Too Much of a Good Thing

       Today is Thanksgiving.  I've been exposed this week to commentary from  gratitude experts, bliss ninnies, and the frankly disgruntled as everyone weighs in on the role of thankfulness in the second winter of our national discontent.  Personally, I am turned off by pollyannas. And, yes, I've read the literature that proves we change our minds for the better when we utilize gratitude.  But the human brain more easily notices what's wrong than what's right...a trait set that's evolved precisely because it has worked so well for the species, and I'm thankful for it.  I'm a second-rate optimist by nature, but a deft pessimist by policy, so gratitude for the expected and the mundane is a real slog for me.  I have no trouble recognizing good news when it shows up, however, so here's some I'm happy to pass along:  there's some real progress being made in understanding and treating chronic pain.  I can get excited about this.

       A couple of months ago, I posted on The Forbidden Subject, wading into the issue of chronic pain and the physical and emotional tolls it takes.  Acute pain is the sharp stuff that warns of injury and goes away when healing occurs.  Chronic pain is the punishing, relentless stuff that stays long after healing and sometimes has no clear or apparent cause.  By the time most of us reach our sixties, we've had at least a taste of it.  Many of us, myself included, live with it daily. I characterize it as the car alarm that won't shut off, even when there's no thief in sight.  Doctors hate to treat it because they often have no clear answers and the most effective treatments either have horrid side effects (steroids, cox-2 inhibitors) or are addicting.  Physicians tend to bristle the minute the subject is broached in the examining room.  As often as not, they wind up adding insult to enigmatic injury by guilting the patient.

       I was thrilled to read in November's Scientific American  that researchers are homing in on the cell structures and neurological processes that cause lingering, amplified pain.  Work is focusing on glia cells, which are part of the normal pain reporting process that supports our response to acute injury.  It seems that, when these helper cells do their job, they often don't know when to quit.  Glia cells and their assistant astrocytes are critical to the body's best response, but they can create an unintentional endless feedback loop that turns on the car alarm and keeps it blaring.  This happens not as a disease process, but as a side effect of health, if you will.  

     The good, healing inflammatory process, made possible by  glia, morphs from Jekyll to Hyde through no fault of our own. That is a critical piece of information, because most people who suffer from chronic pain have learned to see it as personal failure.  When only 15% of the primary care physicians polled say they feel comfortable treating a condition that affects 10-20% of the entire population (not just those over fifty), there's a psycho-social problem layered onto an enormously debilitating health issue (H. Brevik, in European Journal of Pain, Vol 10; No. 4; May 2006).  In many cases the chronic pain results from trying to do the right things.  In my own case, according to one specialist who was not afraid to speak to me honestly once he'd figured out I wasn't shopping for opioids, I probably took physical stoicism too far when I was younger, which likely tripped the glial looping.  I went the natural childbirth route in my thirties, and I pushed my body too far athletically in my forties and through repetitive exercise in my fifties.  Since then, I've refused opiates to dampen chronic piriformis syndrome (basically, a pain in the butt) out of fear of dependence or addiction.  And I've followed the instructions of rheumatologists and physical therapists who have pushed exercise and more exercise as the best non-pharmaceutical treatment approach.  Glia research indicates that mine may be a case of too much of a good thing. 

     And, there's evidence that the glia cells, themselves, actually work to render the best available treatment, opiate painkillers, ineffective with continued use.  Linda Watkins, of the University of Colorado, has shown that morphine and other opiate painkillers actually crank up the activity of spinal cord glia, which then work to counteract the painkilling effects.  In other words, it's possible that addiction to painkillers is not only NOT a moral failing of the patient, but is unavoidable.  Until recently, we just haven't understood what we were dealing with, and, in typical Western puritanical tradition, we've blamed the victim and hobbled the healers.

     In our country, medical research follows the money.  Aging is a high risk factor for chronic neurological pain, so maybe it's the numbers of sufferers in our Boomer cohort that are finally attracting the R&D bucks, even though 59% of sufferers are female (the medically under-served sex).  Who cares.  Suddenly my problem is sexy.  There are currently nine substances being tested as new treatments for neuropathic pain, all targeting the activity of glia; some of these have already passed the safety and efficacy tests in humans.  Drugs that target glia open up new hope not only for the 30 to 60 million Americans who cope with chronic pain, but also those who have become tragically addicted to opiate painkillers.  Finally, we're getting somewhere.

     All of this is going to be tough to squeeze into my momentary turn at expressing gratitude at the Thanksgiving table today.  So I'll tell you about it, instead.  Chances are, you know someone who could use the good news.  Let us give thanks.

[ Image 1: June 29, 2008 in Facial Expression, Human Face, Pain, Wittgenstein; Image 2: topnews.in/.../default/files/chronic-back2.jpg]