Is the New Pain Vocabulary Helping Patient Care?
It doesn’t take attending pain meetings or perusing pain journals to figure out that in the past decade, many new vocabulary terms have emerged that seem unrelated to practical pain practice. As Peter Moskovitz, MD, articulates in his article on maldynia in this issue, a new vocabulary is being used to describe the brain dysfunction that occurs in patients with severe, chronic pain. These include such terms as neuropathic pain, neuroinflammatory pain, central sensitization, centrally enhanced pain, centrally mediated pain, embedded pain memory, sympathetic-mediated pain, neural plasticity, and brain reorganization.
Is this new pain vocabulary helping patient care? At this point in time, I say the answer is no. In today’s medical world, clinical pain practice is more and more an art of communication. We must use words that can be understood by all parties: patients, family, and insurance carriers. Why? Today’s patients and family will not settle for anything less than an understanding of the underlying painful condition and the risks versus benefits of treatment. And yes, the treatment may be expensive, but only a transparent, easy-to-understand vocabulary can justify the expense.
Confusing, complex, or misleading terms like central sensitization, persistent pain, and hyperalgesia may have a place among medical professionals, but they have little place in clinical practice. Hopefully, the new pain vocabulary will prove its mettle in the future, but I find it hard to objectively and positively believe that the new vocabulary is resulting in improved patient care or enhancing patients’ understanding of their conditions.
I recently tried to explain “central sensitization” to one of my patients. My patient politely informed me to take my insults elsewhere, thank you. For the record, the International Association for the Study of Pain (IASP) defines central sensitization as “increased responsiveness of nociceptive neurons in the central nervous system to their normal or sub-threshold afferent input.” This supposed revelation was apparently “validated” by using subjective indices of pain measurement like applying cold or pressure—nothing objective like a pulse rate, pupil size, or strength test.
Another new word is “persistent.” We no longer have severe, mild, moderate, chronic, intractable, or baseline pain. In my view, “persistent” sounds rather trivial and unserious. One of my colleagues recently tried to get authorization for a long-acting opioid on the basis that the patient had “persistent pain.” The request was denied, and my associate asked me what to do. I put in the same request but gave the diagnosis of “severe, intractable pain.” The request was approved within
2 hours, and I got a call from the patient’s insurance company: “Oh, doctor, if the patient is so bad as to be intractable, we want to help.” If the pain is severe, intractable, incurable, incapacitating, or whatever may be the case, call it like it is in plain language.
“Hyperalgesia” is another term of concern. The definition is “increased sensitivity to painful stimuli such as pressure or pinching.” However, it seems that it is a widely “abused” term. Rather than attempt to objectively diagnose and eliminate the pain, practitioners are informing patients to stop their opioid because they have “hyperalgesia.” Rarely is an explanation of hyperalgesia given. Instead, an often unsubstantiated statement is made that opioids are causing or making their pain worse, and they won’t have pain if they stop opioids! The vast majority of patients I see who have what I believe to be hyperalgesia usually are remedied with a dosage change, switch to a different opioid, or the addition of a hormone replacement.
Maybe I’ve misread the motives behind the new terms, but I somehow get the idea that by using them we are trying to avoid admitting we don’t have answers, don’t want to wade in the water of medical treatment, or need a vocabulary so indecipherable that only a research grant can figure it out. My concern is that all of these new terms are other ways to say that when you’re in pain, everything you see, smell, or touch seems to hurt. My advice is to keep “central sensitization” off the chart and out of the clinic. Simply tell the patient, family, and health plan that the pain centers in the nervous system don’t respond normally (ie, “insensitive”).