Pain research and treatment are the topics of this week’s Newsweek cover story. The article centers on chronic pain caused by physical injuries in war, but it has gems for anyone with chronic pain. There’s a great illustration of how opioids and nerve blockers affect pain signals in the Pain and its Pathways graphic.
“‘The public understanding of pain has been that it’s a stubbed toe or a broken bone,’ says Will Rowe, executive director of the American Pain Foundation. ‘But that’s just one aspect of it. Now there’s a growing awareness that pain is a disease of its own.’
“This is far more than a semantic change, Rowe adds: it’s ‘tectonic.’ Docs now know that the brain and spinal cord rewire themselves in response to injuries, forming ‘pain pathways’ that can become pathologically overactive years later. They are trying to sever this maladaptive mind-body connection with a host of new drugs and approaches. Some focus on recently discovered chemical receptors in the brain and muscles. Others pack all the punch of narcotics with less of the specter of addiction. . . . New types of electrical stimulators targeting the brain, the spine and the muscles hit the market almost every year. Fentanyl skin patches, first introduced in 1990, have evolved into a patient-controlled, push-button device called IONSYS, available by the end of this year.”
Later in the article:
“Some of the most promising pain treatments of the past decade have turned out to be disappointments. Studies of some radiofrequency therapies show they work no better than placebos. Spinal-fusion surgery, a recent review found, has ‘no acceptable evidence’ to support it. And if a treatment does work, says Edward Covington, a pain specialist at the Cleveland Clinic, ‘for most people, the effect is temporary.’ There is no cure for chronic pain, period.
“There’s not even any ‘single drug or technology alone’ that can treat all the types of pain, says Eugene Viscusi, director of acute-pain management at Thomas Jefferson University Hospital in Philadelphia. Most people need two or three therapies in combination. Scientists’ new understanding of pain’s broad effects on many levels of the nervous system explains why: a multipart syndrome requires multipart therapy. Viscusi notes that patients under anesthesia still have elevated levels of the pain enzyme Cox-2 in their spinal fluid following surgery. They may not feel pain, but some parts of their brains still think they’re in it. For any treatment to work long term, it will have to address not just the immediate sensation of pain but the other, subtler aspects—and there are surely some of those that scientists don’t know about yet.”
This flowed out of Don’t Give Up on Finding a Treatment. It’s the most effective of all the headache treatments I’ve tried — and the hardest to get.
You may be surprised to learn I feel I’ve had success in treating my headaches. I still have pain, mental fogginess, a super sniffer and many other largely unknown symptoms of migraine. Yet I’m full of hope.
To me, hope isn’t about finding a magic bullet. It’s knowing that I can have a full and joyous life despite my illness. Something that I wrote when I first started blogging explains this idea well:
The Anatomy of Hope, by Dr. Jerome Groopman, draws a line between hope and positive thinking. Groopman, an oncologist and hematologist, has treated patients with life-threatening illness for 30 years, many of whom have survived against the odds. The definition of hope that he offers is that “Hope is the elevating feeling we experience when we see – in the mind’s eye – a path to a better future. Hope acknowledges the significant obstacles and deep pitfalls along that path. True hope has no room for delusion.”
The better future he mentions does not require living without disease. Yes, people often overcome their diseases or are able to live without pain. But the better future Groopman describes can also be learning to live joyously even with debility.
Two years ago I didn’t understand the distinction. I am thankful for the time I spent in denial, but am even more grateful that my current version of being positive is rooted in reality. A reality that means I spend more days than I want in bed, but that I’m not emotionally miserable on those days.
I’m not saying that you just have to be positive and your headaches will go away. Nor do I think you can simply decide to accept your fate and go from there. Like all things in life, it’s a process. There’s no timeline to follow, but you will notice that you’ve began to have more acceptance than you once did.
If you want some help along the way, check out The Chronic Illness Workbook and Chronic Illness and the Twelve Steps. Therapists who specialize in chronic illness can also be tremendous help.
KUOW, one of Seattle’s public radio stations, had a program yesterday on treating chronic pain with opioids with an expert panel weighing in. I only listened to the first half, but what I heard was informative and interesting.
They discussed a recent rise in overdoses among chronic pain sufferers. These are thought to be accidental, resulting from the need to increase dosages when the the patient develops tolerance.
Something I didn’t realize is that, according to the panel, most of the studies on opioids and pain focused on cancer pain, not chronic pain. There’s a significant distinction between medicating people with progressive, potentially fatal diseases and treating people with lifelong pain. Addiction and dependence are concerns, but tolerance — and the higher doses it requires — is a big risk too (not to mention potentially fatal).
Not covered in the program was that opioids appear to change the brain so that the patient actually becomes more sensitive to pain. Building tolerance is not only your body getting use to the drug (called desensitization), but you actually become more sensitive to pain overall (referred to as sensitization), not just the pain that you are specifically treating. It also increases allodynia, which is already a migraine symptom.
This is a summary of the clinical implications of these findings:
“The diminishing opioid analgesic efficacy during a course of opioid therapy is often considered as a sign of pharmacological opioid tolerance. As such, an opioid dose escalation has been a common approach to restoring opioid analgesic effects, assuming that there are no contraindications and no apparent disease progression. . . . [A]pparent opioid tolerance is not synonymous with pharmacological tolerance, which calls for opioid dose escalation, but may be the first sign of opioid-induced pain sensitivity suggesting a need for opioid dose reduction.”
While I firmly believe that pain sufferers should have access to opioids, the issue is much more complicated than DEA intervention. They’re an easy scapegoat and a problem for sure, but the body’s roadblocks may be a greater obstacle. Perhaps we should listen to our bodies and not rely so heavily on opioid pain relief.
Wondering if your pain caused your depression or vice versa? The answer is yes (sort of). Here’s the Mayo Clinic‘s take:
. . . Doctors who treat chronic pain and depression have known for many years how closely these two conditions are linked. Some research shows that pain and depression share common pathways in the emotional (limbic) region of the brain — which may, in part, explain their association.
Depression may increase your response to pain, or at least increase the suffering associated with pain. Conversely, chronic pain is stressful and depressing in itself. Sometimes the two create a vicious cycle. In addition, both chronic pain and depression are influenced by genetic and environmental factors as well.
Confused by doctors prescribing antidepressants even though you aren’t depressed? Again, from Mayo: “Certain antidepressants may relieve pain in some people by reducing their pain perception, and improving their sleep and overall quality of life.”
So there you have it.
Can you tell I’m tired? The night migraines are less painful and I’m sleeping a bit better, but my body is still dazed. I saw an acupuncturist Monday and will go back today, so maybe that will help. Much more on acupuncture later, when I can process and explain all that I’m learning.
Posting on the article Victim of Pain is Also Victim of Uncaring Doctor, Kevin, MD points out that “for every responsible narcotic user, you have another hundred who play the drug games.”
As a pain patient I want to kick and scream (and have), yet I know he’s right. (I’m not convinced it’s one to 100, but do believe that more patients come in seeking drugs than pain relief.)
The problem is impossible to solve. It’s great if the DEA gets off doctors’ backs, but drug-seekers remain. Doctors still have to decide which faction each patient represents. That’s no easy feat. And pain patients will continue to be undertreated.
In any case, the comments on Kevin’s post are of interest to any pain patient.