4th Annual Thoughtful Pain Management WHAT IS CHRONIC PAIN? John D. Loeser, M.D. 4th Annual Thoughtful Pain Management May 29, 2015

PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE OR DESCRIBED IN TERMS OF SUCH DAMAGE. Pain, Suppl 3, 1986

MALINGERING IS A VERY RARE DISEASE. ALL PAIN IS REAL. MALINGERING IS A VERY RARE DISEASE.

TYPES OF PAIN

TYPES OF PAIN Transient Pain Acute Pain Chronic Pain

TRANSIENT PAIN Elicited by the activation of nociceptors in the absence of tissue damage. It is ubiquitous in everyday life and rarely a reason to seek health care. Relevant only to procedural pain, this is not a major issue in clinical medicine. It has, however, been the subject of most experimental pain paradigms in man and animals until very recently.

ACUTE PAIN Elicited by injury to the body and activation of nociceptive transducers at site of damage. Local injury alters the response characteristics of nociceptors, their central connections, and the autonomic nervous system in the region. Healing of damaged tissue occurs with restoration of normal nociceptor function. Common medical problem: health care blocks pain and facilitates healing.

CHRONIC PAIN Triggered by injury or disease Perpetuated by factors other than those that started the pain Body unable to heal because of nerve injury or loss of body part Stress, affective, and environmental factors likely to play a large role.

CHRONIC PAIN Not well managed by Cartesian concepts. Requires bio-psycho-social model. May be induced by CNS changes in response to injury that are not reversible even though healing occurs. Modulation can be detrimental or beneficial, hence role for psychological therapies.

TYPES OF CHRONIC PAIN Associated with cancer Associated with nerve injury Associated with systemic illness Unknown causation Palliative care and chronic pain

PAIN IS MULTIDIMENSIONAL No single measure adequately describes it. It is a label for a group of observations. There are components of pain such as site, intensity, duration, frequency, and qualities.

Anything you know that works for acute pain is likely to harm a patient with chronic pain. The only thing they have in common is the four letter word, pain.

TODAY WE KNOW THAT ACUTE PAIN IS A SYMPTOM; CHRONIC PAIN IS A DISEASE. (AND A VERY EXPENSIVE ONE) NOT ALL DOCTORS OR ADMINISTRATORS OF HEALTH PLANS UNDERSTAND THIS. 13

THE PUBLIC IS MISINFORMED ABOUT CHRONIC PAIN AND ITS TREATMENT BY PROVIDERS AND BY DRUG AND DEVICE MANUFACTURERS, TO SAY NOTHING ABOUT THE LAY PRESS. 14

Doctors pour drugs, of which they know little, for diseases of which they know less, into patients—of which they know nothing. Voltaire

RELIEF OF PAIN IS A PRIMARY REASON FOR HEALTH CARE 16

CONCEPTS ARE IMPORTANT FOR DIAGNOSIS AND TREATMENT 17

“All diseases of Christians are to be ascribed to demons”. St. Augustine 354-430 18

ARISTOTELIAN OR CARTESIAN CONCEPT Noxious Stimulus Pain 19

HARD-WIRED NERVOUS SYSTEM 20

HARD-WIRED NERVOUS SYSTEM 21

MODULATION OF SENSORY EXPERIENCES IS THE RULE, NOT THE EXCEPTION. PERIPHERALLY GENERATED STIMULI PLAY UPON THE NEUROMATRIX, INFLUENCED BY EXPERIENCE AND ANTICIPATION, AND RESULT IN THE REPORT OF PAIN. 22

ONE CANNOT UNDERSTAND THE PAINS THAT BRING PATIENTS INTO DOCTORS’ OFFICES SOLELY ON THE BASIS OF ACTIVATION OF NOCICEPTIVE SENSORY ENDINGS OR UPON THE EFFECTS OF INJURY ON THE NERVOUS SYSTEM.

KROENKE 24

Nerves exist in a patient, who is, first and foremost, a human being and not just a biological machine.

Pain requires consciousness; it is an emergent property of the human brain.

“NOTHING CAN PROPERLY BE CALLED ‘PAIN’ UNLESS IT CAN BE CONSCIOUSLY PERCEIVED AS SUCH”. W. K. Livingston 1998, p.207

“Pain is not just a stimulus that is transmitted over specific pathways but rather a complex perception, the nature of which depends not only on the intensity of the stimulus but on the situation in which it is experienced and, most importantly, on the affective or emotional state of the individual. Pain is to somatic stimulation as beauty is to a visual stimulus. It is a very subjective experience.” A. I. Basbaum 1987

Hurt and Harm Are Not the Same.

CHRONIC PAIN IS NOT A STATE OF OPIOID DEFICIENCY.

OPIOIDS FOR CHRONIC PAIN? Is there evidence for efficacy? Are there side-effects? Is addiction a potential outcome? Can a patient be weaned off opioids? Diversion is a major issue. Our focus should be on relieving the pain in our patient, not being part of a police state.

The health care provider should focus upon the patient’s functional status and quality of life, not upon the report of pain level.

Use your social reinforcement to reward wellness, not sickness behaviors. Ask the patient to tell you what he or she can do, not what they cannot do.

Non-specific treatment effects are often the difference between success and failure in the patient with chronic pain. Be sure that what you prescribe does not make the patient worse.

THANK YOU