WHERE PAIN BEGINS
The sensation of pain begins in your peripheral nervous system. The nerves that tunnel under your skin react differently to various stimuli; a light touch, a tickle or a punch will all elicit a unique response from these nerves. The feeling of “pain” comes from a specific type of receptor, called nocicepters (no-see-sep-tors), which detect temperature, pressure and stretching in and around our bodily tissues. When nocicepters are triggered, a nerve impulse is sent to the spinal cord and, subsequently, the brain. However, in the case of sudden injury or the threat of a worse injury, your spinal cord is capable of some decision making: reflexes originate in the spinal cord. The dorsal horn is responsible for these “quick thinking” choices that cause you to wrench your hand quickly away from the hot stove. When the impulse reaches your brain, it is at this point that you “feel” pain; because just because you’ve taken your hand off the hot stove doesn’t mean your burns will go away. Your brain not only learns from the experience of pain, but it must then rationalize what to do in order to heal the injured body part.
Healing begins in the brain.
Your brain starts asking itself rapid-fire questions about the pain:
Is it sharp? Has this pain been felt before? Is it worse than the last time? Where is it, exactly? Is it spreading? Would a kiss make it better?
By the time the pain signal arrives in the thalamus, it approaches the limbic system, which decides whether or not this pain will make you cry.
(So, the answer to that last question is left up to the limbic system.)
IT SEEMS SIMPLE, RIGHT?
Unfortunately, pain is far more complex than this overview might lead us to believe. The true experience of pain is not as linear and well-defined as theory states. Everything else that is going on in your environment — and everything that has ever gone on in your environment during a painful moment — influences how your brain will process painful stimuli.
Which means we all experience pain differently.
To even further complicate things, there are two distinct types of pain.
When we discuss pain, we are either talking about somatic pain or visceral pain. The major difference is location: somatic pains arise from tissue and skin, while visceral pain come from inside, in the viscera and internal organs. Nociceptors detect both types of pain and when the injury heals, they stop firing. The injury stops hurting; the ache subsides.
I have a chronic, progressive inflammatory condition called endometriosis. With this condition, the cells that make up the tissue that lines a woman’s uterus finds itself implanted in various spots outside of the uterus — fallopian tubes, ovaries, the uterine cul-de-sac and intestines are common sites, though some women have had it travel to their lungs and even their brain. That tissue is identical to uterine tissue that is shed during a woman’s monthly period — so it reacts to the various hormonal fluctuations that are part of a woman’s menstrual cycle in the same manner — it bleeds no matter where it is. Of course, since it’s not near the vaginal vault, it has no escape route. Instead, it bleeds and reforms on the same hormonal cues as the uterine lining, but causes inflammation and irritation since it remains inside the pelvic and / or abdominal cavity.
In short, it hurts. It hurts a lot. It’s a gnawing, grinding kind of pain for me. A pain that swells and has been known to knock the wind out of me or make me lose my thought in mid-sentence. In my experience, it is at its worst and most intolerable level right after I’ve finished a period — presumably when the lining is beginning to regrow. I have one fallopian tube and ovary that have been ravened by it and it wears the scars of a “chocolate cyst” — ovarian cysts that form and fill up with brown, sticky old blood that’s the consistency of fresh tar and about as pleasant to discover in your underwear. In addition to the pain, endometriosis makes me perpetually nauseated, fatigued, hormonally unstable at best and deeply depressed at worst, not to mention the referred pain of sciatica, the near inability to have a bowel movement or urinate when the pain is at its height and the excruciating pelvic pain associate with sexual intercourse and orgasm.
I no longer have a sex drive. I no longer enjoy food. I live for heating pads, anti-anxiety pills and cheap underwear that I don’t mind ruining.
Doctors don’t like chronic pain — and they’ll be the first to tell you that. Medical school teaches you to diagnose and treat — not manage. Pain is seen as a sign of something else, but is rarely looked at as a disease all its own, with its own story. Healthcare has evolved to be a business because in the last several decades, doctors were paid according to what tests they ordered and not necessarily the health of the patient. A doctor could, essentially, write an invoice for whatever treatment they offered the patient and be reimbursed for that amount — regardless of whether or not the patient’s problem was solved. Therefore, medicine became about the exchanges between the provider and the payer, not the physician and the patient.
It soon became quite obvious that medical professionals and hospitals had no incentive to get patients feeling better — in fact, they had financial incentive to keep them sicker. This was, of course, completely unsustainable, and now we’ve arrived at a point where American healthcare as-is can’t sustain itself. So, there’s currently a massive reform underway that aims to regear providers to keep patients out of the hospital. Gone are the days when they can invoice for every single test they order — now they get paid a set amount and have to make do. They have to provide quality care that’s also cost-effective. They are penalized for poor patient outcomes and, in addition, poor patient satisfaction ratings. It’s no longer enough for a doctor to be capable of ordering a test or writing a script — they’ve got to smile, too, and be agreeable and warm. They have to document all of this, of course, dotting their i’s and crossing their t’s with pathological precision, lest they be audited or sued by a disgruntled patient.
What could be the greatest foible, then, for the modern physician?
A PATIENT WITH CHRONIC PAIN.