Complicated and Uncomplicated Chronic Pain

As 2021 comes to a close, we wish to summarize what we personally consider to be the

greatest issue in pain management. Physicians have observed for centuries that some chronic pain patients are not only more severe than others, but some have excruciating, constant pain that casts the poor suffering individual into a humbled, bed-bound state. Unfortunately, throughout the past half-century or so, many concerned parties, whether intentional or not, have tried to lump all chronic pain patients into one category and call them all persistent, or simply chronic. This has led to calls for “one size fits all treatment” and inflated statistical figures on the numbers of pain patients who need help (i.e., 50 million people).


THE REAL ISSUE


Chronic pain has traditionally been defined as pain that continues past the normal

healing time for an injury or disease, which is about ninety days. There has been no generally

accepted separate classification as to the severity, constancy, or periodicity of pain that lasts

longer than ninety days. Consequently, chronic pain surveys and statistics always include

persons with the common, mild to moderate painful afflictions such as bunions, carpal tunnel, fibromyalgia, headaches, TMJ, irritable bowel, back strains, plantar fasciitis, and mild

neuropathies and arthropathies.


Cries of undertreatment of these common chronic pain problems ring hollow since

every community has a plethora of medical practitioners, pharmacies, health food stores, and fitness centers that well tend to vast number of persons who have these common pain

problems. It may also be that all the recent lobbying and advocating for “chronic pain” doesn’t seem to connect with the “body politic” because the vast majority of chronic pain patients are getting good, adequate care in every community. This is not to say that treatment for their common, mild to moderate conditions can’t be improved, or that their treatment isn’t needed.


The real issue, however, is that there is a sub-set of chronic pain patients who develop

what can justifiably be called “complicated chronic pain.” Most have tried a plethora of

treatment options but are left with severe, constant pain that has a specific set of pathologic

complications. It is this group that is undertreated, poorly understood, and needs advocacy,

attention, and treatment for their “complicated chronic pain.”


THE COMPLICATIONS


The hallmark of complicated chronic pain is constant pain which is associated with

cardiovascular, metabolic, and hormonal abnormalities. Complications include hypertension,

tachycardia, glucose elevations (pre-diabetes, and diabetes), and adrenal-gonadal hormone

deficiencies including cortisol, estradiol, and testosterone among others. These complications can lead to heart attack, stroke, heart failure, autoimmunity, diabetes, obesity, depression, and dementia, among others.


THE PATHOLOGICAL TRANSFORMATION


Thanks to modern research and science, we now have a fundamental understanding of

why some unfortunate individuals transform from a mild, periodic, chronic pain, to a constant, ferocious, and disabling pain state. We now know that injured or diseased tissue from “whatever” initiating cause can generate bioelectricity that may enter the spinal cord and brain (the central nervous system CNS), create tissue destructive inflammation, and damage or “knock out” some critical tissue sites that normally eliminate or control pain. This development is now called “neuroinflammation.” The transformation process in now often called “centralization” or “central sensitization.” Some pain specialists like to call complicated chronic pain “neuropathic pain.”


WE NEED A NAME


A syndrome is a clinical state in which one pathologic defect causes multiple

abnormalities and symptoms. Hence, we recently began calling the complicated chronic pain state the “Intractable Pain Syndrome.” The term intractable was first used by British physicians in the last century who championed treatment of severe incurable pain. The term intractable is now used in some laws and is in popular use in some pain circles. There may be a better term than the “Intractable Pain Syndrome.” Maybe we should just call it “Complicated Chronic Pain.” Regardless, understanding that inflammation can develop in the CNS and cause complicated constant pain is essential, as these patients need a different treatment approach from the more common, uncomplicated chronic pain patient.


WAY FORWARD


Going forward into 2022, we define the Intractable Pain Syndrome as “an inflammatory

disorder of the central nervous system that causes constant severe pain and is associated with cardiovascular, metabolic, and hormonal complications.” Furthermore, we will advocate that this tragic syndrome be understood, and that its proper treatment demands not only symptomatic pain relief, but specific treatment of the disease that originated the syndrome, along with specific treatment of its complications.

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