Intractable Pain Definition

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Definition of Intractable Pain

• Dictionary/Regulatory  Definition: Intractable pain is a state in  which the cause cannot be  removed or otherwise treated and no relief or  cure has been found after  reasonable efforts. 
• Clinical  Definition: A severe constant incurable disabling pain  that interferes  with activities of daily living, produces pathological  complications and  a shortened lifespan.  

By Forest Tennant MD, DrPH 

     The difference between simple chronic pain and intractable pain is what is known as pathologic sympathetic overdrive (PSO). This major medical complication is characterized by excessive electrical activity in the body's sympathetic nervous system. Excess electricity causes hyperarousal and pathologic overactivity of the sympathetic nervous system: the system that controls the body’s stress response. A  comprehensive grasp of this complication is crucial for effective treatment. 

     This pathologic complication is the root cause of IP’s debilitation, profound suffering,  and shortened lifespan. Even though I recognized & published the difference between Chronic and Intractable Pain over twenty years ago, *  it is still poorly understood within the mainstream medical practices of today. This contributes greatly to the undertreatment and mistreatment of IP patients. 

     The severe, constant, and disabling pain of IP causes anatomical defects in the brain, which leads the cells in the brain to generate excess electricity. This is how Pathologic Sympathetic Overdrive (PSO) starts.  The brain must get rid of the excess electricity to prevent damage from the “burning” of brain tissue. The brain rids itself of excess electricity by sending it into the sympathetic nervous system. This system is comprised of nerves that connect the brain to the heart, blood vessels, skin, lung, and gastrointestinal system. The best-known neural connection in the network that connects the brain to bodily organs is the vagus nerve, but there are fewer known nerve connections in and along the spinal cord. 

     The pathologic sympathetic “overdrive” (PSO) of excessive electricity produces a typical set of easily recognized symptoms and physical signs.  These include an elevated pulse rate (tachycardia), high blood pressure, cold extremities (sometimes exhibiting a bluish hue),  goosebumps, dilated pupils, and hyperactive reflexes. Another common symptom is temperature spikes and flushing, often followed by chills.

     Amazingly,  while the nation persistently clamors about the importance of controlling blood pressure, making Americans very aware that hypertension leads to numerous serious medical conditions, and is in fact one of the leading causes of death in the U.S., I cannot identify a  single lay magazine or medical journal that even refers to the undeniable correlation between severe, unmanaged pain and high blood pressure.  Strangely, there is a conspicuous absence of discussions even in medical publications about the necessity of adequate pain management to reduce blood pressure.

     PSO  interferes with normal respiratory function. The lungs may not expand and bring in the normal level of oxygen, and carbon dioxide may elevate in the blood. Inadequate oxygenation may lead to lethargy, fatigue,  amotivation, muscle weakness, and mental impairment. 

     An  IP patient’s ability to sleep, and especially achieving adequate REM  sleep, is greatly reduced by PSO.  The hazards of inadequate sleep are well-known: fatigue, depression, amotivation, poor mentation, and hormone imbalances. A tragic misunderstanding is the belief that somehow a lack of sleep is better than taking a bedtime sedative. This notion lacks any scientific merit. 

     There are lesser known but other serious and debilitating sequelae of PSO. The gastrointestinal system becomes so impaired by PSO to the point that loss of appetite and malabsorption (nutrients do not assimilate) and malnutrition is present in essentially all IP patients. The disturbed nutritional metabolic deficits can lead to either significant weight gain or loss. Constipation and diarrhea will often alternate, while stomach pain and bloating are routine. Patients are often misdiagnosed as having irritable bowel syndrome (IBS), with treatment that gives no consideration that bowel symptoms will persist without control of the underlying IP. 

     PSO has a  significant impact on the endocrine system, similar to the body's "fight or flight" response during moments of stress. With IP the stress is constant. This physiological response involves an increase in adrenaline  and cortisone levels in the bloodstream. Normally, this  stress response is temporary, allowing the adrenal and pituitary glands to recover and remain intact. With the constant pain and electrical overdrive of IP, the glands hypertrophy {enlarge abnormally} trying to keep up their hormonal output to protect the body. Unfortunately, the glands will often deplete. IP patients have died due to adrenal failure, as the glands could not produce enough cortisone and adrenaline to maintain life. PSO tends to especially cause the pituitary gland to enlarge. Some uninformed surgeons have “removed the pituitary tumor”  without understanding the root cause of the enlargement, or the imperative need to manage pain. 

     If  PSO goes on long enough, and the pituitary and adrenal glands exhaust or wear out, testosterone and estradiol will deplete. While most people are aware of the impact of such depletion on libido and menstrual functions, what even many medical practitioners miss is the critical role these hormones play in tissue healing, pain reduction, and various mental functions.

     Since PSO raises cortisone on and off for as long as one has IP, calcium is extracted from bones and teeth. Osteoporosis may develop and teeth may deteriorate. Sudden loss of a tooth is common in IP as is chronic dental caries (cavities). 

     PSO in an adult  IP patient will often cause some level of adult attention deficit disorder (ADD/ADHD), which is the exact clinical syndrome that occurs in a child with hyperactivity or attention deficit disorder. Furthermore,  when the IP patient develops the same “attention deficits”, they will need the same medications that a child does to normalize attention span,  carry out the 3Rs (“reading, riting, rithmetic”), and activities of daily living. The mental aberrations of IP, unless treated with today’s hyperactivity medications (e.g., Ritalin®, Adderall®, other), can be so debilitating that the IP patient can become a lonely, despondent invalid, who becomes expensive to care for and totally dependent on family and society. The medical profession rejecting or dismissing the recognition of ADD/ADHD in IP patients can only be classified as blatant professional oversight. 

     It is essential to point out that a medical practitioner who understands PSO  can distinguish an IP patient from a simple chronic pain patient with a  5-to-10-minute physical examination. For starters, the IP patient with  PSO will show some abnormality of pulse rate, blood pressure,  temperature, or breathing rate. Some reflexes will be hyperactive, and the pupil may be dilated.  Hands and feet will be cold to the touch and may  show a blue discoloration. Teeth will be missing and/or show a lot of decay. Mentation and speech may be slow and deliberate. Movement may be slow. These physical signs correlated with the history and symptoms provided by the patient and family will easily and quickly nail down the presence of IP and PSO without the need for blood tests or brain scans. 

     This essay is a call for all parties concerned to fully understand the difference between Chronic  Pain and Intractable Pain with pathologic sympathetic overdrive (PSO).  Every IP patient, family, and medical practitioner must fully understand that the PSO of IP will cause dire complications. Each IP patient and their family needs to recognize and record their PSO manifestations and present them to their medical practitioners. Sadly, this author cannot identify a single education effort by a recognized medical publication,  organization, or academic institution that has or is currently trying to educate on the obvious and blatant clinical manifestations of the sympathetic pathological complications of IP. Like most things in medical science and practice today, the demand and education must “start at the bottom and work up”. 

*Tennant F, Herman L. Intractable or Chronic Pain: There is a Difference. West J Med2000; 173-306.