10 Important Lessons About Pain

[Guest guest]

10 Important Lessons About Pain by scha

[The source of the information presented here is a patchwork of

medical research, exhanges with medical professionals, and personal

experience. Any errors are likely to be mine.]

1. All pain is not the same

Somewhat independently of the diagnosis that is it's 'first cause,'

pain tends to occur in patterns which are then distilled into

syndromes so they can be researched and discussed in a common

language.

It is possible to correctly diagnose the original cause of pain,

whatever combination of injury, infection, or genetic defect may be

involved, and yet be mistaken in the diagnosis of the pain itself.

A story: a patient has been suffering with very fierce, relentless,

poorly managed pain for a quarter century, and now has the formal

diagnosis of fibromyalgia (which is really more a pain syndrome than

a full diagnosis). This is a mistake, however. Somehow doctors have

failed to note damage to specific nerves. As a result the patient

has been told to exercise, and not taken seriously when she

complains that this makes her pain much worse.

Once the nerve problems have been correctly identified, it becomes

possible to treat the pain, but the treatment largely inverts what

the patient had prescribed under the " fibromyalgia " label.

2. Nociceptive versus neuropathic pain

Pain medicine distinguishes between two types of pain. There is

nociceptive pain, which is the ordinary pain that we all sooner or

later experience, that is grounded in tissue strain or injury.

Opioid pain medications are quite effective at reducing this type of

pain and compared to many of the alternate drug treatments have a

benign side-effect profile. There is a non-nociceptive kind of pain,

referred to as neuropathic pain, that springs from damage to the

nervous system itself.

This second type of pain is not reproducibly controlled by any pain

treatment now approved for use in humans. There are experimental

drugs, which have been used with animals for a long time, which are

effective, but they tend to have associated toxicities that rule out

their use in human beings. There is one called MK801 that has been

known since the early 80s.

3. Neuropathic pain treatments

The approved treatments are a motley assortment of off-label drugs,

most of them originally prescribed to treat one or another

psychiatric or neurological disorder. They are slow to act, require

extended trial periods to determine efficacy, and have a good many

more side-effects than the opioid medications. These drugs have as

their main advantage a 'respectability' that due to our culture does

not extend to 'controlled substances.' However, if you can match the

right drug with the right patient, you can sometimes get some

measure of relief.

Opioid medications can also be used to treat neuropathic or " nerve "

pain, but with partial and varying success. Because you aren't

hitting the right receptors, it's harder to avoid side-effects. MS

patients report that marijuana helps, and studies show that the

cannibinols that are the active ingredient in marijuana slow the

neurological damage in several progressive disorders whose end point

is total dementia.

Alright, those are the pedestrian lessons. Bookmark them, they may

be of some use to you if you encounter a patient like me for whom

pain is a primary symptom.

4. The biology of pain

When you start to get into the biology of pain, the lines separating

this symptom from other neurological complaints start to look very

artificial. The same processes that are implicated in pain lead to

other tissue and nervous system pathologies. For nociceptive pain,

nerves are still critically involved, but in tandem with whatever

tissue injury is triggering them. In neuropathic pain, the same

abnormalities that cause fatigue and cognitive slowing are often

implicated.

The balance of the problem may tilt toward either the central or

peripheral nervous systems, toward pain or non-pain symptoms, and

may spread from one side to the other or progress in both

simultaeously.

5. Pathologies of the brain and nervous system

Brain loss like I have experienced can be both cause and effect of

chronic pain, and interrupting the cycle can help to reduce future

damage.

How the brain is used determines its development. I have always had

a 'thinker' element to my personality, so my brain has been asked to

take repeated runs at difficult questions for just about as long as

I've been alive. There is probably a fair level of redundancy at

work there, in the physical instrument, because it has performed

these tasks so consistently over the years.

People tend to assume that brain damage means impaired speech. They

do not know [or want to know, necessarily] that everything which

contributes to an aware state is registered through the brain, and

any part of that can be injured and cease to function. Most of the

damage in my brain is not to the cerebral cortex, where the 'higher

functions' reside, so I can still string a sentence together. Pain,

altered sensations that are unpleasant but not painful, sensory

confusion, disorientation, visual and auditory distortion, and motor

impairment can and do become extreme while higher functions we

associate with a 'healthy brain' are intact.

You could think of it as an emphasis. Because eventually the damage

to other brain centers will directly or indirectly contribute to the

damage in the centers of abstract thought and communication.

6. Trade-offs between pain relief and cognition

Pain in this context is difficult to treat in part because one wants

to preserve the level of cognitive function that remains, and there

can easily be a trade-off. On the plus side, by relieving pain you

improve sleep [with endocrine, immunological and other benefits] and

reduce the total processing load. On the down side, drugs prescribed

for neuropathic pain often list fatigue and disorientation among

their more common side effects.

When you treat the mu-opioid receptors of the nervous system, one

effect can be a compensatory increase in sensitivity in the NMDA

receptors that are implicated in neuropathic pain. Usually this is

not so pronounced that it cancels out the benefit, and the

compensation may grow less pronounced over time.

There are non-NMDA receptors in the brain, also involved in

neuroexcitation, including the AMPA receptors. Like the NMDA

receptors, these are activated by glutamate. There is no effective

blocking agent, however, for AMPA receptors. What we can do,

perhaps, is to safely escort excess extracellular glutamate away

from these receptors. Which may be why some have found Gluathione so

helpful for pain and unpleasant neuro-excitatory states.

If we understood all the mechanisms, perhaps it would be possible to

reverse neuropathic pain in all patients by manipulating receptors

and their " ligands " or binding molecules. But we don't have that

kind of understanding, and so what works for one patient can easily

fail another.

The nervous system is not just an enormously complex system of

communication and storage networks, but it moves at this blinding

speed. Throwing something into a flow that fast is tricky, and you

have to be very careful.

On the other hand, because of that same speed, one can literally die

a thousand deaths in the span of a few minutes. Instantaneous

processes, repeated endlessly, can create a powerful sense of time

slowing down, and make possible 'an eternity of suffering' within a

finite block of time.

7. Applying rules from life

Many of the rules we know from " life " apply, because they are rules

of CONSCIOUS life, which is as much a product of mind as matter.

For example, 'if you don't like this conversation, go and start your

own.' The joke about this is the guy who steps on his own toe to get

rid of a headache. But there are other, more sophisticated,

variations on that theme. Stimulating one part of the brain to cope

with hyperstimulation in another may seem counter-intuitive, and is

almost certainly a risky strategy, but sometimes it's all you have

left, because there is no dimming the bad conversation between

damaged nerves that is driving you insane.

We all learn not to make a fuss about pain, because " it's temporary,

and fussing over it just makes it worse. "

This is not true for some of us. The pain is chronic, and so bad

that talking about it is the alternative to being consumed alive by

a fire like the fire of hell, that burns and burns without ever

consuming you.

There are variations in pain sensitivity between healthy people, and

much wider variations among the ill. Sometimes illness brings loss

of sensation, which can be its own kind of agony. There are people

who love to boast about their tolerance for pain, how they never

take anything for it. They imply that this is a virtue, the product

of a stoic wisdom. Pain medicine suggests they are full of hot air,

because they have no way of knowing whether the pain they endure is

even a flash in the pain compared to someone else's.

8. Pain is relative, but only to itself

One of the many weird aspects of progressive, severe chronic pain is

that one is constantly saying, quite accurately, 'I am at my limit'

but then the intensity and/or duration are cranked up several more

notches and the next time you say 'I am at my limit' your limit has

moved farther down the spectrum toward " a living hell. " Pain is

relative, but only to itself. The fact that I now feel something

even worse does not make the pain I was feeling last week / month /

year any less difficult, it just moves the upper limit of tolerance

farther up the pain scale.

This can be a real difficulty in establishing the efficacy of pain

treatment. If you get me back to where I was last week, you've

reduced the total burden of pain but since last week was already

intolerable I may not notice much of a change.

9. Pain is multilayered

There is how I feel, and then there is how I FEEL about how I feel.

You could count the layers of that particular onion forever, except

that the deeper you go the less you can do to ease it and the more

the onion makes you cry.

The mind becomes the all-important agent of arbitration between pain

and the will to live. Friends, family and loved ones may feel that

the pain patient has become short-termpered, intolerant,

dictatorial, insistent on having his or her way.

They may be right! But they may also miss the context for this

evolution, which is really that the mind is fighting a lonely battle

to maintain a state in which the will to live can persist. This is

obviously not limited to physical pain, it comes into play for me

just as much in relation to sensory overload, cognitive impairment,

etc. But the immediate stakes may be higher when searing pain is one

of the elements in the mix.

10. You don't know the half of it [and neither do I]

The patient with severe, chronic pain may appear exquisitely

sensitive to others, and yet be effectively DEsensitized to the

better part of the pain they are experiencing.

I have developed a kind of dystonia - a persistent, involuntary

impulse to hold my body in unnatural positions that have to become

quite painful before I even notice them. The nervous system can only

absorb so much information at once. The upper limit varies between

individuals and within individuals from one moment to the next. But

a really significant portion of pain may not be registering at all,

in the patient who others compare to 'the princess and the pea.'

This means that one has to be alert. Take the whole question of bed

rest. There are studies showing that the value of bed rest for pain

management is generally overstated, but on some occasions it is

going to be helpful. But the pain patient may avoid it, because it

is easier to stimulate other parts of the brain sitting up.

Because pain circuits are overloaded, patients may not realize that

they are in fact making themselves worse by getting inadequate rest.

Because pain circuits may be impossible to quiet, caring observers

may promotote a level of rest that would in fact simply make the

experience harder to bear.