Why is My Pain So Bad and Why Can't I Get Relief?

WHERE PAIN COMES FROM AND HOW TO GET RELIEF

At some point in our lives, we have all experienced some level of pain. As of the time of this writing, I have not found anyone that enjoyed their pain and few that were thankful for it! Pain is a necessary part of life and one we avoid at all costs, but where does it come from? Anyone that has ever suffered from long-term pain has probably heard “Your pain is all in your head”. This old saying is, at least, partially and technically correct. All pain is primarily in the brain – at least it is generated in the brain. Not being a medical doctor, my mind often thinks in simple terms. In parts of our brains, there is a map, or a representation of every part of our body. There’s even a part of your brain that knows what’s going on with your left big toe!

PAIN DEFINED (AND EXPERIENCED!)

“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.

International Association For the Study of Pain

When discussing pain, it is important to have a concise definition of what we are talking about. Please notice the words “and emotional” in the definition of pain. This point is critical in the diagnosis and treatment of pain. Often we think of pain as being something caused by tissue damage. According the experts, this is not true. Pain, according to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience. In simple terms, pain makes us miserable, both physically and emotionally. According to the experts, without the emotional experience, there is no pain. Conversely, pain always results in a negative emotional experience – by definition. Now that we have a good working definition of pain, let’s look at traditional methods of treating pain. Our current medical model often uses one of two approaches. The first approach uses the theory that all pain is bad and the medical professional will prescribe all pain medication needed to abate the pain. We’ve already seen that this is a good short term approach but often results in increased pain and addiction. The other popular way of treating pain is to “just suck it up.”. Many medical professionals are extremely cautious of creating an addiction in their patients. While this is thoughtful and well intentioned, acute pain, left untreated, can often result in an over-sensitization in parts of the brain that create pain. There must be a better way!

What if we could reduce or eliminate the emotional component? Would we experience pain differently if we were able to reduce the emotional distress? This is something we’ll discuss in a moment, but as we say in Tennessee, chew on that a minute!

The Path of Pain – Toes Are For Finding Furniture in the Dark!

Every inch of our skin contains special nerve sensors called nociceptors. Nociceptors are specially designed to carry pain signals to the spinal cord. When you wake up in the middle of the night and find the foot of the bed with your big toe, nociceptors are stimulated and send a signal from your toe, up your leg, and all the way to your spinal cord. As they enter the spinal cord, the nerve ending terminates close to what is called a second order neuron in the spinal cord. The first order nerve from the nociceptor sends a signal to the second order neuron, which sends the pain signal across the spinal cord and up to the opposite side of your brain. In other words, you stub your left toe, the pain signal goes to the right side of your brain. This isn’t critical to understanding, just interesting. Another interesting fact is that the primary neurotransmitter involved in pain transmission is called “substance P”. Really! Substance P? That’s the best neuroscience could come up with? Okay, enough humor at the expense of smart people! Once the pain signal reaches the brain and is routed to the appropriate region of the brain, the brain does something amazing! It analyzes the signal, past history, injuries, other pain, our emotions and mental state, and the magnitude of the signal and makes a decision. The brain, then decides whether the toe injury is dangerous and creates a pain sensation based on how dangerous it believes the injury is! As a Christian therapist I can’t help but being a little amused at this marvel of creative genius! In the Old Testament, King David said “I am fearfully and wonderfully made”. Even with the best advances in neuroscience, we still only have a basic understanding of the complexity of the human brain. Sorry! Got a little sidetracked! Once our marvelous brain has analyzed everything, it makes the decision to create no pain, a little pain, or excruciating pain; all based on how much threat the brain thinks we are in. Little threat – little pain. A lot of threat – a lot of pain. There’s a LOT more, but this is the basic path of pain, and how we experience pain.

Acute Pain vs. Chronic Pain – My Furniture Finding Toes vs. My Aching Back!

No discussion of pain would be complete or accurate without making one distinction – that being the distinction between acute pain, or nociceptive pain, and chronic pain, or what we often refer to as centralized pain. To help us make this distinction, let’s look at an example.

MY IMAGINARY EXAMPLE!

Let’s suppose that one bright sunny morning, I am driving to work. As I approach the intersection I notice another car approaching the same intersection to my left at a high rate of speed. Although I have the green light to proceed, the other car plows through the intersection and slams into the driver’s side of my car. My car is thrown across the intersection, slamming into a big truck. For two hours I am pinned in the mangled car. My right leg is broken and two vertebrae in my back are crushed. Once freed from the car, I’m rushed to the hospital for emergency surgery. Although the surgery is successful, I wake up in terrible pain. This was ACUTE pain, and had resulted from extensive tissue damage. Acute pain is generated when the nociceptors in my body send pain signals via the spinal cord to my brain. My brain interprets these signals (and other stored data) as a danger and begins to generate pain in the brain, which is felt in my body as if it were generated there. Luckily the doctor has already prescribed a powerful opioid pain reliever to keep me as pain free as possible. Fortunately, I am able to remain somewhat comfortable during the healing process. Once I’m able to leave the hospital, I’m given a prescription for another opioid medication to help me with the pain I’m experiencing. By now, I’ve been on pain medication for 2 weeks and the pain is being managed somewhat. Time goes on and I continue to need pain medication to help manage the pain. Now, three months after my accident, my injuries have mostly healed and tissue damage is minimal. Still, my pain without the medication, is intense. I have serious difficulty without my pain medication and am still taking it three times a day just to help manage the pain. Now I have developed CHRONIC pain and my pain has become CENTRALIZED. Centralized pain occurs when the brain becomes so sensitized that it begins to create pain even when no tissue damage exists. Even with this, the pain continues to worsen. I attempt to manage it by increasing the dosage I take, but this causes me to run out before I’m able to get it refilled. Now I have real problems. My pain is worsening, even with increased dosages, but now I’m out of my medication and the pain is unmanageable. I can’t sleep, eat, or function due to the severe pain.

LET’S LOOK AT WHAT HAS HAPPENED IN MY BODY.

During the accident, my body sustained significant injuries. I had tissue damage to my back and my right leg. Nociceptors in my back and leg sent pain signals toward my spinal cord. At the neural terminations, stress hormones and neurotransmitters sent the message to the second order neurons in my spinal cord to my brain where the pain signal was generated. The sensation of pain, while in my brain, told my leg and back to be still and minimize the damage. Once in surgery, the damage to my body was repaired, but the tissues were still damaged and healing. The strong opioid medication filled the opioid receptors in my brain and body and prevented the pain signals from being transferred. This eased the pain, at least partially. Over time, my brain knew all the time I was taking substances to prevent the pain and began to sensitize my nervous system, overriding the medications I was taking. This created a tolerance to the medication, lessening the effect of the dosage I was using. I responded by increasing my dosage in an attempt to alleviate the pain. My body again responded by downregulating my opioid receptors, again, lessening the pain relief at the same dosage, and at the same time, over-sensitizing the neural circuits in my brain to pain. As I increased the dosage, my body responded by further downregulating my opioid receptors. This eventually resulted in addiction to my pain medication. Worse still, my pain still persisted, even with high dosages of pain medication. My brain had, in effect, learned to create pain by the months of a particular neural network being constantly stimulated. The end result is that I am now addicted to my pain medication and the pain has become unmanageable.

INTEGRATED PAIN MANAGEMENT – A BETTER WAY TO TREAT PAIN!

Back to my back! My initial injury created acute pain. My doctors prescribed opioid pain medication to help. Before I’m accused of beating up on doctors over my fictitious example, please let me say that I love they doctors that have treated me and have given me excellent care, including helping me manage pain while I heal from injuries and surgeries in the past. Doctors, like the rest of us are extremely busy helping hurting people and deserve our thanks and applause. That said, recent research in neuroscience has brought a wealth of new discoveries and insights. Many of those are in the treatment of chronic pain, and in the prevention of chronic pain. Back to my fictitious example. What if, my recovery and pain management plan included addressing the emotional component of pain? What if, during my recovery, I learned to relax my mind and my nervous system, effectively closing the pain gates and shutting down stress hormones that maintained my pain. My proposal for better pain management is this:

Begin with a multi-disciplinary, and an integrated, whole person approach. This means seeing pain in a whole new light. Instead of seeing pain as simply the result of tissue damage, and treating accordingly, we will see pain as a result of both tissue damage, and our brain believing we are in danger. This will involve not only doctors but psychotherapists in addition. Doctors have training and skills that allow them to treat tissue damage effectively. On the other side, psychotherapists are trained to treat psychological and neurological issues as a specialty. By combining these two valuable skillsets, the patient gets superior treatment, with less pain and faster healing times. Physicians get the satisfaction of knowing they have been effective in treating their patients. Insurance companies save significant dollars in the process. This treatment approach seems to be the most effective for everyone.

If this approach interests you, I would appreciate your comments. Please feel free to send your comments to me personally at james@hoperenewedemdr.com