Perspectives on Pain

“In youth, the absence of pleasure is pain. 

In old age, the absence of pain is pleasure.”

Or so the adage goes.  I think we recognize there is value in pain.  Without it one may never learn not to stick one’s hand in the fire.  Pain signals dysfunction; something’s wrong.  And the desire to find the source of the pain and alleviate suffering is compelling enough to address the issues.  Pain is not a symptom that tolerates being neglected.  It can be all consuming, tiresome, occupying every minute of the day as the pain sufferer seeks relief.  It evolves into a fixation unto itself, as the anxiety of pain persisting motivates people to seek relief wherever it may be found and at whatever potentially devastating dosage brings some measure of apparent normalcy back to their life. Inevitably issues of addiction, and abdication from day to day responsibilities, become fixed.   An individual and societal problem with devastating and costly consequences.

There are different varieties of pain.  From a neurologic perspective, we can look at anatomic location and discuss the sources and avenues of recovery from pain.

Headache pain takes on different forms. It can be throbbing or persistent, stabbing or dull, acute or chronic.  It can present with associated symptoms of vision changes, whether blurring or scintillating lights, or extreme sensitivity to bright lights.  And pain can be accompanied by nausea and vomiting.  Often this may result in immediate relief of pain. Judging by the number of imaging studies performed for the symptom of headache there is an assumption that possibly a mass lesion in the head, a tumor, is the causative factor.  Fortunately, this is rare as the number of “negative” MRIs performed attests. Headache pain and migraines are therefore not so often attributable to structural changes in the head but rather biochemical and vascular alterations.  Perhaps precipitated by some inciting environmental factor, something eaten (nitrites), something drunk (alcohol), certain scent (perfumes).  Often the approach to treatment is to minimize, yes minimize, exposure to pain alleviating medicines.  This is contradictory, I know, but imagine flooding the body with pain medicine, in effect ratcheting up the sensitivity of pain receptors, making them sound the alarm even louder for any slight and inconsequential perception of pain, which then results in even more pain medicine ingested.  As I often say to my patients, the makers of Tylenol and Motrin don’t get rich by your not taking their medicine.  Long term adjustments in lifestyle, meditation, biofeedback, massage therapy, are all non medication therapies with lasting benefits.  A short term preventative course of medication therapy may be advisable in certain patients to “reset” the threshold at which headache pain becomes persistent.

Musculoskeletal pain may happen after an accident and require long term accommodations to compensate from the limited use of a limb.  Back pain is a prevalent problem.  Surgical interventions may provide some relief, often temporary. Where mechanical forces “pinch” nerves treatment to deaden the nerve may replace pain with an anesthetized feeling which for some is no relief at all.  Ultimately physical therapy, aquatic therapy, strength training, utilizing TENS units may provide lasting relief from pain.  Again, over reliance on pain medicines may give the illusion of treatment, but rarely treats the source of the pain.  To the extent that temporary pain relief allows increased mobility will have benefits, and therefore judicious use of pain medications has definite therapeutic benefits.

Neuropathic pain may be the most resistant to treatment, which often is lifelong depending on the cause.  Pain resulting from disruption of normal nerve function is common in metabolic disorders like diabetes.  The numbness and pain can be quite debilitating.  Adjunctive medicines like certain seizure medicines, and antidepressants, have demonstrated benefits.  But they are rarely useful alone and inevitably some anti inflammatory and probably narcotic pain medicines are needed at some course during long term treatment. 

Chronic Pain Syndromes including fibromyalgia, and central pain symptoms arising from dysfunction of the thalamic region of the brain, are recognized with increasing frequency, and as new assessment tools become available, new treatment protocols introduced, it is hoped that productivity and improvements in quality of life measures will accrue.  For now treatment options tend to follow the plan as laid out for neuropathic pain.  In all cases, physical therapy, increasing and maintaining mobility are cornerstones to effective therapy.  There is increasing reliance on cannabinoids, medical marijuana, with mixed results.  Unclear whether the alleviation of anxiety in cases of apparent benefit are scaling down the perceived intensity of pain.

Too many people are living with pain.  And there are moneyed interests, legitimate and underground, all eager to cater to the needs of pain sufferers.  The result of which is an opioid crisis.  The medical community, some of us having learned under the paradigm of assessing pain with the same focus as we do blood pressure and heart rate, have had to come to terms with its contribution to the crisis, and still provide needed relief to our patients contending with the emotional and physical toll pain has taken on their lives. We can and should be doing better. 

This is certainly not the last word on the topic.  I welcome your sharing your insights.

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