The chronic pain conundrum

Several days ago I ran into a group of people who work with chronic pain patients. I don’t remember how the conversation got started or why we ended up discussing treatment options, probably because of the work I’m doing, but the conversation stuck with me and it isn’t for good reasons. Let’s face it pain is a pain. Frankly we need pain in our lives, but even with the best things, moderation is key. So what happens when good pain pathways go bad?

I hurt. I hurt a lot most days and there’s not a damned thing anyone can do about it. I’m not even a good responder to pain medication (see: no responder) so that wouldn’t be an option even if I wanted to go that route. But pain is necessary for our survival. Imagine if you will one day you felt no pain at all. You could put your hand on a hot stove and cook yourself, but you wouldn’t notice. Pain keeps us safe and activates very fast reflex pathways in the spinal cord. Ever step on a lego? You know how fast your foot will pull away from the sensation, after the fact you feel like you were the one doing it, you were certainly not.

On the other end of the spectrum are chronic pain patients. People who deal with pain for seemingly no reason, and there are a lot of people (estimated as ~1/5 here in the US). As you can imagine it’s a sad existence because frankly we have no way of confirming what they are feeling. We can’t run a test on someone and see how much pain they are dealing with, we have to communicate with the person and that is messy. In short, people lie and that’s not to say people suffering from chronic pain are lying, but the medications used to treat chronic pain are addictive by nature and it’s a slippery slope from there.

People who are in so much pain they seek out medication are labeled drug seeking when really they are pain-relief seeking. People who find their pain is well controlled with these addictive medications have to fight to continue receiving them because who knows if they are really in pain or just an addict? There are no tests and that’s frustrating for me in particular because I would rather we just believe people when they say they hurt. Then again we have an opioid epidemic so maybe my approach isn’t the best, but hurting all the time is no way to live.

Luckily there are some new alternatives to treating chronic pain, epidural spinal cord stimulation has been shown to treat chronic pain pretty successfully and while the treatment does tend to be less effective over time, it’s still highly effective at treating chronic pain and, in my opinion, one of the best options for treating pain. The downsides are the high cost and risk involved, because even the safest of surgery isn’t without risk and surgery involving the spinal cord isn’t exactly minimally invasive. That isn’t to say it’s not worth it or it isn’t safe enough that this isn’t done on a regular basis, but that not everyone is a good candidate for surgery, assuming they can even afford the option.

The problem is that pain pathways are very complex and have a lot of weird quirks about them. There are redundancies and we don’t fully understand how pain is processed or why everyone has a different tolerance to pain. When these pathways take a hard left and start acting out (e.g., chronic pain) we don’t know what went wrong, much less an effective way to treat the cause. Instead we’re forced to treat the symptom, the pain itself, instead of somehow fixing the pathway. By the way this is my shameless plug to my favorite pathway because it’s so weird, the spinothalamic pathway, which is primarily responsible for pain processing (if you want to know more about how pain is processed that is a good place to start).

Which brings me back to the conversation (didn’t think I forgot the topic of the post, did you?), we started discussing people who deal with chronic pain. Some of the things they were saying involved how people would often claim to not be addicted to the medication, but that they had been on it for a very long time. It honestly made me sad because I know people who cannot get care for chronic pain to save their lives. They are angry and get annoyed because doctors don’t take them, or their pain, seriously. You would be tired and angry too if you were bleeding to death and doctor after doctor offered you a band-aid instead of actual treatment.

Chronic pain is a special kind of hell and I can appreciate why patients would be frustrated with doctors. I would be frustrated too, I’ve been frustrated too, for me and for friends who cannot get care or are worried about being labeled as drug seeking. Of course they are drug seeking, it’s the only thing that fixes the problem, you wouldn’t label a diabetic drug seeking. The catch is you can check blood sugar, you can’t check pain and I think that’s the whole linchpin to the problem. If we had a reliable way to measure someone’s pain level I would imagine patients would have better care.

It’s a problem I’m not able to solve, but I am hopeful that eventually we’ll be able to find a way to measure pain. I just hate seeing people suffer and I hope that there will be something in the future that will let us quantify pain so doctors won’t be so afraid to provide treatment. In the meantime, finding better, cheaper, and safer ways to treat pain wouldn’t hurt either (no pun intended).