Conceptualizing pain

What is pain? We toss the word around a lot without really understanding what it actually means. A loud noise is uncomfortable. Bitter tastes are unpleasant. Ringing in your ears is more than annoying. What about when someone, “hurts your feelings?”

The way every living species of creatures evolved and survives is by processing multiple types of sensory input and interpreting the sum total of it as safe or dangerous. Then its behavior is directed towards safety and rewards while also avoiding threat. These automatic actions in response to this input keeps us in a neutral zone most of the time so we remain functional and comfortable.

Nociceptive pain

The name for this function of the nervous system is called, “the nociceptive system.” When the limits of safety are exceeded for a given part of the body, your receptors will signal danger and cause you to engage in corrective action. The intensity of the signal will depend on the input from a specific part of the body. For example, a bright spotlight shined in your eye would not be tolerated for very long. Your brain knows your eyes would be damaged quickly and the danger signal is sent out for you to close your eyes or move away from the light. But what if the same light was focused on the bottom of your foot? No problem because there is no threat from light alone to that part of your body. Pain is simply a warning signal that there is potential damage to a specific body part.

So, acute pain is necessary and protective. It is a gift and people who are born without a pain system don’t survive more than 10-15 years. They can’t sense danger. Tissues are destroyed and they die of infection. (1)

A nightmare

But there is nothing useful about chronic pain. A delicately balanced signaling system is out of kilter and it can no longer accurately interpret the environment. You are trapped by incredibly unpleasant sensations without any hope of escape. It may be one of the worst experiences of the human condition.

Based on the last 10 years of neuroscience research, new definitions of chronic pain are being created. Here is one proposed by the IASP.

IASP definitions of chronic pain

For the first time since 1979, the International Association for the Study of Pain (IASP) revised its definition of pain. This was made necessary by the research showing clearly that pain could arise from sources other than physical tissue damage. Although the revision is a relatively small one, it has big implications for appreciating the complexity of pain and expanding our ability to assess and manage pain with multi-disciplinary approaches.

Old 1979 definition of chronic pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

Revised 2020 Definition

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

This definition is expanded by 6 key points

1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors
2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
3. Through their life experiences, individuals learn the concept of pain.
4. A person’s report of an experience as pain should be respected.
5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
6. Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

By adding the words resembling that associated with allows for an expanded understanding and appreciation of pain beyond that which was previously limited to actual tissue damage.

Dropping the phrase “describe” the pain, allows for acceptance of pain from those who may not have the ability to describe their pain whether infants, cognitively impaired individuals, those with communicative disorders, or any other reason that a description of pain may not be possible including nonhuman animals.

Commentary on the six key points

1. It logically has to be personal since each person is genetically different and we are programmed with regards to safety vs threat by our past. If you come from a less than nurturing background, more things in the present will seem dangerous because when you were younger they were dangerous. You will spend a higher percent of your time in a “high alert” and the sustained exposure to stress hormones and inflammation will create physical symptoms and serious diseases.
2. Acute pain is the danger signal that indicates that you have exceeded the safety limit of a given structure of your body. The nociceptive system keeps your behaviors in a range to protect you. Chronic pain happens when the signals have become disconnected from the environment and keep firing even in the presence of safety.
3. Pain being a learned experience is well established in the medical literature. One classic study involved looking at childhood trauma. A scoring system was developed called the ACE score (adverse childhood experiences) looking at 10 factors such as various kinds of abuse, parent(s) in prison, addicted to drugs, or having a mental health diagnosis. There is a marked increase in chronic diseases including chronic pain. (2)
4. Patients in chronic pain are often labeled. They include, “drug addict”, low pain threshold”, “faker”, “drug seeker”, “unmotivated”, and the list is endless. Often the labels are even more disparaging. No one likes being labeled. Once a person has been labeled, you can no longer “see them”. Since physical symptoms are created by the patient’s interaction with his or her environment, it is critical to know them and also their life circumstances. How can you solve any problem without deeply understanding it?
5. There is no usefulness in chronic pain. It is a disaster and it always interferes with function, social interactions, and psychological well-being – ALWAYS.
6. Chronic pain is so disruptive to every aspect of your life that words do not come close to describing the depth of suffering. It has been shown that the impact of chronic pain is greater than that of having terminal cancer. (3) The term that best reflects this condition is, “The Abyss.” It is a really dark place without a way out.

Unfortunately, mainstream medicine has not incorporated the last 20 years of neuroscience research into their treatment approach. It continues to recommend random simplistic treatments for a complex problem. It can’t and doesn’t work.

The new IASP definition is a start and opens the door for a better treatment paradigm. Chronic pain is solvable with an understanding of it and the principles behind the solutions. The starting point is for YOU to better understand it and then solve it with using the medical system as a resource. Once you take charge, it is game on.

1. Yancey, P and Paul Brand. Pain: The Gift Nobody Wants. DIANE Publishing Company (1999).
2. Anda RF, et al. “The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology.” European Archives of Psychiatry and Clinical Neuroscience (2006); 256: 174–186.
3. Fredheim OM, Kaasa S, Fayers P, Saltnes T, Jordhøy M, Bortchgrevink PC. Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Acta Anaesthesiol Scand. 2008;52(1):143-148. 

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Good Times

It’s always a wonderful weekend and incredibly relaxing in that everything is right there. Good food, fireplace, hot tub, warm pool and a lot of bantering (that would be the mild term). We do revert back to middle school behavior (at best). My wife keeps asking me the question if guys ever grow up. I think the answer is obvious. It’s a great break for all of us.

We ski in smaller groups and we usually meet at a restaurant in the middle of the mountain called “Watsons” at 11:30, just before the lunch crowd arrives. I don’t ski quite as well as I used to and decided to come in a little early and relax. I purposely worked on enjoying the fantastic view of the valley and could not have been in a better state of mind. It was also one of the few times when I was well ahead of the curve with regards to saving enough seating for 18 people. The restaurant was almost empty.

I was sitting at the end of two tables that seated 12 and had placed my gear on a table for six just across the aisle. Four of my group appeared at 11:20 and sat down at the large table. My plan was working well, and I was having a great time. We were talking about the morning, which included skiing on fantastic snow. Suddenly I turned around and there were four boys between nine and eleven, who had pushed aside my gear on the other table and were sitting down.

Trouble

I pointed out to them that I had another six people arriving shortly and this table was saved. “Where are they? We’re here! You can’t save tables.” They were clearly veteran Alta skiers, but I had never heard of that rule at any ski resort in over my 50 years of skiing. I also didn’t see any signs that I couldn’t save a table. I was caught off guard and firmly restated my case. At that point four more of my “ buddies” sat down at the large table. There were also two older women immediately behind the boys and they started hissing, “Just give them the table.” As I continued my protest, one of the boys looked at me said, “We’ll give you five minutes.” I was getting more confused and flustered. I don’t remember that I would have talked to an adult in this manner when I was 10 years old. Usually skiers just walk on by, since saving a table for your group is the norm (so I thought).

Thrown under the bus

Then I asked my friend, Bill, to come over and sit down at the embattled table with me, since the larger table was continuing to fill up with members of my group. Instead of coming over and helping me out, he said, “Come on, why don’t you let them have it?” while looking directly at them. I was now well into looking like a “grouchy old man” and the women continued to hiss at me. I caved in, but I wasn’t happy. My tranquil meditative state had been severely compromised, and I was being thrown under the bus. My “friend” fist-bumped them and they said, “Thanks!”

Three minutes later, another seven people showed up and had no place to sit. This wasn’t going well, and my group thought all of this was hilarious. I wasn’t happy with them, the kids, the women or me. I really was upset, and it was just over a table. My friends know how much stress I deal with every week and were surprised how triggered I was over such a non-issue. Of course, the more frustrated I became, the harder they laughed – even though I was holding the space for them. I haven’t been that angry in a while. What the heck happened?

Gulliver

The image that jumped into my head was that of Gulliver being tied to the ground after being captured by Lilliputians. Gulliver’s Travels was written in 1726 by Jonathan Swift, and was a disguised commentary on world affairs, as well as on human nature. The book is divided into four sections. The first is about being captured by the Lilliputians, who were one twelfth his size. He was tied to the ground by hordes of them while he was sleeping. They wanted to seal the deal by blinding him. He had to navigate some tricky situations to eventually escape.

I was trapped by people a fraction of my size and age. My “adult” friends finished me off. The similarities to being pulled into the Abyss of chronic pain weren’t subtle. It’s always a combination of factors that pull you into the hole. They add up quickly and escape becomes essentially impossible. When I was pulled into the Abyss in 1990, I didn’t see it coming and it took me 13 years to come out of my tailspin. And it was by pure luck that I did. It took me years to figure out what had happened to me, and longer to learn how to share the concepts with my patients. A few of the variables that can trap you are:

• The source of pain is usually not able to be identified, so no one really believes you’re in pain.
• Although modern neuroscience research has revealed the answers to solving your chronic pain, mainstream medicine continues to ignore the data. Essentially every treatment in spine care that is covered by insurance has been shown to be ineffective. Proven effective treatments are usually not covered. We are pretending to practice medicine.
• Repeatedly having your hopes dashed is a reliable way of inducing a major depression, as demonstrated in animal studies.
• You are labeled and judged.

This list is only a hint of the multiple ways  you are trapped by mental or physical pain. You can’t see them coming and the adversities keep pummeling you from multiple directions. The worst aspect of it is that since there doesn’t appear to be any viable solutions offered to you, where is the endpoint? You eventually lose hope and retreat into an angry survival mode.

I felt trapped and any one of the variables alone would not have stopped me from holding onto my treasured table. I didn’t anticipate all the angles of the situation that took me down. A major one was my own sense of not looking good to the other parties or to me. I was a “grouchy old man.” I am still not sure, as I am writing this piece a couple of weeks later, that I’ve completely let it go…………

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It is also a block to awareness. Once you have labeled someone, you have projected your view of the world onto that person. Anthony de Mello in his book, The Way to Love, teaches that it doesn’t matter whether the label is a positive or negative one. You can no longer see the person for who they are or a situation from their perspective. You are no longer able to really hear them or meet their needs.

When suffering from chronic pain, you are often labeled by almost everyone and anyone, including your doctors and other health care providers. “You are a difficult patient.” Isn’t everyone challenging when basic needs aren’t being met. “You don’t really have anything wrong with you. The pain is in your head.” Really?? Neuroscience research has revealed chronic pain is memorized by the brain (1) and can’t be erased. Unfortunately, mainstream medicine hasn’t assimilated this knowledge and continues to offer ineffective treatments. “You are just looking for drugs to get high or to relax.” First of all, the vast majority of patients on chronic opioids don’t get high and they barely get pain relief. The side effects are often unpleasant. I have seen few people who like being dependent on any medications. People just want some pain relief.

Labeled

Here is an excerpt from an email I received from a reader. She has been working hard with the DOC process and is moving forward.

“My pain doctor told me it’s people like me who caused all this opioid crisis.”

It’s the physician’s responsibility to treat each patient with compassion regardless of the situation. Nurturing a supportive patient-physician relationship is the essence of being a physician. For many reasons, beyond the scope of this discussion, this interaction is often less than ideal. So, not only do many patients in pain not feel safe, they feel like they are under attack from many directions. This creates more anxiety and physically exacerbates the pain. (2) Another risk is that your physician may not see your whole picture and an important diagnosis may be missed. This letter is one patient’s story.

Mary’s Letter

Hi Dr. Hanscom,

I know that you had asked me to send you an email telling you how it made me feel when L&I (WA Dept. of Labor and Industries) “stereotyped/categorized/labeled” me.

The First Surgery

I know that you had asked for another story, but I felt compelled to tell you about the first time I was stereotyped after my injury. It happened in an emergency room in Everett and was about one week after my first back fusion. I had only been home from the hospital for two days when I started getting back spasms. Initially the spasms were very bad but they had progressed to the point where I couldn’t even stand.  I ended up falling to the floor because my legs would not hold me up. It felt as though the muscles in my back where trying to bend me in half backwards. On the third day I couldn’t stand it anymore as the spasms were happening very frequently and I felt almost delirious.

Emergency Room

My oldest daughter called for an ambulance that transported me to the hospital emergency room. I spoke briefly with a nurse about what was going on and then to the doctor. I overheard them talking and saying that they felt there was NOTHING wrong with me, but rather I was there looking for pain medication. Meanwhile I became upset and was telling my oldest daughter about what I had heard. She reached up and put her hand on my forehead and said, “Oh my God Mom you are burning up!” She proceeded to grab a thermometer and stick it in my mouth. After seconds she was freaking out and yelling for a nurse to get in there because I was burning up. The nurse didn’t even believe her so she herself took it again and my temperature was 103 degrees. About this time my younger of the adult daughters arrived.  My two daughters talked about the situation. The younger one grabbed my purse, which had ALL my medications in it, dumped it on the bed, and told the nurse to look at it! She told her that she too had witnessed me falling and that I had NO NEED for any more pain medication. I had more than enough and that they had better do something!

Sent Home with a 103 degree fever

After that they did some blood work, an X-ray, and wrote me a prescription for muscle relaxers. I was basically patted on the head, told me they found nothing, and sent me home. That was on a Wednesday. On Friday morning my phone rang and it was the hospital telling me that I needed to come in and be checked. I had a very serious infection, which was in my spine and my blood and I needed IV antibiotics!

Labeled

I won’t take up more of your time telling you the rest of the nightmare, but I felt like you should know this, BECAUSE they decided what kind of a person I was BEFORE gathering all the facts. It almost cost me my life. If my two adult daughters had not been there to advocate for me, I would be dead. I honestly believe they would have not done or checked anything. They probably would have just sent me home saying it was nothing!

I will guess that by now you can understand why when we first met I was so “angry.” Part of my anger stemmed from my nightmare experience that almost cost me my life. There is also about a six-week window during that time that I don’t remember a lot without help from my kids!

I am SO GRATEFUL that I was sent to you and that you decided to help me! I know that I am probably not as far a long with my entire recovery process as you had hoped. But I know that I wouldn’t even be this far if it wasn’t for YOU!

Sincerely,

Mary

My Perspective

Mary is a patient on whom I have performed two low back surgeries. The second was a fusion that went very well. However, the amount of family stress she has been under is beyond description. When I first met her over two years ago, she was one of the most angry patients I had ever met. I did not think she would return. She has made remarkable progress and is now just on minimal pain meds. I thoroughly enjoy my visits with her.

Her stresses continue, but she’s now trying to find a job, which in this economy is no small task. She has been consistently treated poorly by her claims examiner, and we have had to fight for every bit of her treatment. The subject of labeling came up, and I asked her to share part of her story.

You aren’t going to stop labeling

It isn’t possible or necessary to stop labeling. The key is to be aware when you are doing it, and name the labels to yourself. Once you recognize the label, then you have the capacity to know the person behind it. Recognizing your language makes a difference is also helpful. Epictetus, was a Greek Stoic philosopher, who pointed out that it is one thing to call a person a drunk as opposed to saying that this is a person who drinks a lot. It’s similar to being labeled a “chronic pain patient” versus being described as a person who is suffering from chronic pain. None of us like being labeled. How do you react? What are the labels that you place on others? How are they interfering with your relationships? Are they helping you heal from your pain?

Becoming aware of your inherent need to label, what the labels are, and your reactions to being labeled is an important aspect of your healing journey.

The Cry of Chronic Pain: No one is Listening. WSMA Preceptor, August 2011.

1. Mansour AR, et al. Chronic pain: The role of learning and brain plasticity. Restorative Neurology and Neuroscience (2014); 32: 129-139.
2. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience(2011); 185: 166-173.

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