Chronic pain, especially in cancer patients, is often accompanied not only by physical suffering but also significant emotional and psychological stress. Professor Mitrea emphasised that each patient's perception of pain is unique, and its intensity and nature depend on numerous factors, including previous experiences, emotional state, social support, and even cultural background.

Chronic pain, especially in cancer patients, is often accompanied not only by physical suffering but also significant emotional and psychological stress. Professor Mitrea emphasised that each patient's perception of pain is unique, and its intensity and nature depend on numerous factors, including previous experiences, emotional state, social support, and even cultural background.

To treat pain effectively, it is necessary to understand how it arises and how the body responds to it. Professor Mitrea explained in detail the mechanisms underlying the pain process. This process begins with transduction — converting a pain stimulus into an electrical signal. It is transmitted along nerve pathways to the brain — this stage is called transmission. This signal is modulated in the spinal cord and brain, and finally, in the cerebral cortex, pain perception occurs, accompanied by a physiological and emotional response.

The role of neurotransmitters in this process cannot be overstated. Chemicals like endorphins, glutamate, serotonin, and others play key roles in pain signal transmission and perception. Endorphins, in particular, are the body's natural analgesics, and their action is often mimicked by opioid drugs like morphine. Professor Mitrea explained that the chemical structure of endorphins and morphine is very similar, allowing the latter to effectively reduce pain by acting on the same receptors.

Professor Mitrea focused particularly on the differences between acute and chronic pain. Acute pain is usually short-lived and can be effectively managed with medications. However, chronic pain, such as that associated with cancer or Parkinson's disease, requires a more comprehensive approach, as it involves continuous nociceptor stimulation and the ongoing release of chemicals that contribute to the sensation of pain.

One of the key topics of the webinar was pain assessment. Professor Mitrea stressed that pain is a subjective experience, and therefore, it is essential to believe what the patient says. Pain assessment cannot be objective if the patient's description of pain is ignored. Even if the physician believes that the prescribed therapy should have relieved the pain, the patient may continue to experience discomfort. In such cases, it is important to delve into the pain description, asking additional questions about its location, intensity, nature, and triggers.

Professor Mitrea presented several pain assessment tools that help structure information and draw conclusions about the nature of pain. Among them is the Visual Analog Scale (VAS), which allows the patient to self-assess pain intensity on a scale from 0 (no pain) to 10 (unbearable pain). Questionnaires are also widely used to clarify the temporal characteristics of pain, the conditions under which it increases or decreases, and the effectiveness of previously used treatments.

Particular attention in pain assessment is given to questions about the localisation and spread of pain. For example, if a patient describes pain in the pelvic area, it is important to determine whether it spreads to other parts of the body and how it changes with movement or other actions. This helps identify which nociceptors have been stimulated and what the nature of the pain might be.

One of the key tools discussed by Professor Mitrea is the World Health Organization (WHO) analgesic ladder. This three-step scheme helps physicians choose appropriate medications based on the pain intensity assessed by the VAS scale.

In the first step, for mild pain, non-opioid analgesics such as paracetamol or nonsteroidal anti-inflammatory drugs are used. For moderate pain (4-6 on the VAS scale), the second step, weak opioids such as tramadol are used. Finally, for severe pain (7-10 on the VAS scale), strong opioids such as morphine are recommended.

Professor Mitrea highlighted the importance of a careful combination of pain-related medications. For example, it is not recommended to combine second and third-step analgesics, as this may increase side effects without significantly enhancing the analgesic effect. She also emphasised that drug doses should be regularly reviewed, as patients may develop tolerance to the medications.

Professor Mitrea discussed the side effects of opioids in detail. The most common include nausea, vomiting, constipation, and respiratory depression. She stressed that respiratory depression, often feared by patients and their families, is rarely observed with proper dosing and regular patient monitoring. Doctors and nurses need to distinguish between normal deep sleep and a pathological state caused by overdose. The most reliable method is to wake the patient and check how coherently they can speak. In case of overdose, articulation will be impaired.

While pharmacological therapy plays a central role in pain control, Professor Mitrea also spoke about the importance of non-pharmacological methods. One such method is a distraction from pain. As an example, the professor mentioned a case where one of her patients used jewelry as a way to distract from pain—she would take it out of the box and recall how she bought it in her younger years.

Meditation and breathing exercises are also effective ways to manage pain. These techniques help patients relax, reduce stress, and thereby lower pain levels. Aromatherapy, animal-assisted therapy, and music therapy can also be beneficial in palliative care, especially when pharmacological methods do not provide complete relief.

One of the most challenging tasks in palliative medicine is overcoming patients' and their families' resistance to the use of opioids. Professor Mitrea emphasised that the main obstacle is the fear of addiction, often based on a lack of information. She recommended starting with a detailed explanation of the differences between physical and psychological addiction, as well as the importance of pain control for improving quality of life.

It is important to approach such situations patiently and explore the reasons for the patient's fears. In some cases, patients may refuse treatment because they underestimate the seriousness of their condition or have misconceptions about the illness. Professor Mitrea recommended respecting the patient's choice in such situations but keeping the door open for further consultations and explanations.

In conclusion, Professor Mitrea highlighted the importance of a multidisciplinary approach in palliative medicine. The minimum team composition in palliative care includes the patient, their family, a nurse, and a physician. Depending on the situation, a social worker, psychologist, and chaplain may be involved. The nurse plays a key role in patient care, as they spend most of the time with the patient, meeting their physical, emotional, and spiritual needs.

A social worker can assist in obtaining financial and other social support, while a psychologist can help address the emotional state of the patient and their family. A chaplain or pastor can offer spiritual support, which is especially important in end-of-life care.

Palliative medicine requires a comprehensive approach to pain management, which includes understanding the pathophysiology of pain, proper assessment of its intensity and nature, and the use of both pharmacological and non-pharmacological treatment methods. Professor Nicoleta Mitrea emphasised the importance of an individualised approach to each patient and their family's involvement in decision-making. Adhering to treatment principles such as the WHO analgesic ladder and a multidisciplinary approach to team formation allows for effective pain control and improved quality of life for patients in palliative care.