by Dr. Jackie Gardner-Nix
This huge World Congress on Pain is now held every 2 years and rotates around cities of the world. Two years ago it was hosted in Montreal, and it was supposed to be in Japan this year, but after their Tsunami, the host city for 2016, Milan, swapped years. Just under 8000 health care professionals attended this year, including about 200 from Canada.
This year I found great comfort in hearing many speakers supporting behavioural interventions, such as our approach to managing pain with our MBCPM courses, or cognitive behavioural therapy or acceptance and commitment therapy. In fact, it was acknowledged they should be first line therapy.
There was much acknowledgement that the influence of emotions and beliefs on the experience of pain changes the intensity of the suffering resulting from pain. In the old days more than a decade ago, it was the common misconception that if pain appeared to be exacerbated by emotions, then the patient was hysterical and somehow considered by their healers as “weak”. The term “somatizing” was used to describe the notion of the pain not being due to physical causes, and many health care professionals understood this term to be derogatory. This led to questioning whether it was appropriate to give pain killers, as the pain was not “organic”: read for that “from a genuine physical cause”. Thankfully times are changing: it is now understood that all pain is influenced by one’s psychosocial environment, and even, sometimes, in its causation. Indeed, for certain people who have difficulty identifying their emotions throughout life, physical pain might be the way their body/ mind expresses emotional pain. Our immune systems, necessary for healing, are affected by psychosocial stress.
The Brain in Pain
When pain conditions became long term, research on the brain shows that, after about 5 years in pain, a characteristic pattern emerges of emotional and physical pain brain areas activating to be the “experience” of pain, explaining the suffering. Apparently the patterns seen on research tools such as functional MRIs were characteristic, depending on the pain condition. So the pattern of activation would be different for back pain sufferers versus arthritis sufferers. Of note, this is not a diagnostic tool: functional MRI work is only done in research, and isn’t the same as the MRIs physicians order to assist with diagnosis.
The support network cells of the neurons (grey matter), the glial cells, are acting like telegraphs to other brain centres, getting more areas involved in the pain experience As pain exacerbates, due to emotional stress as well as increased physical activity, the activity throughout the brain in emotional as well as physical pain sensation areas instantly ramps up — it lights up like a Christmas tree on a functional MRI study. Scientists refer to this as central sensitization and may have thought that once it arrives at that stage after years in pain, there was no going back.
The mechanisms through which mindfulness and meditation may be helping to reverse this would be explained by the attitudes we practice in mindfulness, such as reducing anticipation, suspending negative judgments, and being open to new experience. Daily meditation allows us to identify our triggers which increase suffering, and change the directions of our thoughts, actions and beliefs. These insights become “built in” with continuing mindfulness and meditation practice. For example, we have had participants prone to panic attacks report they can now identify their triggers and be able to go to their breath to stop the attack in its tracks. Well, the same can happen for pain exacerbations. In time that Christmas tree in the brain is not lighting up so much any more. Research on meditators is showing that.
The Opioid Situation
Research is showing that opioids for long-term therapy, which includes codeine-containing medicines, continue to show poor performance and additional risks. Among other concerns, they affect hormones adversely, can exacerbate infection, and interfere with the body’s own mechanisms to reduce pain coming from an injured site.
In defense of opioids, where the pain sufferer is dong better on them than off them, and with the understanding that unmanaged pain is stressful enough to cause even more dysfunction of the immune and other systems, opioid treatment can be maintained.
However, if opioids are proving so problematic, and taking into account their risks of diversion to street use, fewer physicians will be experienced in their use in chronic conditions, and it may be harder to find practitioners skilled in treating patients with them.
Opioids and Emotional Pain
Interestingly, following on from recent research on acetaminophen (Tylenol) being helpful foremotional pain, there is now evidence that opioids treat emotional pain as well as physical pain. In fact, we need intact opioid receptors for proper bonding to our mothers, without which we are much more vulnerable to illness and other dysfunctions throughout life.
There were presentations on migraine headache treatments and also on distorted body image where pain is experienced. I can deal with these in a future Newsletter.