The third kind of pain

By DR. VICTOR S. SIERPINA

The most common complaint in primary care practice is pain. Did you know there are several kinds of pain? From the time we were children, we learned the first kind of pain that is nociceptive pain. This is produced by tissue damage. It can be like a diaper pin stick (remember diapers that needed pins?), burn, cut, fracture, inflammation, or colicky pressure in our gut. “Ouch!” we cried as kids, with tears as such noxious stimuli damaged us and we searched for comfort, a hug, a kiss, a Band-Aid.

Another kind of pain is neuropathic pain resulting from changes to the function of the nervous system and injury to the nerves. These nerves remain hyper-sensitized to pain that can become permanent. Chemotherapy or diabetes are the most common causes of neuropathic pain. Other causes include shingles, trauma such as amputation and poor circulation. Neuropathic pain may develop over months and years and can be irreversible. Treatment is different from nociceptive pain and can include drugs usually used as anticonvulsants such a gabapentin. Other integrative options to consider are acupuncture, curcumin, fish oil, alpha-lipoic acid, acetyl-L-carnitine and high dose B100 or B50 multivitamins.

The third kind of pain is a result of changes occurring in the brain itself. This is real pain and is strongly influenced by psychological trauma and emotion. This pain isn’t just “in the head,” but is rooted in functional changes in the nervous system analogous to neuropathic pain. When I was in medical school, the microglia or connective tissue in the brain was thought to be just a structural element holding the neurons. Newer discoveries however have established that in the so-called central sensitization syndrome these anatomical components become activated and result in inflammation and chemical changes in the brain. This often accounts for white spots on MRI. Not only chronic pain, but depression, fibromyalgia, irritable bowel syndrome, interstitial cystitis, chronic fatigue syndrome, sleep disturbances and restless leg syndrome are all thought to be mediated by this mechanism.

Childhood trauma significantly influences how adults experience pain. Women are 50 percent more likely than men to experience chronic, nonmalignant pain syndromes. They frequently experience more adverse childhood traumas like abuse and sexual assault.

Infectious causes such as Lyme disease, mononucleosis, cytomegalovirus, parasites, as well as heavy metal toxicity, biotoxins, some medications, autoimmune disease, sleep apnea, circadian rhythms disorders, thyroid disease and metabolic syndrome have also been implicated in the development of central sensitization syndrome and subsequent chronic pain.

The usual pain medications are of limited benefit for this third kind of pain. Opioids can actually increase activation of the microglia and worsen the situation. Effective therapeutic options include counseling, cognitive behavioral therapy, eye movement desensitization reprocessing, hypnotherapy, meditation, mindfulness, exercise, nutrition, optimizing sleep, acupuncture, aquatherapy, tai chi, yoga, and physical therapy. Antidepressant medications may also be helpful and perhaps other medications to down-regulate the activated microglia by decreasing brain inflammation.

So no, your chronic pain is not just “in your head.” It may well be a result of changes in your brain. Discuss this with your health care provider. You may have more options than you knew.

Dr. Victor S. Sierpina is the WD and Laura Nell Nicholson Family Professor of Integrative Medicine and Professor of Family Medicine at UTMB.