Newport Beach Neurologists

The Analgesic Cycle

by C. Philip O'Carroll, M.D.

INTRODUCTION:

Let us begin first by defining the word analgesia. It comes from two Greek words, 'an' meaning not and 'algesia' meaning pain. The term analgesic therefore is a fancy term for "pain killer."

In our society we have been educated, both physician and general population alike, to think of disease or discomfort in a strictly "medical model fashion." According to this model, wherever there is pain there is injury to a body tissue. A signal of discomfort whether it be indigestion or headache is usually taken to indicate that there is underlying pathology or damage to the various body tissues. You go to your physician, and then begins the hunt for "the diagnosis." Various tests are taken, and the diagnosis is made, following which treatment is prescribed either medically or surgically.

This way of approaching bodily symptoms has been successful in that it has allowed medical science to progress in a logical fashion; however, I think the time has come when that model has to be expanded. No longer does the simple motto "pain equals injury" encompass the experience of human pain and suffering. There are two basic pain syndromes we must deal with. One is called acute pain and the other is chronic pain.

When one deals with acute pain, it is logical to assume that where there is pain there is injury. If one is awakened in the middle of the night by a sharp pain in the belly, it is indeed appropriate to take oneself to the emergency room and get investigated. However, when one is locked into a pain syndrome for 20 years, and experiences pain on a daily basis, then it is no longer proper to assume that there must be a "obvious physical" underlying cause for the pain syndrome. Thus the difference between acute and chronic pain is that acute pain has an obvious causation which may or may not be immediately treatable. In a chronic pain syndrome, the pain is often a self-perpetuating process within the nervous system itself and may have little to do with external injury.

Most people with chronic pain syndromes fall into the trap of thinking that they are indeed suffering from the so-called "medical model of disease." They go to the physician, they get a prescribed course of medical treatment which unfortunately rarely works. The usual scenario is as follows: The patient who is experiencing chronic pain may go to a new physician. The physician is optimistic that he can now intervene successfully. He does tests or perhaps reviewed the previous x-rays. He gleefully points out something that he thinks another physician may have missed, whether this be a small disc bulge or a small bony spur.

A definite diagnosis is given the patient who immediately feels grateful and confident that the doctor now has made the correct diagnosis at last. Medication or other forms of treatment are prescribed. Initially there may be a brief so-called "placebo response", which is gratifying to patient and doctor alike. Inevitably however, the initial period of success gives way to the same old chronic frustrating cycle of pain. The physician will then try different modes of treatment maintaining his optimism until he can no longer tolerate the recurrent cycle of failure.

At that point the patient may be dismissed as "a neurotic" or a "crank", and a souring of the patient-doctor relationship begins. The final ignominy is when the doctor in disgust suggests to the patient "go see a psychiatrist." The patient rightly sees this as a dismissive gesture on the part of the physician, a physician who believes that the patient is experiencing only imaginary symptoms or is a "hypochondriac." Under these circumstances, it is virtually impossible to proceed any further in the relationship.

One of the main reasons for failure in this scenario is what is called the analgesic cycle. Let us explain further. When pain is experienced in the human nervous system, there is a release of chemicals which we will generically call "endorphins." Endorphins are extremely potent, naturally occurring substances that are many times more powerful than morphine or heroin.

When a patient ingests medication on a daily basis for the purpose of treating pain, it is believed that there is a very powerful signal to switch off this endorphin production. Thus, the patient may now become totally dependent on the analgesic effect of the pain pill in order to experience any pain relief. Unfortunately, as the level of the drug begins to decline in the blood stream, the pain recurs triggering another trip to the pill bottle. After weeks or months of this kind of behavior, it is virtually impossible for the patient to experience any relief from any other mode of treatment.

In a true sense, the person has become physically and psychologically addicted to his analgesics. Now most patients think this can only happen with powerful narcotics such Demerol, Morphine, Percodan or Codeine. It is our experience however that this can happen with relatively minor analgesics such as over the counter Advil, Tylenol or aspirin.

The bottom line is, if you are taking daily pain pills you are flashing a powerful signal to your own nervous system that you no longer need the endorphin producing mechanisms. Thus the patients get locked into the deadly cycle of pain-pill/pill-pain. This phenomenon of psychological and physical dependency may also occur even with other modalities of treatment. It is not uncommon to see patients almost addicted to chiropractic manipulation or the manipulations of their favorite physical therapist.

Frequently, these patients will stay with the same therapist for years on end, often experiencing relief only during or immediately after the period of treatment by the therapist. I believe that the same principles apply in these cases as applies to the patients taking daily pain pills. In other words, the patient has programmed their nervous system to releasing pain-killing substances only in the presence of this "powerful therapist."

Is there then an alternative approach to the patient with chronic pain other than the medical model outlined above? I truly believe that there is an alternative. Let us first begin by a brief discussion of what we mean by psychosomatic disorders. Most patients, as soon as they hear the term psychosomatic will often immediately become defensive and hostile. One can almost hear the patient thinking "is he saying it's all in my mind"? Nothing could be further from the truth. Psychosomatic disorders are probably the leading cause of morbidity and mortality in the civilized world.

Psychosomatic diseases include: asthma, coronary artery disease, high blood pressure, peptic ulcer, irritable bowel syndrome, colitis, certain forms of arthritis and probably a whole host of other diseases where the link between stress and disease still has to be elucidated. Many investigators in recent years have found that the risk of death is much higher in somebody who is widowed or divorced.

Clearly then, the psychological environment and behavior of the patient has a great deal to do with the physical well-being of the body. The term psychosomatic implies just this. It simply means that certain diseases or pain states may be caused by a combination of both physical and psychological factors. Psychological factors do not exist outside of the patient's body. They are not somehow divorced from him or floating around in the atmosphere. Psychological and emotional factors have a powerful basis in the chemical interactions of our brain and in turn have a powerful effect on the nervous system control of the body. Stress or anxiety can release a powerful chain of events that if left unchecked can lead to all of the diseases mentioned above.

Our approach therefore is to approach the human being in this integrated fashion, not to consider him or her as a "disembodied organ." When we see a patient with chronic headache, we do feel that this is indeed a true psychosomatic disorder and must be treated as such. Thus we will not rest content with simply giving the patient medication as if this is a simple straight-forward "medical disease" if indeed there is such a thing. We approach the patient therefore from a point of view of trying to understand the physical and psychological mechanisms that are operative and to get down to the fundamental causes of the disorder.

The approach often will involve the following:

1. Weaning the patient slowly and painlessly off of their daily cycle of drugs. There is little doubt that almost any form of treatment will be unsuccessful as long as the patient remains fixed in the "analgesic cycle." This can be achieved slowly over a period of weeks or months, often by switching the patient from a "pain contingent drug schedule" to a "time contingent drug schedule." By this we mean that the patient takes medication at fixed intervals and not according to the signals of pain in his body. On other occasions, if the patient is addicted to powerful narcotics, we may mix the medication in a syrup base and slowly fade it over a period of weeks. This process is called fading and masking, and usually enables patients to come off drugs without withdrawal symptoms.

2. Other types of medication may be used. Medicines such as tricyclic antidepressants may help to stimulate the brain's endorphin producing systems and so have the opposite effect of daily pain pills.

3. The underlying pain behavior and psychological strategies of the patient will be looked at by the psychologist on the staff. We do not profess to be psychiatrists in the traditional sense. Rather we try to point out to the patient the various strategies that they are using to cope with the stress of their life. In many cases, this adaptive mechanism is indeed a very poor one which is causing the patient great distress and pain.

Through application of well-tested behavioral techniques, we educate the patients away from their pain oriented behavior and encourage them to take control of their lives. Examples of these techniques will include biofeedback, relaxation training, breathing techniques and a simple exercise program which is not dependent on an external therapist.

SUMMARY:

It would be very helpful if the patient stopped thinking of their pain in terms of the simplistic "disease model." Rather, they must try and think of their pain now in the "psychosomatic model." In this model, one not only looks at genetic vulnerability or predisposition to disease states, and not just to the physical factors but also to the emotional and psychological factors involved in their symptoms. If they will open their mind to these possibilities, then they have the power to heal themselves within their own grasp. The public must somehow overcome the notion that psychosomatic disorders are figments of the imagination or signal "moral weakness" in the patient. They must come to realize that treating patients in this psychosomatic model fashion probably affords the best chance for them to overcome their chronic pain affliction.

3/94