Welcome back!! This is Part IV in a series on Opiates: Are There Any Good Answers? Last week, we visited with a mom who lost her only child to an accidental overdose. We can all agree this was hard to read but a necessary part of our series. This week, we change directions a bit, and we hear from a lady who has horrific pain issues, but due to the current Opiate crisis, can no longer get pain medication. Many of our readers have written to us, reminding us...begging us…to show this side of the crisis as well, because people who legitimately need pain management are somehow falling through the cracks. Let’s hear from a pain warrior who knows exactly how you feel…and don’t forget to come back on October 31st for a final wrap up of the month in “A Cup of Coffee”, by Linda Tate.
Pain is a strange thing. Years ago, I was in a motor vehicle accident, and as a result ended up with a numb hand for a few weeks. When the feeling started coming back to my hand, I reached for a pen and startled…it was so painful to touch that pen! I sat back and thought about it for a minute. No…it wasn’t pain…it was the sense of touch. I hadn’t been able to feel anything for so long, that when I actually could feel something, my brain misinterpreted that event as being painful.
I came to a conclusion that day: The sense of touch is pain put into perspective.
Touching the pen hurt until I recognized it was just a pen, and it doesn’t hurt to pick up a pen. My brain took that knowledge, absorbed it, filed it away, and pretty soon I was grabbing pens with no pain associated.
We have more concrete methods of dealing with pain….Osteopathic Manipulative Medicine (OMM), Acupuncture, aromatherapy, over the counter remedies such as “Icy Hot” and the old standby “Bengay”, tinctures and Essential Oils. There’s Chiropractic, Massage Therapy, Yoga, Swimming, walking, and stretching.
Human beings have come up with all kinds of other remedies for pain, such as CBD oil infused into a balm, Cannabis that is smoked or eaten, and a Medical Marijuana card to regulate ones intake. We have local shops like Shango, (voted best shop in the state of Oregon), and online sales from places like Nini’s Dreams.
There’s Physical Therapy, Occupational Therapy, and sometimes mental health therapy.
And yet…for some…like myself…pain is still there, day in and day out…knocking on the inside of my eyelids, waking me up at 11, 2, 4, and 6am, robbing me of much needed sleep, which then compounds the pain, making it seem as if I can’t even think straight. The fog begins to develop as more and more sleep is lost, and suddenly I’m faced with the bottom line: Nothing is working.
The anti inflammatories that were once my friend, have now created a bleeding ulcer, and the acetaminophen isn’t even touching the pain. Now what do I do?
Lack of sleep, and never ending pain took a toll on my ability to exercise. Soon, my weight was creeping up on me, damaging both my joints and my self esteem. Going out and socializing was replaced with early bed times in an effort to “catch up” on my sleep. I started calling out for work, unable to wake up and function.
My job was in jeopardy as was every other aspect of my life…friends, spouses, even children, grow weary of the same old story: “I’m too tired…I’m in too much pain…I can’t….”.
Now my DO was faced with a dilemma. Should she give me pain medication? Knowing I’ve tried everything known to man, what should that next step really be about? Should the opiate epidemic play a factor in my medical care? Should my DO determine pain management based on a fear of having their license taken from them?
Often, at this point in the journey, a surgeon is brought into the equation. In this case, the culprit was a herniated disc in the neck. At 39 years of age, it became a choice between ongoing unbearable pain, or surgery. Pain pills were not on the table. There’s an epidemic, I hear. And so, surgery it was…
I would like to say that surgery fixed the problem…but unfortunately, my pain journey hasn’t stopped there. I’ve thought about going out on the street to get heroin…I’ve heard it’s effective at managing pain. I’ve also thought about killing myself. I’d be lying if I didn’t say that. Thankfully I love my family too much to leave them my pain to deal with.
Why won’t anyone help me…
This is Dr. Jorgensen’s response to Patty’s story…and if you are a care provider, you are encouraged to read to the very end, as this article is phenomenal in addressing all the issues above. Whether you are a DO, an MD, a student doctor, a resident, or a community member, this is important information.
This story epitomizes how chronic pain creeps into one’s life. The day most people have a car accident or injury, just sneezed or bent over to pick up a tissue, seemed like every other day. Yet that day…the day they got hurt…their lives changed forever and their chronic pain journey commenced. Medical literature varies on its opinion as to when pain becomes chronic. Is it 6 weeks, 12 weeks, or 6 months? From what I’ve learned from over two decades of seeing patients in pain, 6 weeks is all that is needed to permanently change receptors and create a chronic pain scenario.
Irrespective of the time, this patient’s prose picked up on a critical point. The body’s perception of pain is more important than whether or not it can be proven. The pen represented pain, when in fact it represented an alteration in pain perception… painful nociception in what should have been a non-painful event. Tactile allodynia becomes a new hurdle for the patient.
Why does this happen? Years ago, Dr. Frank Willard gave a lecture on the amygdala. Frank is a world-class Ph.D. anatomist at the University of New England and a hell of a nice guy. He’s one of those amazing educators that can modify explanations to make sense to a 4th grader or a 4th generation surgeon. That lecture changed my professional life and my practice direction.
Frank was discussing amygdalic stimulation in an acute pain response, and how serotonin (5-HT) and norepinephrine (NE), are an anticipated and normal physiologic response to provide an adrenergic surge that manages the initial 48-72 hours post-acute injury. Think about that. Whether a weekend warrior calamity or a work injury, for 2-3 days things hurt but they are manageable and typically improve.
Now, think about a mom whose kids are trapped in a car heading into a lake, or a marine who was just shot but has to save fellow Marines. The mom miraculously pulls a stuck car door open to rescue her kids, and the Marine unknowingly completes the immediate job at hand. They are almost unaware of injury or how what they are doing should not be possible. Both seem to possess superhuman strength due to an adrenaline surge thanks to this physiologic response. The 5-HT and NE are key to fight or flight in acute pain and to recovery and, unfortunately, in the management/treatment of chronic pain.
After that acute surge, the body is supposed to work on recovery. Both injury and pain should begin to resolve. When that does not happen, 5-HT and NE continue to be produced in high quantities. Eventually, the receptors close down because both are produced in too high a quantity, as the acute phase should be done. A few weeks later the body recognizes an overload of 5-HT and NE in the amygdala responds by reducing production. What’s left is too few receptors with too little 5-HT and NE. Now that person is in chronic pain, and the body unable to heal itself with hormonal dysregulation driving the way.
When persisting painful, nociceptive stimuli exceed the recovery, hypersympathetic response (hypersympatheticatonia) and related stressors occur. The sympathetic nervous system elevates pulse and blood pressure while causing stress on other organ systems. Once this sensitivity occurs, the recurring pain burns a memory into the spinal segments receiving the afferent pain stimuli. This results in spinal windup, or an overly stimulated spinal segment. The body still knows what pain is and prepares for fight or flight. The difference: Any physical or emotional stressors are interpreted as pain.
Seemingly minor injuries, an emotional argument with anyone, too little sleep, etc. results in pain spiraling out of control. This is a physiologic protective mechanism gone awry now known as the “allostatic pain theory.” Dr. Bruce McEwen, a Ph.D. at Rockefeller University in Manhattan, had a grad student that discovered this model in the mid-1990s. It has guided my practice ever since Frank Willard introduced it to me.
Allostatic load speaks to the stressors that create pre-sensitization, with the body ready to respond to emotional or physical pain. While the surgery fixed the disc, what it could not turn off was the stress and the facilitated spinal segments. Not managing the acute pain created chronic pain.
Aggressive management of acute pain is essential. Often times medication is part of that process but risk mitigation in the current opioid-phobic environment is no longer optional. Opiates work for pain, but it is our ethical duty to risk assess before we give any controlled substances. At Patient360 we created measures to monitor this and prove compliance, which must happen. Paramount to an acute injury is immediate treatment of acute pain via manual medicine, injections, medication management and/or even psychotherapy or hypnotherapy if emotional duress surrounds the etiologic event. Once these systems are turned on and remain activated for a prolonged period, turning them off is challenging at best. In too many cases, as evidenced herein, it is nearly impossible.
Not all medication management means opiates and even if they do, monotherapy with opiates is no longer the norm. SNRI/SSRI agents to help with the systemic reduction in 5-HT and NE are important considerations. Additionally, neuropathic agents, tricyclic antidepressants to help with sleep and pain should also be part of the treatment paradigm. OMT often reduces need for many agents and for some has altogether eliminated the need for medication. However, noted in prior blogs, OMT is a tool in our bag and not used to the exclusion of other potential benefits. The allostatic pain model is an osteopathic paradigm where function and rational approach to treatment should encompass the self-healing, self-regulatory system that is our body. The body’s physiologic response harming these patients is actually the body trying to heal. The suboptimal healing is due to the injury and the body’s inadequate response.
If functionality can be improved and maintained while OMT alone has kept pain at bay (i.e., manageable), medication may be unnecessary. However, a patient should not suffer indefinitely when treatment options exist to improve quality of life. Moreover, we know physiologically via allostasis that hormonal dysregulation happens. However, what is lacking is an ability to effectively demonstrate what does and does not work. Quality measures exist to prove the efficacy of OMT with functional improvement and pain reduction. When DOs participate in measure tracking, treatment efficacy and cost effectiveness is objectively proven to payers. More importantly, awareness elevates for other providers who learn that non-pharmaceutical and other interventional options exist.
As osteopathic physicians, we are rooted in evaluating/treating the body, mind, and spirit. This patient used her mind and her spirit to will her body to recover. We must assess how best we can complement her determination and spirit to regain as much functionality as possible.
While the cure may not be possible, the fact that heroin and suicide were considered… even briefly… means we are not addressing her pain and functionality needs. Drugs or interventional procedures may not be what she wants, but the alternative being on heroin or suicide demonstrates the need for her medical team to do a better job. Direct conversations improve communication and open up treatment options allow for the type of holistic care that a Doctor still would want us to provide.