Is RA Pain "Chronic Pain?"
Chronic pain: more complicated than it's definiion
The recent, ongoing crackdown by the U.S. government on opioids to treat chronic pain is a direct result of that definition. Since signals from nerves surrounding an injury travel to the brain, which in turn makes the injured person “feel” pain, once an injury heals, it can no longer cause “real” pain.
That makes sense on the surface, but the problem of chronic pain is far more complicated than that. For instance, this theory about pain ignores pain caused by ongoing disease, the kind that presents as “chronic pain” but is actually chronic acute (temporary) pain caused by the disease itself, such as RD.
So, why are we treating these very different types of chronic pain as if they were the same? Maybe because it’s easier.
The neuroscience behind chronic pain
Here's what I've been learning in the Therapeutic Neuroscience Education class I took recently: All pain comes from the brain. This is true: the sensation you experience when you stub your toe doesn’t come from the suddenly damaged tissues themselves. It’s caused when the nerves within those damaged, outraged tissues zing emergency signals up the spine to the brain, hollering at it to do something—now!—about the situation. The result? You bark “Ow!,” cuss, and hop around until your toe finally calms down.
Makes good, scientific sense to me.
TNE says that chronic pain, however, is what happens when (and no one knows why) the nerves around an injury become hypersensitive/hyperactive. Instead of calming down once the tissue heals, they continue to send panic signals to the brain. Even small sensations—a light touch, or the soft scrape of clothing over the area—may feel like severe pain. An example might be someone who develops fibromyalgia or someone who injures their back but keeps on hurting long after they’ve healed.
TNE theorizes that opioid pain relievers, which work in the brain, not in the tissues, may work well to relieve the acute pain of severe injuries, like broken bones and deep tissue wounds. But, the thinking goes, once the injury is healing, the pain signals from the nerves to the brain lessen—and so does the need for such powerful analgesics. And although using opioids even after the tissues heal might seem to relieve “phantom” pain caused by those now hyperactive nerves, doing so becomes dangerous. They put the person using them at risk for opioid dependence, addiction, opioid-induced hyperalgesia (increased “pain” from confused pain receptors in the brain), dangerously increased dosages of the drug, problems from side-effects, and maybe even death by overdose.
For this reason, practitioners touting TNE feel that using safe, alternative pain management techniques like mindfulness, meditation, cognitive behavioral therapy, TENS units, physical therapy, exercise, nutrition, and mental health counseling are better than prescribing opioids. These can help to relieve (if not necessarily eradicate) pain that’s generated by overactive nerves and the brain, not by long-healed tissues.
Sounds good, as far as it goes.
RA pain is a different kind of chronic pain
But RD pain, caused as it is by disease-activity-induced inflammation, is different. RD pain comes and goes, a phenomenon called a “flare.” Sometimes it lasts only for a few hours, sometimes for a few days, and sometimes for weeks or even months. It might be mild one day and severe the next, while the day after that, there’s no pain at all. During flares, the nerves within the inflamed tissues in and around the joints send the same kind of panicked distress signals to the brain that they would if the tissues were injured: Fix this! Do something right now! The brain responds with pain that presents just the same way acute pain does—because it is acute pain. Opioids relieve some of this pain quickly and efficiently, just as it does with pain caused by a broken bone or a deep tissue injury.
Imagine a doctor telling you that you should meditate or practice mindfulness to relieve the pain of an acute traumatic injury! It’s ridiculous, particularly given that there is a far faster, far more efficient, and much more immediately effective medication available.
I should also say here that it’s true that RD pain relief is directly tied to RD inflammation, and that when the inflammation is relieved, the pain generally fades. The trouble is that with RD, relieving inflammation is kind of a crap shoot. The drugs currently available don’t work on everyone, they don’t always keep working, and sometimes they don’t work at all. In the meantime, the disease sure does work. The inflammation it causes continues to provoke sometimes severe, unrelenting, and unpredictable pain.
Which, of course, is all in the brain. In the end, I don’t think that RD pain should be classified as “chronic pain.” The disease is the “chronic” culprit.
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