12th June 04:59
nerves in chronic pain (stress psychiatric psychiatry depression morphine)
Even though this article doesn't mention FMS it seems that the "plasticity" of
the pain system very well fits the experience of fibromites.
FROM THE NEW YORK TIMES MAGAZINE
BY MELANIE THERNSTROM
A MODERN CHRONICLER of hell might look to the lives of chronic-pain
patients for inspiration. Theirs is a special suffering-its dimensions
materializing at the Tufts-New England Medical Center pain clinic in Boston.
Here, in a small examining room, only three things exist: the doctor, the
patient and pain. Of these, pain predominates.
"Some of my patients are on the border of human life," sighs Dr. Daniel Carr,
the clinic's medical director. "Chronic pain is like water damage to a
house-if it goes on long enough, the house collapses. By the time most
patients make their way to a pain clinic, it's very late." What doctors see in
a chronic-pain patient is a ruined body and a ruined life. It is Carr's job to
rescue the crushed person within, to locate the original source of pain and to
rebuild psychically, psychologically, socially.
Chronic pain-continuous pain lasting longer than three months-afflicts an
estimated 50 million Americans, with costs in disability and lost productivity
totaling more than $100 billion annually. Only in recent years, however, has
chronic pain become a focus of research. "It's a field on the verge of an
explosion," Carr says.
Pain had always been understood as a symptom of underlying disease: Treat the
illness, and the pain takes care of itself. Yet the experience of patients
shows chronic pain often outlives its original causes, worsens over time and
takes on a puzzling life of its own.
Research into "neural plasticity"-the capacity of neurons to change their
function-has begun to shed light on what happens. Unlike ordinary or acute
pain, which is part of a healthy nervous system, chronic pain resembles a
disease, a pathology of the nervous system that produces abnormal changes in
the brain and spinal cord. Far from being an unpleasant experience, endured
simply with a stiff upper lip, this pain harms the body, unleashing negative
hormones like cortisol that adversely affect the immune system and kidney
Disseminating the new knowledge about pain will be difficult, however. Pain
treatment resides primarily in the hands of ordinary physicians, most of whom
know little about it. Less than one percent have been certified as pain
specialists, and medical schools give the subject very little attention. Still,
the American Board of Pain Medicine now provides a list of board-certified
doctors on its website (abpm.org).
Daniel Carr is one of the nation's leading pain specialists. A day spent in
his clinic demonstrates the dangers of the wait-it-out approach to pain. A
typical patient is Lee Burke, 56, who learned eight years ago that she had an
acoustic neuroma, a survivable brain tumor, behind her left ear. The recovery
after surgery to remove the growth was supposed to be a mere seven weeks.
Instead, Burke awoke with headaches-lancinating, lightning-hot pain-that
knocked her out for periods ranging from four hours to four days. She never
returned to her job as an executive at a real estate company. When pain came
between her and her husband, she left him-and her home. "It was easier to be
alone with the pain," Burke explains.
Asked to describe the headaches, Burke says, "It's like being slammed into a
wall and totally destroyed." She looks at Carr with the peculiar stricken
bewilderment-why? and why me?- seen on faces of many pain patients. "It's like
knives are going through my eyes," she says, starting to weep.
While Burke blots her face, Carr sits calmly, hands in his lap, his
concentration fixed. He asks Burke to close her eyes and taps her head with
the corner of an unopened alcohol wipe. Within a few minutes, he has found a
clear pattern of numbness, suggesting the occipital nerve in her face was
severed or damaged during her surgery. Carr regards this as revelation-the
demystification of her pain.
Pain makes a child of everyone. Burke's voice is smaIl as she asks, "If the
nerve was cut, why does it cause pain?"
It's a question researchers have only recently been able to answer. Doctors
used to be so confident that severed nerves could not transmit pain - they're
severed! - that nerve cutting was commonly prescribed as a treatment. But while
these nerves may stay dead, sometimes they grow back or fire spontaneously to
produce stabbing, electrical or shooting sensations.
When Nerves Misfire
Picture the pain wiring of the nervous system as a warning device that protects
the body from tissue injury or disease. Acute pain is like a properly working
alarm system: The pain matches the damage, and it disappears when the problem
does. Chronic pain is like a broken alarm: A wire is cut or hurt, and the
entire system goes haywire. "The repair doesn't occur because the system itself
is damaged," explains Dr. Clifford Woolf, a pain researcher at Massachusetts
General Hospital in Boston. It is called neuropathic pain because it is a
pathology of the nervous system.
Why does chronic pain often worsen? Woolf's research demonstrated that
physical pain changes the body in the same way emotional loss watermarks the
soul. The body's pain system is plastic, meaning it can be molded by pain to
cause, yes, more pain. Nerves recruit others in a "chronic-pain windup." The
nervous system revs up and undergoes what Woolf calls "central sensitization."
As for Lee Burke's neuropathic pain, Carr prescribes Neurontin, a new
antiseizure drug that also acts as a nerve stabilizer and can quiet misfiring
nerves. Within four months, Burke feels 50 percent better. She can move her
head side to side and sit up to watch TV instead of lying prone in agony. She
says, "Dr. Carr is my savior."
The Case for Tough Treatment
Why did it take seven years for Burke to get relief? "There's tremendous
ignorance about neuropathic pain," Woolf says. "Most doctors don't know to
look for it." One confusing factor: Not all patients with similar conditions
develop chronic pain. Physicians might look at a patient's MRI scan and say,
"The bone's all healed" and conclude there is no reason for pain. But the pain
is not in the muscles or bones; it is in the invisible hydra of the nerves.
Such confusion is what caused the delay in successfully treating Burke. Before
coming to the clinic, she had consulted Dr. Martin Acquadro, a caring,
competent physician and the director of cancer pain at Mass General. Observing
that she had severe muscle spasms in her head, neck and shoulders, Acquadro
diagnosed tension headaches and treated Burke with Botox injections, tricyclic
antidepressants and migraine medications. She tried range-of-motion physical
therapy, stress-reduction courses, psychiatric treatment, yoga, meditation. She
took 1,600 milligrams of ibuprofen a day, along with 12 cups of coffee
(caffeine is a treatment for migraines).
Acquadro hadn't thought of Neurontin, and he feared opiates. "When a patient
is depressed or anxious, you're leery about narcotics," he says. "I was being
Though only an estimated five percent of chronic pain patients using opiates
such as morphine are considered at risk for developing addictive behavior, the
drugs have a reputation for being dangerous, and social biases-class, race and
***-influence who they are prescribed for. One study shows that patients at
centers that predominately treat minorities are three times more likely than
others to receive inadequate pain relief. Their requests for medication are
more likely interpreted as bad "drug-seeking behavior."
Women tend to be less aggressive in demanding pain treatment or may behave in
ways misinterpreted as hysteria. The longer pain goes untreated, the more
desperate the patient becomes-until those behaviors look like the problem.
Whenever Acquadro sent Burke to specialists, she'd break down in pain. "They
figured I was a basket case," she says. "And I was."
Link to Depression
In fact, almost everyone who has chronic pain eventually develops anxiety and
depression. Surprisingly, pain and depression both share the same neural
circuitry. The neurotransmitters and hormones modulating a healthy brain-like
serotonin and endorphins-are the same ones that control depression. "Chronic
pain uses up serotonin in the brain like a car running out of gas," says Dr.
WIlliam Breitbart, chief of psychiatry at Sloan-Kettering. "If the pain
persists long enough, everybody runs out of gas."
Medications that treat depression also treat pain. Depression or stressful
events can in turn enhance pain. But to make stress reduction a primary
treatment is like trying to repaint walls in a crumbling house. "Chronic pain
is not just a sensory or affective or cognitive state," says Woolf. "It's a
biologic disease afflicting millions of people. Soon, I believe, there will be
effective treatment because the tools are coming together to understand and
The most important tool in Woolf's lab is the new "gene chip" technology that
identifies which genes become active when neurons respond to pain. "In the
past 30 years of pain research; we've looked for pain-related genes one at a
time, and come up with 60. In the past year, using gene-chip technology, we've
confirmed hundreds more," Woolf says happily. "All we have to do is find the
key genes, the master switches that drive the others."
Woolf is particularly interested in certain abnormal sodium ion channels seen
only in damaged sensory neurons. He believes he's close-perhaps a year
away-from identifying which of these channels are most important. Then, if the
animal data applies to humans, pharmaceutical companies could design blockers
for these channels, and develop new drugs.
The biggest question of pain research now is: Will a blocker for neuropathic
pain help all the people who already have it?
Woolf hesitates. "We don't really know," he says. But he's confident that
doctors will be able to stop pain before it becomes so debilitating. A genetic
component may well put people at a higher risk for developing such pain. "And
within a decade," says Woolf, "we'll be able to predict that susceptibility,
and prevent the pain early on."
Sam in Texas §(τΏτ)§
Minds are like parachutes; they function best when open.
A closed mind is a good thing to lose.
"Minds are like parachutes; most people use them only as a last resort."
15th June 01:02
nerves in chronic pain
This is a very very interesting article. So often I read something and get
to the end and think "what the hell was that all about. But this article I
read and understood and it does seem to make an awful lot of sense doesn't