Pain, as unpleasant as it is, serves a useful purpose. It warns of possible tissue damage and guards against further injury. It is a complex phenomenon, though, and a pain signal relayed from a peripheral nerve to the spinal cord to the brain is modified and interpreted significantly along the way. New understanding about how this signal is transmitted, and how it is boosted or blocked, demystifies some types of chronic pain and opens the door to more aggressive pain treatment.
Special nerve endings in skin and muscle--in the fingertips or toes, for instance-- respond to chemicals released by damaged cells. The nerve fires and a pain signal is sent.
SPINAL CORD: THE PAIN GATE
The pain signal travels along the nerve. A single nerve, like those in the leg, may be up to a metre long. The nerve carries the signal to the spine, branching and forking where it meets the spinal cord. Sensory signals are carried to the dorsal horn, the back part of the cord, whereas nerves at the front part of the spinal cord carry motor signals from the brain to the muscles. The spinal cord relays the message up to the brain. It's a two way network, however, messages travel down the spinal cord from the brain at the same time, dictating how the pain signal is to be interpreted. The dorsal horn of the spinal cord becomes, in effect, a gate that either allows the signal to pass through unadjusted, dampens the signal or boosts it.
Nerves don't connect directly to one another, instead, the signal must leap a gap called a synapse. This happens when the transmitting nerve releases a chemical--a neurotransmitter-- that prompts the next neuron to fire.
Conscious awareness of pain happens when the signal reaches the brain. New imaging techniques have mapped out at least 200 areas of the brain that respond to different types of pain.
PAIN SENSITIZATION AND ITS TREATMENT
A heightened sensitivity to pain can occur when the nervous system adapts to chronic, long term pain in several ways.
Additional nerve connections can develop in the spine in response to chronic pain, boosting the number of channels carrying the signal.
The neurotransmitters associated with pain can also increase in number. A more powerful pain signal manages to bridge the synapses between the nerves.
Narcotics can mimic specific neurotransmitters and effectively block the transmission of pain signals. New research suggests aggressive pain management may eventually reverse physiological effects of heightened pain sensitivity.
(Source: Merck Manual of Medical Information, Canadian Medical Association Home Medical Encyclopedia)
Doctors are reluctant to prescribe narcotics, fearing patients will become drugged-out zombies. But new research shows they can be used with little risk of addiction.
Dana Timothy freely admits she has taken heavy-duty narcotics thousands of times during the past decade. But she insists that she is neither an addict nor a drug abuser.
The thirty-eight year old wife, mother and law school graduate suffers from chronic pain. She was born with a severely curved spine. When she was a child, a flawed operation to straighten her back left her worse off. Her vulnerable body was consumed by pain--and it just intensified with each passing year.
She has found that the only way to keep her pain in check is through the daily use of narcotics medically known as opioids. Her list of prescriptions has included Morphine, Demerol, Percocet, Fiorinal and Methadone.
Dealing with the pain has been only part of her struggle. She also had to battle the traditional medical view that narcotics are highly addictive and their use should be restricted to the terminally ill or for short-term emergencies such as immediately following surgery or a horrific accident.
It took her years to find a doctor willing to keep prescribing her the medications she desperately needs. Most physicians wanted to cut her off.
"To me, narcotics represent a moment of blessed relief from pain. Suddenly.... I'm able to draw a breath without hurting. I'm able to bear being in my own body again." explained Ms. Timothy who lives in rural Ontario.
"People who have pain and use narcotics are simply trying to return themselves to a state of bearable normalcy," she added. "They are not using narcotics to shift themselves to some kind of desirable altered state."
In fact, the odd thing is that Ms. Timothy has never experienced the so-called high normally associated with narcotics. It's as though the drug is all used up just suppressing her pain."
Ms Timothy is not alone in her suffering. Patients of all sorts--from those with degenerative diseases to accident victims--have endured excruciating pain with little help from their doctors.
Slowly, though, the medical establishment's approach to pain is beginning to shift. In 1993, the College of Physicians and Surgeons of Alberta became the first medical regulatory body in North America to recognize the value of using narcotics for treating chronic pain. It issued guidelines stating that it's okay to use narcotics when everything else has failed. Since then, medical regulators in more than half the Canadian provinces and American states have adopted new pain guidelines or they are now reviewing the issue.
It's been hard to get this new message out to the rank-and-file physicians, many of whom are still extremely reluctant to dispense narcotics.
They were taught in medical school that the stuff is inherently addictive. The old theories assumed that simply exposing people to the powerful drugs would create an insatiable thirst for more and the patients would turn to crime, stealing VCR's or resorting to prostitution to pay for their habit.
Flaws in this kind of teaching gradually became apparent with the treatment of cancer pain in recent years. Some cancer specialists were willing to prescribe the drugs to ease the misery of the dying. After all, long-term addiction is not an issue for someone who is expected to live for only a few months.
But as cancer therapies improved and tumors shrank away, doctors found that the cancer survivors were able to stop taking narcotics. They had not turned into drugged-out zombies. Most wanted off the drugs, glad to be free of the unpleasant side effects, such as drowsiness and nausea.
Russell Portenoy, head of the Dept. of Pain Management and Palliative Care at the Beth Israel Memorial Hospital in New York, was one of the first physicians to draw attention to the trend. He reviewed a series of studies, involving more than 20,000 patients and found that fewer than a dozen of them became addicted to the drugs. "The risks of addiction have been wildly overblown."
Dr. Portenoy noted that all patients develop a physical dependence to the drugs and go through withdrawal symptoms when they are removed. However, once this gruelling process is completed, the vast majority no longer have cravings for the narcotics.
A lot of misconceptions regarding narcotics arose from the failure of the medical community to recognize that physical dependence and addiction are not one and the same thing.
Physical withdrawal--which can take the form of muscle cramps, chills and nausea--occurs when the body is adjusting to the absence of narcotics on which it had become dependent.
Addiction on the other hand, is a craving for a sense of euphoria. Some people seem to be born with a risk of developing addictions and may seek out narcotics and other substances that create a high.
Ironically, many chronic-pain patients---such as Ms. Timothy--don't even get a buzz from the narcotics. And newer narcotics, which are slowly released into the body, means that there's even less chance now that patients will get a sudden jolt, or high, when they take their medication. So, they are unlikely to develop a permanent craving for the drug, once it is out of their systems.
"Yet, even those people who are at risk of addiction can be treated with narcotics, as long as they are closely monitored" Dr Portenoy said.
For all the grief that pain brings to humanity, it is vital to our existence. It is a warning signal alerting the brain that there is something wrong. "If you stub your toe, a pain signals is sent to the brain telling you to watch out, take care of your toe," said Roman Jovey, a Mississauga, Ont., physician who has devoted a significant part of his practice to the treatment of chronic pain.
Pain signals travel along nerves, say from the toe, to the spine. In particular, the signal enters the dorsal horn, or back part of the spinal cord. Once, there, a group of chemical messengers known as neurotransmitters help relay the pain impulse over a gap, called a synapse, to another nerve leading to the brain. The neurotransmitters essentially fit into receptors, much like a key being turned in a lock and opening the gate to the brain.
Narcotics or opioids, work because the chemical structures are similar to the shapes of some neuro-transmitters. They can plug up the receptors, preventing the real pain messages from getting through. But there are many neurotransmitters associated with different types of pain. That is why certain opioids seem to work better than others for some patients--and sometimes, nothing seems to work at all.
People are also able to turn off their pain for short periods of time. Dr Jovey points to the example of the football player who makes a touchdown while hobbling on a broken ankle, or the soldier who rescues a buddy even though his own arm has been blown off.
There's good reason to be able to block pain--if only briefly. "Eons ago, if a saber toothed tiger was chasing you, and you sprained your ankle, and couldn't get away, you would be dead meat," Dr Jovey explained.
From observations of wounded athletes and soldiers, pain researchers concluded that the brain can send neurotransmitters back down the spine to close the gate. "We have known about this for years," Dr Jovey said "But what we didn't know until recently is that the opposite also happens." Pain sensations can also be intensified.
Indeed, an explosion of new research in the past five years has demonstrated that critical neurological changes can occur if the brain continues to receive a constant barrage of pain signals. The neurotransmitters associated with pain transmission increase in number. And additional nerve connections develop in the part of the spine that sends pain signs to the brain in a process known as neuronal plasticity.
As a result, "These pain signals coming in from the periphery are actually turned up in intensity." Dr Jovey said. "It's as though the body won't let the brain forget that something is wrong."
For chronic pain patients, the consequences can be harrowing. The nervous system becomes "hot- wired," said Brian Goldman, a pain expert and assistant professor at the University of Toronto. "It takes lower and lower intensity of stimulation to fire up the pain pathways."
"As it gets worse, even a non-painful stimuli such as a tickle or even a light touch, is experienced as very severe pain." Dr Goldman said. "Chronic pain patients will tell you that they can't stand a hug from a loved one because it hurts too much."
This heightened "sensitization" goes a long way to explaining once baffling medical cases, in which the pain seemed way out of proportion to the original injury. There are lots of examples of people who suffer whiplash in car accidents and never seem to recover. Many of these patients were written off as fakers and malingerers, or diagnosed with psychiatric problems, when physicians were unable to clearly identify a physical cause for their extreme pain said Dr Goldman. Much still needs to be learned about why some get over injuries and others don't. Meanwhile, there seems to be no reasons that chronic pain patients should be allowed to suffer. The problems is that many doctors haven't been properly trained in controlling pain.
Because any number of neurotransmitters and pain receptors may be involved, a patient may have to try a lot of different narcotics before finding one that has a lasting effect. Extremely high doses may be required. Many physicians give up too soon.
"There is much individual variation in the effective dosage from one patient to the next," Dr Goldman said. "I treated a woman who was taking three grams of morphine a day. If you or I took that much, we would stop breathing. But she took it... and she is the rock of her family. It has completely transformed her life."
Years of experience have demonstrated that high doses of narcotics don't lead to organ damage which a lot of other drugs do. What's more, many patients learn to adjust to the drug side effects, although constipation remains a continuing complaint.
Dr Goldman noted that narcotics are not panaceas. They don't work for every chronic pain condition. In the case of tension headaches and migraines, narcotics sometimes make the condition worse.
"But for people who do show improvement in function, why deny it?" Dr Goldman asked. Indeed, getting the pain under control may be the first step to eliminating it.
In a recent study published in the Journal of Pain and Symptoms Management, Helen Hays, an associate clinical professor at the University of Alberta, provides the first tantalizing evidence that the chronic pain cycle can be broken. Dr. Hays aggressively treated several patients with a mix of medications, including narcotics, to the point that their pain was eliminated.
After a year of this intensive treatment, the patients were slowly taken off the drugs--and their pain did not come back.
The work, although preliminary, suggests that if the pain signals can be completely blocked for a long enough time, it may reverse the changes that led to the over sensitization of the nervous system.
"Maybe, just maybe, this is the answer we've been looking for " Dr Jovey said. That would be a great relief to Ms. Timothy and the countless other chronic pain patients.
Between 80 and 120 million Americans suffer from chronic pain at some point in their lives. The cost to the U.S. economy is estimated at $85 to $90 billion annually in lost productivity.
Incorrectly treated, chronic pain often results in depression; disability; and unnecessary hospitalization, surgery and tests.
"Too many people are suffering needlessly with sometimes tragic and fatal consequences," said Joel Saper, MD, a neurologist and chairman of the Michigan Council on Pain. "Severe pain sufferers are affected physically, emotionally and financially. We have a responsibility to enable people to access the most advanced care available for the treatment of pain." Pain: It hurts, it costs, it kills. What can you do?
Your ability to implement the strategies recommended depend on your attitude, your commitment, your motivation to really do something about your problem. Your recovery depends on the extent to which you can adopt and incorporate the strategies listed below.
Take Responsibility For Your Pain.
Are you responsible for your problem? Do you attribute it to some quirk of heredity, abusive parents, or the stressful people in your life? Are you the one who is ultimately responsible either for holding onto your pain or are you going to do something about it? It may be difficult to accept the idea that the decision is yours whether to maintain or whether to overcome your problem. Yet, accepting full responsibility is the most empowering step you can take.
Taking responsibility means you don't blame anyone else for your difficulties. It means that you also don't blame yourself. Is there truly any justification for blaming yourself that you have pain? It is more accurate to say that you've done the best you could in your life up to now with the knowledge and resources at your disposal? While it is up to you to help change your current condition, there is no basis for judging or blaming yourself for having it.
When you take responsibility for overcoming your condition, it does not mean that you have to do it all alone. You are more likely to be willing to change and to take risks when you feel adequately supported. A most important prerequisite for undertaking your own program for recovery is to have an adequate support system. This can include your spouse or partner, one or two close friends, and/or a support group or class specifically set up to assist people with pain disorders.
Once you have decided to acknowledge your share of the responsibility for your pain, your ability to actually do something about it will depend on your motivation. Are you motivated to change? Are you motivated enough so that you will be willing to learn and incorporate several new habits of thought and behavior into your daily routine? Are you motivated enough so that you'll be willing to make some basic changes in your lifestyle?
It has been said that, "Suffering is the great motivator of growth." If you are feeling considerable pain from your particular problem, you're likely to be strongly motivated to do something about it. A basic belief in your self-worth can also be a strong motivation for change. If you love yourself enough to feel that you sincerely deserve to have a fulfilling and productive life, you won't settle for being impeded by pain.
You will demand more of life than that.
Being motivated also means truly honest with yourself. Any person, situation, or factor that consciously or unconsciously rewards you for holding on to your condition will tend to undermine your motivation. For example, you may want to overcome your problem of being house bound. However, if consciously or unconsciously you don't want to deal with facing the outside world, getting a job, and earning an income, you will tend to keep yourself confined.
If you find that you have difficulty developing or sustaining your motivation to do something about your condition, it is important to ask yourself about what rewards you will get for remaining in your current state.Visualize Your Goals. It is difficult to tackle and then overcome a problem unless you have a clear, concrete idea of the goal you are aiming for. Before embarking on your program for recovery it is important for you to ask and answer the following questions:
- What are the most important positive changes I want to make in my life?
- What would a recovery from my present condition look like?
- How will I think, feel, and act in my work, my relationships with others, and my relationship with myself once I've recovered?
- What new opportunities will I take advantage of once I've recovered?
- Once you have defined what your own recovery might be like, it can be helpful to practice visualizing it.during the time you allocate for practicing deep relaxation, take a few minutes to imagine what your life would look like if you were entirely free of your problems.
- Visualize in detail any changes in your work, recreational activities, relationships, and your body-image and appearance you would like to achieve. It is important to put this down on paper.
- Write a script of how your life would ideally look when you have recovered. Be sure to cover as many different areas of your life as possible.
NOTE: Bill Stephens has RSD and lives in USA. We could all learn something from Bill's common sense approach to pain.