On Measuring Pain

Maybe with the new technology we want have to ask patients, “on a scale of 1-10 how much pain do you feel?”  Maybe our machines will ask the brain and body directly and the body will express our pain ineffably.  We will get precise answers and we can judge our therapy and our medication based on what the brain/body relates.   We are just about there.

  New work at the University of Michigan has been measuring the brains of subjects undergoing pain of heat, for example.(see for example http://articles.latimes.com/2013/apr/10/science/la-sci-pain-measure-fmri-20130409).  They show a characteristic brain pattern.   Later pain shows similar patterns and provides the scientist with a measure and brain pattern of pain.  What they found is a typical neural pattern for each person’s pain.   The way they did this is by putting patients in a fMRI scanner and then added warm to very hot stimuli to see the brain response.  They also teased out emotional pain as differentiated from physical pain.  And they could then know what subject was in pain.   Something I did thirty years ago. But we will leave that for the moment.   Just to say that we could tell about patients coming in for sessions as to what level they were on.  Those heavily depressed and deeply into birth trauma had those long slow brain waves and very low body temperature.   The key index for hopelessness is those brain waves and body temp.
It is the rare depressive who doesn’t show those signs.

   The investigators then looked at painkilling drugs  (remifentanil).  It not only suppressed the neural signature but also the subjective report of pain.  Here we see that drugs can inhibit the reactions to pain but perhaps not pain itself; this may be particularly true when pain is imprinted and endures.  What they are hoping for is a reliable measure of pain so they can titrate, for example, what kind of tranquilizers to inject.  And they could measure effectiveness of drugs.  They want to take subjectivity out of the equation so that high-tech scanners could do all of the work.   Yet, they admit, they still will need patients’ reports.

Here is the dilemma: will the suppression of pain eliminate that pain?  Or will there be a rebound with more pain emerging after suppression by medication?  If we only look at current behavior and cognitive effects we may go off the rails and think that the pain has been done away with.  Or, if they rely only on the machines they may falsely see that the patient does not need painkillers when she clearly does.  Our patients descend slowly into imprinted painful memory and we know right away how much pain there is.  But we are not practicing general medicine where doctors need machines like that.  (see: The New England Journal of Medicine. April 2013).

   Our advantage here is that the patient teases out for us the difference between emotional and physical pain.   We don’t have to extrapolate from a number on the machine to the patient’s condition.   When see a patient entering a session with 95.6 body temperature we know what to expect.  And we know where the patient will be going; it is just a matter of helping her get there.  And at the end of the session when body temp goes up three degrees we see a normalization process taking place.   The patient is indeed becoming normal, not only in her “mind” but everywhere in her system.

  Here is the problem with the research: if they see big signatures of pain with no obvious pain they might refer the person for addiction help.  But suppose that pain is heavily hidden and maybe the person herself is unaware of it.  It doesn’t mean she has not pain; it means that it is buried under loads of repression and may be inaccessible for the moment.  It is not addiction; it is simply that we cannot see the pain they are in.