The Acute and Chronic Pain Are Two Different Phenomena
Dedicated to the 33 years old man who told me about opioids: “Doctor, this drug cut-off my head, not the pain in the knee… Should I take it livelong?”
THE ACUTE AND CHRONIC PAIN ARE TWO DIFFERENT PHENOMENA /resume/
Bogdan Rouytchev, MD, Private Pain Clinic, Sofia, Bulgaria
5th NATIONAL CONFERENCE FOR THE TREATMENT OF PAIN
WITH INTERNATIONAL PARTICIPATION, Veliko Tarnovo, Bulgaria, 03-05.06.2010
The experience of the Pain Management Clinics in the last few decades raises a number of questions and debates. The following resume is an extrapolation of the experience, gathered through our Pain Clinic during the last 5 years, with references to the general clinical literature and theory. The formation of “Chronic Pain Management” as a separate discipline is an evolution in the modern medicine, comparable only to the one caused by the separation of Anesthesiology and Reanimation from the broader field of Surgery, more than half a century ago. It is now clear that, on the one hand, this separation raised Surgery to unbelievable heights, while on the other hand laid the foundations of the modern Intensive Care. It seems that at present a modernization of the Chronic Medicine as a whole is required, moving it from the technological to the moreover biological and holistic approaches. It is well known that acute pain (trauma, operation, etc.) is stress-related; it alarms the body of potential external threats in the presence of normal internal homeostasis. In acute pain the opioids serve as mediators and cease the production of stress-hormones or simply cut-off the information about the particular event, thus preserving the homeostasis of the individual. Chronic pain, on the other hand, is itself caused by distress and signifies broken homeostasis. This explains why opioids are ineffective in pains related to degenerative processes and why blocking information in the central nervous system therefore does not solve the problem. The difference between the two is simple – time. The realization of “chronos” and of life, as such, is a neuro-psychological process. Therefore, the “anaesthesia” of this process “amputates” certain periods of time from the consciousness. But neither life in an induced coma, nor a lifelong neuro-block is a feasible solution in chronic pain. What’s more – chronic pain stems out of systems much older, in evolutionary terms, than the nervous one, such as the humoral system and most importantly – the Bonghan channels. This explains the positive effect of Aspirin and the other NSAID here, as well as the overall higher success rate of alternative holistic methods, which target the simultaneous effect on the body, psyche and organism of the “individual”.
Figure 1. A stereomicroscopic image of the lymphatic vessel around the caudal vena cava of a rat. The photograph (left) and its illustration (right) show the novel threadlike structure (solid arrow) that passes throw the lymphatic valve (open arrow). The photograph was taken in vivo and in situ, and a piece of black paper was put under the lymphatic vessel to exhibit the target clearly. The scale bar is 100 mm. MORE
ACUTE AND CHRONIC PAIN – TWO DIFFERENT PHENOMENA Dr. Bogdan Rouytchev, Pain Clinic, Sofia
In the last decades, the establishment of specialized pain clinics led to the accumulation of a new clinical experience and observations requiring new theoretical framework to explain the phenomenon of pain. The present overview summarizes the five years of work at the Chronic Pains Clinic, which was founded at the University Hospital St Anna in Sofia but has become an independent clinic in the last two years. More than 930 files of patients with various neurological, muscular-skeletal and psycho-traumatic chronic pains have been analyzed in the light of both classic and modern theories of pain. Different treatments have been applied: anesthesiological, pharmaceutical, meditative, Qigong therapy and several types of holistic acupuncture following the rules of the traditional Chinese medicine. In more than 60% of the cases an average healing effect in several months to a couple of years was achieved. Unfortunately, the lack of general medical theory seriously undermines distinguishing between clear functionality levels in the systemic approach to and analysis of the phenomenon of pain. This creates contradictions among different medical specialties which often are distant and disconnected. As it is well known, the very existence of specialists in pain management is still contested and even undermined by many medical doctors who are trying to reduce the pain to mere symptoms of a disease. However, here comes the great contribution of the American anesthesiologist Dr. John Bonica who in the 1950’s pulled together a team of various experts to work on the chronic problem of ‘pain’ in every individual case regardless of the patient’s disease causing the pain. This focus on the ‘pain’ as a phenomenon gradually started changing the world’s view on conventional medicine as a whole by reclaiming the integrity of the suffering individual as opposed to breaking him down to objects of different ‘specialties’ in groups of nosological units. In the same way, the group of specialists – orthopedist, specialist in internal diseases, psychiatrist, etc. – gradually started being replaced by just one specialist in pain, most often anesthesiologist further specialized in treatment of chronic pain. Moreover, by putting pain management in the center of attention, we become obliged to disregard the relative boundaries not only between different medical specialties but also between different Medicines known to humankind. In other words, we have to take into account the possibility for integration between the Classic Western and Traditional Eastern medicines as far as the understanding and treatment of pain are concerned. Before I proceed with presenting the main theses of this overview, I only have to say that the author of this overview has followed the clinical and exploratory journey of a medical doctor with the profile described above – one who has become an expert in Pain management through 30 years of anesthesiological practice in management of surgical, labour and traumatic pain, 15 years of parallel further qualification in Pain management and traditional Chinese medicine as well as 5 years of chronic Pain management.
DEFINITION OF PAIN:
“subjective sensory sensation and emotional experience related to the existence of consciousness capable of identifying the stimulus as unpleasant”.
MY OWN THESIS
– acute and chronic pain have two completely different natures: i.e. biological expedience, reasons for its occurrence, mediators, impact on the individual and therefore different ways to stop them.
Generally speaking, these are traumatic and degenerative pain.
ACUTE PAIN is a warning of a sudden danger whose purpose is to preserve the integrity and homeostasis of individual/body, organism and psyche/personality. Most often acute pain is external, and much more rarely internal such as in case of rupture of a blood vessel/an organ or embolic vessel occlusion. In any case it is a sensory signal for an occurrence that causes stress and is experienced as painful. From the perspective of Hans Selye’s theory of stress, an individual faces an instant choice between flight, fight or freeze (surrender, as the only option for self-preservation). This sensory signal is caused by trauma – an acute disruption of tissue integrity – and triggers release of the well known catecholamines, corticosteroids, glucose , coagulation factors, etc. The body and psyche are ready to fight or flight in order to adapt. All strengths and reserves of an organism are mobilized in order to cope as quickly as possible with the challenge and move to a safe place where finally to stop bleeding and start the processes of regeneration. Only in that moment the organism could retreat by triggering feedback signals to the stress – endorphins. Of course, this is what happens in case of a successful outcome (stress management – adaptation). Failure to the challenge may mean death or continuing suffering – distress in Selye’s terms.
ACUTE PAIN MANAGEMENT therefore has to relief the stress and makes the individual adapt. This could happen through a controlled switching off consciousness, local (spinal, epidural, regional)sensory blockage or sedative medication. In any case the use of opiates is effective because it is NATURAL and stops the stress factor. Thus it maintains the homeostasis by preserving the individual’s reserves. It must be noted that pain management through hypnosis is a type of controlled consciousness alteration, and pain management through acupuncture in cases of chronic pain works also through the natural endorphins, i.e. we think that by their nature the opioids act as a feedback signal and stop the production of stress hormones, which leads to general retreat and calls off the mobilization in order to ensure an opportunity for regeneration. Chronic pain including the surgical pain in cases of organ transplantation could be fully controlled and individual’s homeostasis maintained.
CHRONIC PAIN in itself is caused by distress and indicates a homeostasis that has been misbalanced for a long time. This is already another ground. Generally, in both cases pain is transmission of information. It must reflect the occurrence, the location of its impact, perspectives for its development, and perspectives for the individual’s behavior. Apparently the triggering factor should be harm-causing for the phenomenon to occur – nociceptive. In one of the cases though the occurrences is sudden and triggers general stress whereas in the other one it happens more gradually, unclearly and brings tormenting feelings – distress. Here the harm is rather a process than an incident. The harm-causing factor is most often an internal one – degenerative, or a former external one which has filtered gradually and without being noticed in the process of unsuccessful coping with the stress. Moreover, the degeneration and anxiety do not precede but follow the phenomenon. In chronic pain, we have to convince ourselves that there is distress to get stressed about … It is curios that in acute pain the anxiety goes away when the boundaries of the occurrence are set up – and it is left in the past! Whereas in the chronic pain, it is namely the repetitiveness of the discomfort that builds up the individual’s anxiety about the future. The two pains are based on opposite subjective viewpoints on the one-direction axis of time. The big question is what is the purpose for the individual of this chronic warning? The biological meaning of acute pain warning is clear: warning – reaction – adaptation of the individual which leads to preservation of the individual’s life and of the species. Where we could look for protective ‘salvation’ in the chronic pain, what it is supposed to protect us from? The answer to this question will determine the principle of its management.
We assume that there is an obvious difference in the biological purpose of the two types of information: avoiding severe danger (immediately!) in the case of the acute pain and becoming aware of the chronic danger in the case of chronic pain.
Let’s not forget that Hans Selye’s theory of stress adaptation syndrome is strong because as a genuine natural principle it is valid for every level of interaction between the ‘self-organizing system and environment’. In other words, coming from macro to micro scale, the stress principle is valid equally at inter-individual and individual level, at the level of organs and tissues, as well as the cell level. Recently, some reports suggest speaking about the equivalent of ‘emotion’ also at molecular level, which only confirms the possibility for ‘stress-adaptation’ at sub-cellular level. At each separate level though, stress is expressed through different manifestations and mediators. Therefore, there are too many possibilities for internal stress – in the body or just in a separate part in an organ, or even in a tissue – for example, cartilaginous. During prolonged exposure to stress without any possibility for adaptation, a cartilaginous part could not regenerate, will fall in distress and degenerate. The individual perceives this as a discomfort and gradually occurring, un-localized pain. The local cells suffer or even slowly die. However, this does not include stress reaction in the macro-organism of the type ‘hypothalamus – hypophysis – corticotropin-releasing factor’, but rather a local stress reaction of the type fluid retention, release of toxins, and non-infectious inflammation. This hypothesis explains well the observed insufficient effectiveness of opiates such as analgesic agents because their anti-stress level in that case is not necessary. And the other way round: the hypothesis of a local stress explains the important anesthetic effect of NSAIDs such as acetysal /Aspirin/ and analgin /Metamizole/, which has slightly stronger impact on tissue level. However, unfortunately so far the hypothesis does not answer to the question of the very biological purpose of the chronic pain. Why the individual should suffer anxious torments, if he does not have a chance to correct his behavior? Or maybe he has one?
We have to accept that unlike the acute pain when the individual adapts to the external environment, here he is forced to adapt in the opposite direction – to the internal environment. Probably the purpose of this pain is for the individual to start asking himself the question:”What’s going on?” And with repetitive irritation he is being reminded that he has to look for the true answer by adapting his behavior – activity-rest, mobility-immobility, nutrition-fasting, communication-isolation, etc. He strives to find the right way away from the suffering. Apparently, there is a hidden, more personal reason which should be discovered by doctor and patient. Whereas the purpose of the acute pain is to get answer to the question “What do I do? , the chronic pain prompts the question ”What do I do wrong?” And more back in time is the beginning of this wrong behavior, more difficult it is to identify the diversion from the right path. However, the practice teaches that until what needs to be corrected is corrected – a movement of the muscles, posture, emotion or a complex habit which causes the stress over this particular cartilaginous part – no opiates will help. Moreover, in general the blockage of the information in the nervous system does not resolve this issue. There is a simple reason and it is called ‘time’. Becoming aware of life as such is a nervous-psychological process which runs in parallel to ‘Chronos’ and by it. In other words, the information flows ONLY in parallel to the axis of time! „Anesthesia” as a blockage of such a process would mean „amputation”of awareness in certain periods of time. But neither a life in induced coma, nor a lifelong nervous block could be a choice of treatment for chronic pain. The process is distressful and to be reversed it requires change in the individual’s life and hopefully there will still be some space for regeneration…
Therefore, the SIMULTANEOUS influence over the physical body, organism and psyche which is applied by alternative and holistic treatment methods in pain clinics is more causal and leads to much better results compared to the treatment with opiates…
If we name these reasoning „Clinical Philosophy of Pain”, it means we have just formulated a principle to distinguish between the two pains. However, when the science of Philosophy formulates correctly a principle, it must be valid for the same matter also in the distinct sciences. In the specific case, neither histochemistry through looking for new receptors, not pharmacochemistry through looking for new molecules able to affect the central nervous system could change the principle of chronic pain management. The clinical practice confirms that in that case there is another level of stress in the individual, i.e. it would be much more prosperous to look for data in the direction of tissue anti-stressors and accelerators of regeneration. But for the current hypothesis to be fully truthful, it needs to answer to two more questions:
- How acupuncture, which as we mentioned before, removes acute pain exactly by releasing endorphins, could remove also the chronic pain? Today it is considered that most probably the effect of acupuncture is based on a system which is evolutionary much older than the nervous system and even older than the blood-humoral system and the release of endorphins is just one of its effects when removing acute pain. We are talking about the amazing signal system of the Bonghan channels that was described three years ago, which are considered to be the anatomical substrate of the acupuncture channels. This system probably begins with the first division of the fertilized egg and formation of the first ‘channel’ between the two daughter cells. With the next divisions the channels develop a complex net throughout which run space-and-time-bound impulses, including throughout the whole life cycle of an adult individual. They pass signals for regeneration or development to every single part of the body and each single tissue. The system was discovered in 1960’s and re-discovered just recently thanks to the nanotechnologies. The most amazing is that these micro-fibers situated in the lymph vessels throughout which, it is proven, could run also optic signals, when colored in certain way, react as DNA-carriers… This theme is colossal and extremely revolutionary for the medicine as a whole, but in that case it only confirms the understanding of Eastern medicine about chronic pain and explains its successful management through its means.
The second concluding question to the hypothesis is the following:
- Is it possible “a correction of individual” in cases of cancer patients? The answer is undoubtedly connected again to the changes at cellular level. No case of regeneration of cancer tissue back to healthy tissue is known. As far as pain is concerned, the axis of time is also valid here, moreover two different “paces” of its unrolling are possible As far as one of the theories of cancer says, some of the individual cells switch to life “in another time”, i.e. live at a different pace, divide themselves at a different pace and therefore grow quickly in a tumor against the neighboring “normal” cells. Note this isolated case – it is not known whether the cancer pains are: 1) caused by the tumor itself, 2) a result of the treatment or 3) caused by other, unknown reason? In case there had been no infiltration of external stress, it had happened through the innermost of the organisms – the nucleus of the cell. All surrounding tissues are under stress without any chance for adaptation – in this case the individual’s homeostasis is passed “internally and by constitution”. Therefore we speak about palliative patient care which brings pain management closer to the level of a life-long nervous block, „life in an induced coma” and all forms of „amputation” of consciousness and time. However, what is amputated unfortunately is the time of the normal cells to the level of partial euthanasia such as alcoholisation of parts of the spinal cord for example, or as known, in some countries there could be final euthanasia…
In conclusion: There was a case in which the patient died of pancreatic cancer. While we kept her pain under control at her insistence till the last month and week with moxa (following the rules of the Eastern medicine), a huge degenerative wound in her leg healed before she died. The homeostasis of the macro-organism remained out of control but the local distress was removed…
An option seemingly opposite to the presented thesis which actually only confirms the philosophy of it.
Selye, Hans – Stress Without Distress, School Guidance Worker, 32, 5, 5-13, May 77
Ханс Селие, Стрес без дистрес, София, 1982 г.,НИ
Definition of Pain, 24 August 2005, NewScientist.com news service. Original review: Science & Consciousness, September 3, 2005
Maurice Mussat Dr. – Physique de l’acupuncture. Hypothèses et approches expérimentales – LIBRAIRIE LE FRANCOIS, Paris – 1972Manaka Y, Itaya K, Birch S. (1995). Chasing the Dragon’s Tail, Brookline, Paradigm Publications. … 2. Who Can Ride the Dragon, Paradigm Publications, 1999
Shang Charles, Boston University School of Medicine: The Meridian System and the Mechanism of Acupuncture/ Morphogenesis an d the meridian system/.
David Milbradt, Lac, Bonghan Channels in Acupuncture, Acupuncture Today April, 2009, Vol. 10, Issue 04
CANCER PAIN – 4th World Congress on Pain, Budapest, workshop outline