Yes, Yes, Yes!

Having longed for objective evaluation of pain, it is more than pleasing to see that the English are doing something about it. Someone call off the placebo dogs and bring on some help.

There are few more encouraging articles than the recent one by Schweinhardt et al in NMR Biomed. 2006 Sep 19;19(6):702-711.

Even as the “placebo/everyone is catastrophizing” crew is still churning out articles on the “weakness” of those with chronic pain, and the “obvious” psychological overlay, the MRI scientists at Oxford are approaching the problem rationally with functional MRI.

What is particularly encouraging is the shift in agenda. Whereas far too many of the prior “scientists” approached pain evaluation with a jaundiced eye toward the proposition that anyone is actually in severe pain, the Physiology Dept. at Oxford is assuming that many sufferers have been subjected to the “unnecessary exposure of patients to molecules with limited or no therapeutic value”. Hear! Hear!

At least we are in this much agreement with the placebo afficionados. Many of the so-called “pain drugs” are no better than placebos. Is this a condemnation of patients trying to get pain relief or is it a condemnation of drug companies who do imprecise testing? For some odd reason, pain is one area where double blind studies don’t seem to hold much appeal for manufacturers.

There is also the problem with testing and evaluation which appears to forget the essential differences between nociceptive (normal) and neuropathic (nerve injury) pain. For example, we cite the recent article from the Dept of Psychiatry at Johns Hopkins and the Psychology Dept at the Univ. of North Carolina (To be fair. pain clinics get sick and tired of people using pain to control their environment or to focus their anxieties–it really can get annoying, and this is what drives certain places to occasionally rush past the REAL cases of pain–the phrase “throwing out the baby with the bathwater” comes to mind).

Edwards et al in Clin J Pain. 2006 Oct;22(8):730-737 recently used questionnaires in healthy women and noted increased “temporal summation of thermal pain” in those who “catastrophized” their pain on the questionaire. This assumes however, that the questionnaire was worded correctly to avoid varied interpretation of what pain related words meant. Nevetheless, being aware of a fair proportion of pain patients who probably should not even be in the clinics, we extend to the researchers the possibility that their pain questionnaire was vocabulary neutral, even if such wording is very rare. (How do you ask if pain is severe, without some possibility of interpretive misunderstanding? A certain percentage of respondents will read the same words differently. School children getting shots and central pain patients will both think the pain really hurts, but they are a universe apart.)

What really sticks in the craw is the conclusions by the researchers, namely; “These preliminary findings highlight the importance of coping in shaping individuals’ responses to noxious stimuli, and suggest that interventions that decrease pain catastrophizing may reduce the burden of acute and chronic pain.” The central words in that sentence are “preliminary” and “may”. What does a central pain patient have in common with healthy young women, beyond Weir Mitchell’s statement that his bravest officer (after developing central pain from a bullet to the neck) developed the emotional temperament of a nervous young woman? To quote from “The Mosquito Coast”, “What I love about you people is your utter lack of presumption” (spoken sarcastically to tne self-righteous preacher who thinks he can speak for God).

How can questionnaires of any variety in 38 healthy young women establish that “interventions that decrease pain catastrophizing may reduce the burden of acute and chronic pain”. From what we can tell, the researchers were not even testing chronic pain and unless we are wrong about that, any extrapolations to this area are worth precisely nothing.

By comparison, what was interesting in the Schweinhardt study was the idea of pharmacologic functional MRI (phFMRI). The authors note that “The assessment of pain depends to date entirely on the subjective report of the patient, in contrast to many other clinical conditions where biomarkers that help determine the severity and stage of the disease enable the physician to monitor the course of the disease and treatment effects longitudinally.” Yes, Yes, Yes! We need OBJECTIVE data to spare the doctor, and especially to spare the bona fide pain patient, from all sorts of psychobabble and an endless goose chase of medicines, which may or may not objectively benefit pain.

As a solution to this problem, the Oxford team suggests that “Functional magnetic resonance imaging (FMRI) is particularly suited to investigating the effects of pharmacological agents on pain processing within the human central nervous system. Combination of FMRI and drug administration is termed pharmacological FMRI (phFMRI).”

Those with severe pain are just as sick of being accused of “catastrophizing” as pain clinics are of those who catastrophize. Better communication is needed, and if phFMRI can help alleviate some of the misunderstanding and eliminate the dross while finding the gold, nothing short of a cure could be better news for the severe central pain patient. We only hope phFMRI researchers know that any study of central pain must be done dynamically, ie. the central pain must be evoked DURING the fMRI, or it cannot yield a correct interpretation of what is severe pain and what is not.

It is not that we could not use some help from the psychiatrists/psychologists. We could. If they only knew. It is just that we are not convinced they know what they are doing in chronic pain without some means of objective evaluation. Without it, they overtreat the “crocks” and undertreat the valid cases of severe pain.

“Yes” to “biomarkers” of pain. “No” to opinionated guesses on whether we have it.

Catatrophize this! When all is said and done and after testing can finally measure pain, pain disparagers may find that not only was central pain not exaggerated, but that words themselves could not comprehend the agony. The skeptics may find that the difficulty was not in overstating but that the poverty of language prevented anything except understating burning dysesthesia.

One thing that for certain is not overstated is that this burning lasts forever, till the end of life, without surcease, without regard for our being human beings, without taking notice of our claim to being children of God. Scientists discover new species every day, both alive and extinct, but let us claim a new species of pain and their brittle brains, unable to stretch, shatter apart like glass. Let not those “experts” whose minds will stretch only so far and no further imagine that truth is bound by language already exant. They will be needing new words for as long as they live.