CHRONIC INTRACTABLE PAIN

Chronic intractable pain is best thought of as chronic pain that has no significant chance of being altered by usual treatment modalities or natural healing. This is pain that often has been amplified by the severity of pain signals reaching the Central Nervous System and causing a wind-up phenomenon at the Dorsal Horn of the Spinal Cord. It may even involve rapid depolarization and ectopy at the site of injury or the cell bodies in the Dorsal Root Ganglia. There may be sympathetic coupling, Limbic Kindling, or other forms of Central Sensitization happening. Finally depression or other psychogenic factors may also be involved in pain increases.

The result is pain that is physiologically amplified and often psychologically augmented. The patient experiences pain that feels overwhelming and represents an unwelcome change in life. Too often these patients are told by their physicians that there is nothing left to treat and they must learn to live with their pain. The truth is that there is almost always more that can be done if pain is treated as one of the presenting illnesses. It may be that the treating doctor has run out of options, but most often there are available pain specialists, who can work with the treating physician to improve the patient's pain control. Living with intractable pain is certainly a tough task for the patient to manage, but it is easier to do in the face of ongoing treatment planning aimed at decreasing the amount of pain that must be accommodated.

In treating intractable pain, the pain should be broken down into its various components. There are many schemata for classifying pain. We prefer to look at it in the following way:

Nociceptive Pain
Inflammatory Pain
Muscle Spasm Pain
Neuropathic Pain
Central Pain
Wind-up Pain

In managing all of the types of chronic intractable pain present in any one patient, we are best able to help that patient to make the most adaptive adjustments possible in the realm of the biological, psychological and social cascades that cause increased and relentless pain. Treatment should start with a clinical understanding of each type of pain and where it may be playing a role in our patients' discomfort. Since so many patients present to their primary care physicians with symptoms of pain, it is important to try to prevent acute pain from advancing to chronic pain. Additionally, most chronic pain can be effectively treated by primary treaters. In cases of truly intractable chronic pain, the primary treating physician should make use of pain specialists to add modalities of treatments, such as spinal blocks, complex pharmacological combinations, pain based psychotherapy and psychopharmacology, implantable devices and structural and ablative surgeries. It is critical for primary care physicians to direct the treatment of their patients with chronic intractable pain, because the day to day management will usually return to them, even if they have referred the patient to specialists.