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Brain Atrophy with Chronic Pain: A Call for Enhanced Treatment

Recent studies clearly show that chronic pain unto itself causes brain atrophy and altered neurochemistry and sensory function of the central nervous system.
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2. A 55-year-old male executive has severe back pain with radiculopathy in both legs. For about five years he experienced interrupted pain care consisting of standard interventions, opioid dosages, and a variety of neuropathic, anti-inflammatory, and anti-depression agents. By age 60, he had to retire and was unable to adequately concentrate, read, or do calculations to retain employment. He remains at home and cared for by his wife.

3. A 40-year-old male television camera technician developed a severe back injury requiring multiple back surgeries, fusion, and implanted rods. Despite an implanted intrathecal morphine pump and numerous medical treatments including opioids, he developed such memory loss and cognitive abilities that he could not work or do such activities as balance a checkbook.

4. A 40-year-old registered nurse was referred with severe pain due to fibromyalgia. Her resting morning cortisol was under 1ug/dl, and she had tachycardia over 100 beats per minute. Despite multiple treatments including opioids, she mentally deteriorated over a five-year period to the point that she could not work and had to live at home with her parents.

The above cases are examples of clinical observations of severe chronic pain patients. They are presented here with little knowledge of underlying causes of their mental deterioration or whether they have brain atrophy.

Clinical Ramifications

A review of the anatomic, physiologic, and neurochemistry studies of chronic pain on the brain clearly suggests that some chronic pain patients will develop clinical syndromes of poor attention span, cognitive abilities, and possibly dementia.1-8,11-18 Is this happening? This author believes this to be the case based on long-term observations of chronic pain patients. Although chronic pain patients, in my experience, seldom admit to a loss of cognitive or mental abilities, they often complain of a poor memory. Is it time that chronic pain patients in treatment be sequentially monitored over time with mental scales such as the “Mini-Mental Exam?” Should we be trying to provide better diets, nutritional supplements, and dementia-preventing mental exercises such as crossword puzzles? Perhaps the pain patient who claimed her B-12 shot really helped knew what she was talking about. Can psychologists who specialize in dementia prevention help us? Shown in Table 2 are four cases from my personal practice which were undertreated for years before referral to me and who, I believe, developed mental deterioration. At this point, I have a poor understanding of how to diagnose, prevent, or treat mental deterioration in chronic pain patients, but these studies on brain atrophy provide insight into clinical observations.

Mechanism of Brain Atrophy

There should be no better subject to discuss in the hallways of medical practice than the possible causes of brain atrophy and neurochemical abnormalities that occur in chronic pain. Considering that some studies also show a loss of nerve density of peripheral nerves and spinal cord of pain patients, an electrical phenomenon must be considered as a cause. Is electricity being retained by damaged peripheral nerves (e.g., change in electrical capacitance) and thus causing a “hot wire” affect that fundamentally inflames, dissolves, and scars tissue? Does pain cause a hormonal or immune dysfunction that can literally dissolve gray matter? Hypercortisolemia has been observed in chronic pain patients and is known to cause a demented state.21-23 Severe pain is also well-known to cause hypertension and tachycardia, particularly during pain flares. Both are known to affect cerebral blood flow. Whatever future research points to as causation, physicians should take their best shot now at preventing the disappearance of gray matter. In addition to better pain control, it is obvious that we need better strategies to normalize electrical conduction, hormone metabolism, and restoration of tissue.

Table 3. Who Needs to Be Educated About Brain Atrophy

 

  • Patients
  • Psychologists
  • Clergy
  • Families
  • Social Workers
  • Insurance Carriers
  • NP’s/PA’s
  • Pharmacists
  • • Medical Boards
Table 4.Some Clinical Recommendations and Approaches

 

  • Educate all parties
  • Include brain atrophy risk in consent form and agreements
  • Early and aggressive treatment
  • Nutrition
  • Electrical control measures
  • • Mental, intelligence, and memory screening and exercises

Start Education Immediately

The number one thing physicians should immediately do with this new research information is educate all concerned parties including patients, families, psychologists, pharmacists, surrogates, insurance carriers, and medical boards (see Table 3). In particular, any party—such as a family member who is critical of opioid treatment—needs to be bluntly told that withholding treatment, including opioid therapy, may subject the patient to brain atrophy and the loss of intelligence, memory, and possible development of dementia. Simply, the risks of delayed or undertreatment appear too great. On the other hand, we do not yet know whether opioids or any other treatment can prevent or restore brain atrophy or altered brain physiology and neurochemicals.

Clinical Recommendations

It must be recognized that we may not be able to either prevent or restore brain tissue in chronic pain states. Nevertheless, these new research findings suggest some intuitive and logical measures. Education of ourselves and patients is, naturally, first on our list. Second is sooner and more aggressive treatment with all methods that are currently available. For example, alcoholic as well as some other forms of dementia respond to nutritional therapies. Since excess electricity produced in chronic pain states may be a causative factor, techniques to reduce and control electrical flow may be in order. Certainly, the encouragement of mental exercise, increased physical activity, and social interaction should help keep brains active. Above all, doctors who treat severe chronic pain patients should focus on this complication and eagerly share any hints and tips they uncover. It’s also my recommendation that we attempt to identify psychologists who have interest and skills in working with dementia.

Last updated on: December 18, 2012
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