[UPDATED JULY 2023]
Although pain seems like "a pain", actually it is essential for our survival. Pain protects us from ourselves. It prevents us from damaging our bodies. Indeed people who are born with no pain perception look as if they have been traumatised! They are covered in cuts, bruises, sores, because they do not realise that they are damaging themselves. Pain is the local method of avoiding damage – it makes us protect the effected part of the body and makes us keep it still so that healing and repair can take place. If pain becomes more generalised then pain is accompanied by fatigue. What this means is that chronic pain and chronic fatigue go hand in hand and therefore so did the treatment. We learn through experience what is painful, this makes us avoid those painful experiences and therefore protects our bodies. Although it is desirable to learn about pain, this can also cause problems because if the underlying causes of the pain are not identified we "learn" more pain.
In the ideal situation we damage our bodies with say a cut or bruise, the local pain makes us care for that damaged area by protecting it and keeping it still so that healing and repair can take place. With healing the pain goes.
What happens if the pain does not go?
If the root source of the pain is not identified it creates a problem because then the pain increases. The body naturally thinks that increasing pain means we will take more care, identify the source of the pain, keep the limb more still and therefore the body winds up the pain signal to try to elicit the appropriate response. Effectively we learn to feel more pain because there is an upgrading of this pain response. This is not a psychological effect – this actually occurs within the cells themselves.
This makes it very important to identify causes of pain and allow time for healing and repair, otherwise the pain will get worse.
Sleep, Pain and Pleasure
The best time for healing and repair occurs during sleep. If we lose sleep we are slow to repair. Furthermore we cannot make many of the hormones and neurotransmitters which down-regulate pain. These include dopamine and opiates. Dopamine and opiates are a central part of the pain and pleasure reward system. The two things go together creating evolutionary drives which direct us to act in the right direction. So for example when we need food we get a hunger pain and that hunger pain is satisfied by eating, which give us pleasure. If we lost these associations we would quickly die from anorexia! Indeed all the actions that we take to ensure our survival are driven by this pain-pleasure axis. Pain is driven by dopamine – dopamine drives us to initiate things and make things happen and the reward is a release of our endogenous opiates or endorphins. So, for example, a young man who wishes to procreate his genes will suffer all the pains of courtship, but will be rewarded by endorphins when he finally jumps into bed with his beloved!
The problem for many physicians is that most people with chronic pain present some way down the line with learned responses well established. Often by the time they get to see doctors they have a learned pain response, their pain threshold is low, chronic pain is associated with chronic fatigue, sleep is disturbed and this compounds all the above problems.
Treatment of chronic pain
Try to identify the causes of the pain
This is where investigations such as MRI scans can be very useful. A major cause of many pains comes from the diet either through allergies, pro-inflammatory effects of sugar and refined carbohydrate, toxic load from too much food, toxic load from social drugs (caffeine, alcohol) or prescription medication.
Finding the cause is important for very obvious reasons. Many people are tempted to use painkillers, but the problem here is that although these work fine in the short term, in the long term the body adapts to these painkillers and they become ineffective.
Always think total load – local triggers plus dietary triggers can amount to an intolerable situation!
Identify useless inflammations and remedy them
Pain almost invariably is accompanied by healing and repair and this involves inflammation. A certain amount of inflammation of course is essential, but too much becomes destructive. Inflammations from allergy or auto-immunity are useless inflammations. Inflammation, like pain, can also become a learned effect and become self-perpetuating. Central to this is the ONOO cycle, which is well described by Professor Martin Pall in which there is a vicious positive feedback mechanism which winds up inflammation. See Inflammation. Think of:
- Essential fatty acids. See VegEPA for more detail.
- Vitamin D – vitamin D is the sunshine vitamin and made as a result of the action of ultraviolet light on skin. Sunshine is pro-inflammatory and to mitigate this the body has evolved a system of making vitamin D, which is anti-inflammatory. Humans evolved running naked under the African sunshine getting lots of vitamin D – it diffuses from the skin to the rest of the body where it has a generalised anti-inflammatory effect. The further away from the Equator one lives, the more diseases one sees associated with inflammation such as autoimmunity, allergies, multiple sclerosis, heart disease, cancer and so on.
- Vitamin B12 – this has a marked down regulating effect on the ONOO cycle because it mops up peroxynitrite, a free radical resulting from superoxide dismutase and nitric oxide combining. The central player in Pall’s ONOO cycle is NMDA – a receptor which stimulates inflammation. See B12 - rationale for using vitamin B12 in CFS for more detail.
- Antioxidants – much inflammation is caused by free radicals and having good antioxidant status will help protect against this. See Antioxidants
- Foods and diet – western diets are pro-inflammatory. Humans can eat a wider variety of food than any other animal and this is because they have amazing ability to detoxify foods via the P450 enzyme detox system. If this system does not work efficiently then foods and other chemicals instead of being detoxified generate free radicals and this can be highly damaging and pro-inflammatory. See The Paleo Ketogenic Diet - this is a diet which we all should follow.
Tweak neurotransmitter and hormone levels in order to increase pain thresholds
See Edge effect. As we age, our ability to produce neurotransmitters which guide and shape our behaviour declines. There are many things we can do to boost endogenous production of neurotransmitters and therefore increase pain threshold. This is covered at length in Eric Braverman’s book "The Edge Effect", but a few examples are given below.
- Acetylcholine – increasing levels of acetylcholine is probably the mechanism by which anticholinergic antidepressants help pain. A small dose of amitiptyline at night for example can be a useful pain killer.
- GABA – this is the main neurotransmitter which tells us to chill out – the main drugs which work on this are benzodiazepines and gabapentin. However, we can increase our own production – green tea contains theanine an amino acid, which stimulates GABA production. Meditation is also known to increase GABA levels.
- Dopamine – dopamine is the neurotransmitter which allows us to anticipate a reward. The sensation of reward comes from endogenous opiates. So exercise and sexual activity are obvious examples – with exercise there is obviously a pain to be experienced in running, but once one has got over a certain threshold we then get the opiate buzz. Caffeine stimulates dopamine release and is often helpful in pain relief. Adrenalin (and noradrenalin) form downstream from dopamine – they accumulate in the adrenal gland during sleep and are released in pulses to help us cope with stress during the day – no sleep and no adrenalin, so poor stress tolerance!
- Serotonin – levels are increased by full spectrum light and sunshine, together with aerobic exercise and increasing muscle strength. Keeping fit is good for our neurotransmitters and our pain thresholds. Chocolate (not with the milk and sugar bits!) raises serotonin levels.
- Low dose naltrexone – is a technique of proven value to increase brain production of our own opiates endorphines. See Low dose naltrexone
- Minerals – broadly speaking sodium and calcium excites nerves and muscles whereas magnesium and potassium relaxes them and switches them off - so one would expect the latter two to reduce pain thresholds. This is certainly my clinical experience. Magnesium has been dubbed "Nature's tranquillizer". See Magnesium - treating a deficiency. Potassium is abundant in vegetables, nuts and seeds and there is good reason to eat these foods daily.
- Electrical techniques – these undoubtedly have an effect on neurotransmitter levels. There are many available – acupuncture is an obvious example, as indeed are TENS machine.
Interestingly an alkali environment in the blood switches nerves off whilst an acid environment switches them on. Indeed, it is possibly this that drives hyperventilation – when we hyperventilate there is a temporary alkalinisation of the blood. However, this is not sustained because the kidney quickly compensates by excreting bicarbonate. See Acid-Alkali balance
Without good quality sleep and enough of it, all the above interventions will not work well. See Sleep is vital for good health - especially in CFS. Sleep is disturbed by pain and if this is the case then some sort of pain killing drug may be necessary to allow sleep. If the pain killers alone are insufficient then sleep tablets such as benzodiazepines should be used.
Improve energy supply
Many people can distract themselves from their pain but only if they have the energy to do so. Chronic pain and chronic fatigue go together – help one and you will help the other. Many of the treatments for both are the same! Do my work up for CFS paying particular attention to the mitochondrial package. See CFS - the central cause: mitochondrial failure.
When things get complicated, it is often almost impossible to tease apart the threads of chronic pain, chronic fatigue and inflammation and it is the combined approach that gets the results.
- Vitamin D
- Edge effect
- Low dose naltrexone
- Magnesium - treating a deficiency
- Sleep is vital for good health - especially in CFS
- CFS - the central cause: mitochondrial failure
- B12 - rationale for using vitamin B12 in CFS
- The Paleo Ketogenic Diet - this is a diet which we all should follow
- Acid-Alkali balance
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