Complications of Uncontrolled, Persistent Pain

Complications of Uncontrolled, Persistent Pain – By Forest Tennant, MD, DrPH – Jan 2018

To the unfortunate patient who is afflicted and the practitioner who treats it, incurable, persistent pain is truly its own disease regardless of its underlying cause.

Persistent pain, which is also often characterized as chronic or intractable, has all the ramifications of a disease in that it may have pre-clinical and overt phases.

I like that he calls it “persistent pain” instead of “chronic pain”, a term which has become synonymous in the public’s eye as a whining, complaining, catastrophizing, gonna-be addict.   

It may be intermittent or constant, as well as, mild, moderate, or severe.

The most unappreciated clinical feature of persistent pain, however, is the plethora of complications that may result — particularly if the pain is constant and unremitting.

It is exactly this factor, “constant and unremitting”, that makes chronic pain so devastating to a person’s life. When pain cannot be escaped, it feels like being trapped in a hostile body.

As has been shown in countless experiments, when animals become trapped in a painful situation they cannot escape, they become depressed almost to the point of immobility.

Nowadays such a reaction is called “catastrophizing” about pain (tell that to the poor mouse getting random electric shocks all day every day).

Many recent and emerging studies clearly document that persistent pain exerts profound impacts on the body’s

• endocrine,
• cardiovascular,
• immune,
• neurologic and
• musculo-skeletal systems

Presented here is a review and classification of some of persistent pain’s complications to give the practitioner a basic understanding that persistent pain may produce a symptom complex or syndrome that must be recognized at the clinical level.

Even though our understanding of the occurrence and mechanisms of the persistent pain syndrome are still quite limited, it is clear that the diagnosis and treatment of persistent pain’s complications must be simultaneous with pain treatment.

Deconditioning Complications

Any area of the anatomic body that experiences severe persistent pain will soon “decondition.”

This area will cease normal, symmetric, coordinated movement, and the patient will simply self-splint, immobilize, and decondition the area.

This leads to a number of complications including muscle atrophy, neuropathies, and in late stages, contractures. Muscle, nerve, and joint weakness, and deterioration result.

It is not uncommon to see the patient with severe, uncontrolled pain progressively deteriorate due to muscle atrophy and contractures and go from cane to walker to wheelchair.

A single painful location on the body soon begets some others.

Much of this is the “overload and overuse syndrome.” To make up for a weak, painful area, joints, nerves, and muscles elsewhere in the anatomy will attempt to compensate and work overtime.

Unfortunately, chronic overuse and overload may lead to tissue degeneration at secondary pain sites causing arthropathies, myopathies and neuropathies

Hormonal Complications

Based on emerging research data, it appears that uncontrolled persistent pain may affect about every endocrine system in the body.

It has long been observed that acute pain is often accompanied by hypertension and tachycardia, and it is now clear that persistent pain may actually trigger indolent hypertension and tachycardia.

For the purpose of evidence of pain, you could take your blood pressure during the times you’re in the most pain and notify your doctor if the readings are much higher than normal.

This would give them a piece of concrete numerical evidence that might allow them to act and prescribe opioids “for your blood pressure” since opioids are no longer allowed “for your pain”.

Insulin and lipid metabolism may be altered, and recent studies with spinal cord injuries and systemic lupus erythematosis suggest that persistent pain may accelerate the atherogenic process.

Cardiovascular death is a common occurrence among persistent pain patients likely due to a multitude of factors.

The impact of persistent pain on the hypothalmic-pituitary-adrenal-axis is profound and paramount to understanding the complications of persistent pain.

Severe pain is a potent stressor — perhaps the most potent — that stimulates this system.

Pain is essential to an organism’s survival so it knows what to avoid, so important it can override many other sensations/feelings.

If severe, persistent pain isn’t controlled, adrenal exhaustion and decreased serum levels of glucocorticoids, including cortisol and pregnenolone, may result

Although the complex assault on the endocrine systems of the body by persistent pain begs for more research, it is clear that the severe, persistent pain patient may experience all the ramifications of excess and/or deficiency of glucocorticoids.

Abnormal glucocorticoid states may have debilitating consequences including

• mental deficiencies,
• muscle weakness,
• edema,
• osteoporosis,
• diabetes, and
• stone formulation among others.

Also, likely related to glucocorticoid abnormalities is the common observation of severe tooth erosion and decay. Furthermore, abnormal glucocorticoid levels likely interfere with pain control.

Classification of Major Complications of Persistent Pain

Hypotestosteronemia is now recognized as a common complication in persistent pain patients — both male and female. Opioid treatment potentiates testosterone deficiency

Testosterone also interacts with endogenous opioids to provide pain relief, and it is essential for libido in both sexes. Fortunately, testosterone replacement is now a simple clinical procedure thanks to a number of available agents

Immune suppression is present in the persistent pain patient. It is manifested clinically by poor resistance against infections and slow healing of wounds or injuries. Hormonal abnormalities are most likely responsible.

Serum testing of persistent pain patients typically shows a variety of serum immune abnormalities.

Persistent pain patients, particularly those with an autoimmune disease such as fibromyalgia or systemic lupus erythematosis, may develop infections such as chlamydia, cytomegalus, and herpes.

It may be that the same nervous tissue the produces pain is so injured that it becomes fertile ground for viruses that like to invade nerves.

Neuropsychiatric Complications

Persistent pain generates excess electrical activity in peripheral nerves, spinal cord, and brain.

This “hot wire” effect appears to cause degeneration of nerve tissue — particularly in the dorsal horn of the spinal column.

How can anyone with medical training believe that constant pain wouldn’t cause neurological damage?

Normally, pain is supposed to motivate an organism to escape what’s causing it, leading to enhanced survival. But if your body is sending those pain signals from internal issues (adhesions, joint misalignments, intestinal inflammation, etc.), escape is almost impossible (except by death, which becomes an attractive option when literally unbearable pain is not treated effectively).

A recent controlled study shows that low back pain patients may develop cerebral atrophy.25 It follows that dementia and other organic brain syndromes may result.

The problems of

• insomnia,
• depression,
• suicide,
• attention deficit,
• memory loss, and
• cognitive deficiencies

are extremely common in persistent pain patients.

The precise biologic mechanisms by which persistent pain causes these complications is not totally clear, but they likely occur due to multiple adverse biologic affects including

• neuroanatomical degeneration,
• hormonal abnormalities, and
• neurochemical depletions at synaptic junctions.

Clinical Management of Complications

• Functional assessment of “deconditioning” and “overload-overuse” deficiencies should be done at the initial physical examination
• Routine blood pressure and pulse monitoring by the patient is helpful to gauge pain control.
• Blood pressure should be below 140/90 mmHg and resting pulse below 84 per minute.
• Mental evaluation to detect depression, attention deficit, insomnia, memory loss, and cognitive deficits is advised.

Standard treatments for these complications are essential to provide an acceptable quality of life for pain patients.

Yes, but “acceptable quality of life” is no longer considered a reason to treat chronic pain. In fact, most doctors seem to believe that living in constant agonizing pain is “acceptable” (as long as it’s not they themselves).

Abnormal concentrations of cortisol or pregnenolone may indicate poor pain control. Low concentrations of any of these three hormones may require replacement when aggressive pain treatment isn’t successful in normalizing serum concentrations

As part of routine clinical monitoring, the practitioner should develop procedures and protocols to periodically assess the complications of uncontrolled pain.

Treatment modalities should be aggressively pursued if previous complications worsen or new ones appear.

That will be difficult when opioids are no longer prescribed for such pain.

Summary

Severe incurable, persistent pain will invariably produce a number of complications like any other disease.

While complications have been categorized here as deconditioning, hormonal, and neuropsychiatric, future research and clinical experience may provide a more useful and detailed classification.

It is certainly proper to refer to severe persistent pain as a disease or syndrome.

The pain practitioner will need to assess the pain patient for complications and develop strategies to simultaneously control persistent pain and its debilitating, often lethal, complications.