Laughter may not be the best medicine, but it can help those suffering chronic pain, according to research presented at last week's meeting of The European Pain Federation (EFIC) Congress, held in Florence, Italy.

A team of Swiss researchers reported that laughter and humor can increase pain tolerance and improve quality of life. According to Thomas Benz (RehaClinic Zurzach, Switzerland), targeted humor interventions should be part of pain therapy.

In the Swiss team's research, people laughing at comedy films were able to keep their hands in ice water longer than those who were not laughing. Subsequent measurement showed that increased pain tolerance remained present 20 minutes after laughing.

A possible explanation could be that humor activates the release of endorphins and relieves muscular tension, thus having an effect on pain on both a mental and physical level.

"As a result, humor helps to reflect pain, thus helping both the patients as well as their carers to deal better with stress," said Professor Willibald Ruch, Zurich University. "Humor can be used specifically as a cognitive technique, for example in terms of a distraction to control the pain and increase pain tolerance."

However he cautioned that laughter needs to 'come from the heart' in order to relieve pain. "Our studies show that only 'real' delight, actually experienced and accompanied by a Duchenne expression, leads to increased pain tolerance."

In a 'Duchenne smile' not only are the corners of the mouth pulled upward, but the eyes are also involved with typical small wrinkles at the outer corners. Professor Ruch said that faked smiles and laughter do not improve pain tolerance.

This year's EFIC meeting was attended by 4,000 pain specialists from 75 countries and covered all aspects of pain management. Using similar experimental techniques to those employed by the Swiss team, Norwegian researchers reported that smokers and former smokers are more sensitive to pain than non-smokers. Their study of more than 10,000 people showed that smokers had the lowest tolerance to pain, followed by former smokers.

Men and women who had never smoked had the highest pain tolerance. "These results suggest that nicotine consumption leads to a long-term hyperalgesic effect," said Dr. Aslak Johansen of the University Hospital of North Norway, Tromsø.

Pain and hunger

In one of the more unusual experiments reported at EFIC, UK researchers found that pain is less intense when you are hungry. Researchers from Liverpool University used a painful laser on the hands of people who had been fed, or who had fasted overnight. Reported pain was stronger during the sated than during the hungry state.

"Hunger and pain are basic homoeostatic drives that compete for behavioural responses when experienced together," said Dr. Hazel Wright, one of the study authors.

Management of pain in the clinic

EFIC President Professor Hans G. Kress (Vienna, Austria) said that for many patients, life without pain is only possible with use of prescription opioids, however access to these drugs varies enormously. In many countries they are practically unobtainable, whilst in others they are overprescribed. Calling for more rational use of opioids he said that these drugs are now prescribed 7.5 times more often than they were in 1990. Annual consumption worldwide has climbed from around 7 to over 58 milligrams per capita.

However, even within the WHO European Region there are major treatment gaps, he added. In countries such as Kazakhstan and Tajikistan the use of opioids remains 'vanishingly low.' Inside the EU, Poland, Lithuania and Latvia have the lowest rates of opioid prescription.

"There are obviously unmet medical needs, and healthcare policy makers can no longer be allowed to ignore them while millions of people are condemned to lives of agonising pain. This is medically and ethically unacceptable," said Professor Kress.

Education

Despite one in five EU citizens suffering chronic pain, doctors across Europe are woefully under-educated about pain management, according to results from a major EU survey presented at EFIC.

The findings, from the APPEAL (Advancing the Provision of Pain Education And Learning) study - the first Europe-wide study on pain education, show an 'alarming' lack of dedicated teaching about pain in undergraduate medical schools in Europe, say researchers.

The study reviewed 242 medical schools in 15 EU countries and found that 82% have no dedicated courses on pain that are compulsory for all students.

"With the exception of France and a handful of schools in other countries, which have made headway in the provision of pain teaching, there is a striking lack of dedicated teaching on pain across Europe," said Dr. Emma Briggs, Lecturer, King's College London. "This raises the question as to whether the provision of pain education in undergraduate medical studies is fit for purpose to address the current and growing unmet public health need."

Based on the findings, the APPEAL researchers recommend the introduction of compulsory pain teaching for all EU undergraduate medical students and the establishment of a European framework for pain education.