Daily Afflictions

The forecast calls for pain. — Robert Cray

Pain is a difficult topic to discuss with consensus. A primary manifestation of suffering is “the inexpressibility of pain,” as poetically characterized by Harvard University professor Elaine Scarry in her book The Body in Pain: The Making and Unmaking of the World. In moments of acute pain, language becomes a circumscribed tool for contemplation rather than an effective portal for communicating anguish. However, chronic pain can cast even the most articulate person into a state of laconic despondency, learned helplessness, and defeated apathy. The enthusiastic urge to survive pain can be discouraged by ineffective interventions, false promises, or negligence. Being alone and in pain is a nadir in the abyss of human misadventures. Suffering for a short period of time may lead to resilience, but long-term suffering alters neurophysiology and often leaves irreparable damage to our psychological well-being. Pain is a protective adaptation, but like long-term inflammation, what initially serves to protect the body can ultimately ravage the body.

And so the joke goes, how is your chronic pain? Oh, you know, it’s chronic. There is no easy way to ask someone how suffering feels, and there is no comprehensive way to describe suffering. Even more frustrating is the problem of convincing someone else that your suffering is real. After all, modern medicine remains in a state of relative infancy when it comes to fully understanding how nerves and muscles interact to produce neurophysiological devastation—let alone how to quantify levels of pain. Part of the problem in diagnosing and treating pain-related symptoms happens when physicians rely on a statistically significant regression toward the mean (symptoms usually get better on their own without intervention). Other issues can also complicate quality of care, such as somatoform disorders (presenting pain with no identified physical correlates) and the occasional factitious disorder (pretending to be in pain with ulterior motives). However, for those who are truly suffering but haven’t been clinically acknowledged or assuaged, feelings of being dismissed and shunned can almost be worse than the pain itself. Few care providers have the stamina or sustained interest to mitigate the immeasurable complaints that patients report on a daily basis, and palliative care is often better in principle than practice.

Some useful distinctions for describing the sensations of torment are acute versus chronic and manageable versus unbearable. Likewise, is the pain treatable, or is it unresponsive to intervention? Is the source of pain structural or peripheral? Most everyone knows that pain clinics are revolving doors for those who have unsuccessfully been able to find a “cure” for agonizing physical conditions. Managing pain can become a euphemism for excusing opioid dependence when nerve blocks and physical therapy are less than miraculous. If the recommended dose of painkillers represents an impotent gesture, inevitable acts of desperation can result in self-medicating the symptoms until a satisfactory level of oblivion has been achieved. Opioids and alcohol may work for acute pain, but they provide little relief (or make problems worse) when used to address prolonged pain. Subsequently, an inability to function due to pain becomes an inability to function indefinitely. Untreatable pain can cause mental health problems or exacerbate existing ones, and the learned helplessness of chronic pain may lead to severe depression or suicide. Wasted time and resources are spent searching for relief, and emotional vulnerability can be the gateway to credulity (i.e., “alternative” therapies).

Having endured a craniomandibular condition for more than twenty years, I feel my apprenticeship in the pain game has a marginal splash of credibility. Nonetheless, no one should be so presumptuous as to qualitatively compare types of pain or assert preeminence in the trenches of misery. However, I can say that remaining emotionally centered and sociable in the grip of physical anguish can be an insurmountable task. Triggers for irritation present themselves like an all-encompassing trip wire, and no one generally wants to invite the perennially dispirited to elaborate dinner parties (or any parties). Pain is not pretty, and it’s not considered polite. People are conditioned to move toward positive reinforcement and reminders of misfortune tend to interfere with festivities. The legacy of lifelong pain is inevitable isolation.

From a psychotherapeutic perspective, adapting to some types of pain can be as simple as unsentimental acceptance. Contrary to assumptions, impulsive attempts to reduce pain can paradoxically increase pain when the associated anxiety intensifies one’s awareness of suffering. Distraction and sublimation can also be effective techniques for reducing the tyranny of persistent discomfort. For example, focusing on something pleasurable or engaging in something productive can diminish the impact of perpetual distress. Becoming an “observer” of pain through mindfulness is another approach to keep your uneasiness from transforming into an overwhelming hostage situation. Likewise, noticing pain but refusing to become reactive is how one might establish a reasonable threshold of tolerance (i.e., you can have pain, but pain can’t have you).

As troubling as it is to contemplate the varieties of painful experience, there may be a few promising advances in treatment along the rocky overhangs. Several universities, including Trinity College Dublin, have recently studied a molecule known as MCC950 that’s capable of suppressing a key gene responsible for initiating the body’s inflammatory response.¹ In addition, MCC950 would be cheaper to produce than current protein-based treatments and does not include associated side-effects. This molecule would also have a shorter duration effect to reduce interference with the body’s natural immune response during infection.

Other possibilities for future pain management include interrupting pain receptor synthesis with an antibiotic called anisomycin. Pain and memory receptors appear to use similar mechanisms in the brain. Anisomycin has the capacity to turn off pain-amplifying signals in the spinal cord, thereby reducing hypersensitivity to pain producing stimuli. As a result, the physiological memory of pain is attenuated or erased. Of course, much more testing needs to be done before clinical trials will be initiated.

Whatever can’t be said about pain, much more needs to be said about how to alleviate it. To live without excessive suffering makes all the difference between endurable existence and optimum living.

1. A small-molecule inhibitor of the NLRP3 inflammasome for the treatment of inflammatory diseases. Nature Medicine, 2015, DOI: doi:10.1038/nm.3806

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