Applied Evidence

A new paradigm for pain?

J Fam Pract. 2016 September;65(9):598-600,602-605

From The Journal of Family Practice | 2016;65(9):598-600,602-605.

References

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2. Markenson JA. Mechanisms of chronic pain. Am J Med. 1996;101:S6-S18.

3. Rainville P, Duncan GH, Price DD, et al. Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science. 1997;277:968-971.

4. Bushnell MC, Duncan GH. Sensory and affective aspects of pain perception: is medial thalamus restricted to emotional issues? Exp Brain Res. 1989;78:415-418.

5. Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale. Neurology. 1997;48:332-338.

6. Fassoulaki A, Triga A, Melemeni A, et al. Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer. Anesth Analg. 2005;101:1427-1432.

7. Woolf CJ, Chong MS. Preemptive analgesia—treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg. 1993;77:362-379.

8. International Association for the Study of Pain Web site. IASP Taxonomy. Available at: http://www.iasp-pain.org/Taxonomy. Accessed January 10, 2016.

9. Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine. 1980;5:117-125.

10. Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14:502-511.

11. Villemure C, Bushnell MC. Cognitive modulation of pain: how do attention and emotion influence pain processing? Pain. 2002;95:195-199.

12. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: implications for healthcare. In: Lanius R, Vermetten E, eds. The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Cambridge University Press; 2010. Available at: http://www.unnaturalcauses.org/assets/uploads/file/ACE%20Study-Lanius.pdf. Accessed January 11, 2016.

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14. Kross E, Berman MG, Mischel W, et al. Social rejection shares somatosensory representations with physical pain. Proc Natl Acad Sci. 2011;108:6270-6275.

15. Geuze E, Westenberg HGM, Jochims A, et al. Altered pain processing in veterans with posttraumatic stress disorder. Arch Gen Psychiatry. 2007;64:76-85.

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Implications for primary care

In our estimation, an evaluation of pain must be based on awareness of the signs and symptoms of all 3 mechanisms of pain perception: nociceptive tissue pathology, nerve injury that alters nervous system processing of sensory stimuli, and/or psychological injury that alters nervous system sensory processing. This approach opens up a whole new menu of treatment options and helps to demystify patients whom we previously regarded as difficult to understand and treat. No longer should we be stumped when we cannot find a traditional cause for pain (ie, tissue injury).

When screening in the primary care clinic reveals signs and symptoms of the third type of pain, the next step should be to look for the presence of psychologically traumatic experiences. Assessments of anxiety, depression, and developmental trauma¹³ should be added to the patient assessment. If pain due to psychological factors is identified, consider:

counseling
cognitive behavioral therapy
therapies such as eye movement desensitization reprocessing and somatic experiencing, both of which are already used to alleviate the stress associated with posttraumatic stress disorder
pharmacotherapy with a serotonin-norepinephrine reuptake inhibitor (SNRI), such as duloxetine or venlafaxine
hypnotherapy.

Reassurance goes a long way. Above all, when you are caring for someone who has pain without clear tissue pathology or who has recognized intensified emotional pain processing, reassure the person that the pain experience is not in his or her head, but rather in his or her nervous system. (See "Case study: Were psychological factors driving these symptoms?")

You can explain that research suggests that emotional, cognitive, or developmental factors may have affected the way his or her nervous system processes sensory information. Such discussions go a long way toward helping patients understand their experience, as well as feel validated. And that can lead to improved compliance with therapy going forward.

CORRESPONDENCE
Bennet Davis, MD, 2455 E. Miraval Primero, Tucson, AZ 85718; bdavis@ipcaz.org.