Monday, April 11, 2011

Family Medicine: "No Brain, No Pain" or "Know Brain, Know Pain"

"Doctor, Are you saying that my pain is all in my head?", asks my patient. "No brain, no pain." is my usual response. The pain is recorded in the brain, asking for a response from the pained person. Acute pain, such as accidentally touching a hot plate or stove burner, generates a quick response leading a person to move away from the hot object. Chronic pain, on the other hand, lumbers up the spine ("Slow" C fibers) through the limbic system where all of our life files (joys, pleasures, miseries, etc) are located. It beats up the life files, unless they are protected, then moves forward in the brain pronouncing that, by the way, you have pain.

Those simple concepts have a lot to do with how we analyze and treat acute and chronic pain.  They also have a lot to do with how we explain acute and chronic pain.  Chronic pain seems to be the more challenging one for  patients, physicians and society.

Another aspect of chronic pain is that it gets "engraved" in the brain.  It may register pain even when the body isn't hurting and it takes a while to forget the pain.  "Wind up" is another unfortunate element of chronic pain in that, the longer the pain is around, the more intensely it hurts, even with the same provocation.  Hyperalgesia, painful sensitivity to less and less touch, is another unfortunate component of chronic pain.  Sounds like a bit of unfairness, right?  Right, but that's how it works.

Heredity is another interesting consideration in chronic pain.  If you "picked the wrong parents", you may be at risk for the same pain threshold they inherited or the same response to pain.  If one or both of them have a chronic pain syndrome that is treated with chronic opiate medications, and their pain  hurts worse and worse and worse, you are at risk for the same response to pain and to opiates.  More unfairness.

Since chronic pain is such a challenge, physicians are prone to avoid treating it and/or to refer patients to a "pain management" physician.  These doctors will inject your back or neck if that's where the pain is located or prescribe physical therapy and medications as indicated.  They usually are trained as anesthesiologists, but some might be physical medicine and rehabilitation experts, while a few were trained in  a primary care specialty.  'Another doctor", you moan, thinking that it's just not fair.

The best place to have your pain issues evaluated and treated is through your personal/ family physician since they know you and your family and some things about your pain threshold.  Even if one of your parts needs the pain management subspecialty care such as injections to the lumbar spine, your personal physician should be very helpful by co-ordinating your pain care as part of your overall health care.  Unfortunately, many personal physicians are becoming "opiophobic", fearful of prescribing opiates, because of a fear of peer pressure and being scammed by a drug addict or by a person who sells (diverts) the prescriptions.  They are becoming less and less likely to treat patients with chronic pain and more and more prone to refer them to pain management centers for someone else to do the treating.  That's not  fair either, right?  Right, we need to change something.

"No brain, no pain" is a helpful way to think of how we have pain and "know brain, know pain" is a very important way for physicians (and patients) to think about diagnosing and treating  the pain and its associated issues.  There is a lot to learn together to minimize suffering from chronic pain.  If we connect better with each other, patients and family physicians (or other primary care physicians) can do better at avoiding pain and/ or arranging earlier intervention before complications such as hyperalgesia,, wind up or engraved pain arise.  Let's work together and make things "fairer" for all.

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