In all of medicine there may be no bigger mystery than chronic, nonmalignant pain — especially to those of us who treat it. Pain usually serves a biological purpose, yet in chronic pain patients, pain symptoms seems to exist with little biologically useful purpose. We know that pain can be ignored by soldiers and first responders in crises, yet chronic pain improbably exists in limbs that are amputated or paralyzed. We know that pain that is considered debilitating in one culture can be barely acknowledged in another culture. And finally we know the same pain event that resolves in one patient can turn into chronic pain with its associated debilitating features in another.
These ambiguities and even paradoxes in the experience of pain strain the physician/pain patient relationship as both parties become frustrated at the ability of chronic pain to confound treatment.
Clearly pain is necessarily to our survival. In rare cases, humans are born without the ability to encode and process harmful stimuli in the nervous system and endure dangerous consequences. Medical textbooks tell the story of “Miss C.” a Canadian girl who was born with a congenital insensitivity to pain. Miss C. “showed no physiological changes in response to noxious stimuli. Similarly she never sneezed or coughed, had an extremely weak gag reflex, and no corneal reflex. As a child, Miss C. bit off the tip of her tongue and sustained third-degree burns from her inability to sense pain. As an adult, she developed severe erosion and infection in her knees, hip and spine from failing to shift her weight or turn over in bed known as “Charcot joint.”
It is also clear that pain perception can be “turned off” in some instances. In parts of India, in an ancient agricultural ritual that is still practiced, villagers hang from hooks embedded in their backs to bless children and crops, yet show no sign of pain. In Africa, India and other places, trepanation, a type of primitive brain surgery in which a hole is drilled into a patient’s skull , is still practiced without painkillers and no outward appearance of distress on the part of the patients.
Our interpretation of pain is also influenced by past experiences, state of mind, expectations, culture, family and the “meaning” ascribed to the pain. One of the best examples is childbirth which women endure and repeat for the obvious benefit at the end. Childbirth is so painful, it is said facetiously, that if men had to go through it, the human species would “die out.”
In my years of practice I have had the opportunity to see and participate in the rehabilitation of more than 10,000 patients with chronic or persistent pain. Most of these patients have not responded to treatment with medications, surgery, anesthesia interventions, prescription drugs (mainly opioids/narcotics) and are still seeking a “cure.”
Sadly, there is no “cure” for chronic pain but it can be well managed and patients can have a high quality of life. When patients receive “multidisciplinary treatment” which provides a cafeteria of different approaches like physical therapy, exercises, psychological support and medication when needed, they almost invariably get better. Through active participation in their treatment and embracing a new attitude, most patients learn effective self-care, self-efficacy and self-management of their pain and go on to live useful lives.
Earlier this year, a federal advisory group made up of the FDA, National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Departments of Defense and Veterans Affairs and the Agency for Healthcare Research and Quality, released a National Pain Strategy plan to address America’s problem with chronic pain. The proposal, based on multidisciplinary treatment and addressing the biological, psychological and social factors behind chronic pain, is good news for patients and the clinicians who treat them.
Sridhar Vasudevan is the author of Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians.