for people over 65 years of age and with comorbidities. I believe that it should be free for all people from risk groups, and this certainly includes older patients. Suffice it to say that approximately 30 percent patients who have had shingles will develop postherpetic neuralgia. But among people over 75, such people will be over 70 percent! Therefore, all older people should be vaccinated.

The vaccine itself is recommended for all healthy people over 50 years of age, as well as for people over 18 years of age if they have serious comorbidities that lead to a weakened immune system.

And if we are talking about the costs of the vaccine, on the other hand there are the costs of pain and their treatment, disability, the patient's travel (often with a caregiver) to a pain clinic, and the costs of medicines. I think these costs are much higher than the costs of the vaccine.

The pain can last for the rest of your life.

Do you have any doubts that you need to be vaccinated?

I have no doubts. I have been working in a pain clinic for over 25 years and have seen hundreds, if not thousands, of patients with postherpetic neuralgia.

“I see the human dramas of patients I have been treating for 5, 10, 15 years and more. In some cases, the pain seems to be under control, but after a while it returns again. These people would not have had to suffer so much if this vaccination had been available earlier.”

Older people are often afraid of vaccinations. How to convince them to do this?

For me, the best ambassadors for vaccinations are patients who themselves have postherpetic neuralgia. They know from their own experience how serious and troublesome the disease can be. Chronic pain, regardless of its cause, destroys nerve cells in the brain. It's as if our brain was atrophying – that's why depression, sleep disorders, and cognitive disorders occur. This can be seen after 10-15 years of chronic pain. Patients suffering from chronic pain have a higher risk of dementia and Alzheimer's disease. Pain destroys our brain. If it can be prevented, it must be done.

Magdalena Kocot-Kępska, MD, PhD, works at the Department of Pain Research and Treatment at the Department of Anesthesiology and Intensive Care, Collegium Medicum, Jagiellonian University, and is the president of the Polish Society for the Study of Pain.