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Emerging Alternatives In Treating Chronic Pain
What is the last frontier in medicine? For that matter, what is the last frontier in science? Some would proffer that it is either deep space exploration or an exploration of that thing we call the “mind.”
We all know well the constituents of deep space exploration, namely sending cool and expensive satellites out there to look at black holes, dark matter, antimatter, doesn’t matter, stars imploding (not talking Hollywood stars here, folks), Doppler shifts, expansion of galaxies, etc.
But what about the “mind”? What is the mind for that matter? It certainly is not the brain (you can lose your mind but your brain is still there). However, you could argue that the mind is just an extension of the brain, an invisible “organ” so to speak.
Neuroscientists have been wrestling with this construct at light speed over the last 20 years since functional magnetic resonance images have become available. Prior to that, the speed of neuroscience was at a glacial pace and relied only on weird clinical examples like Phineas Gage. (If you don’t know about him, Google him dammit.) We know that this “organ” and its function can change with magnetism and a technique known as TES, which stands for transcranial electrical stimulation. This is already happening in humans, in whom we can bombard, albeit harmlessly and temporarily, a certain part of the brain with a high magnetic field and change the person’s mind.
For that matter, neuroscientists can shut down a whole section of the brain. Wow, how valuable would that be for this upcoming holiday season when your significant other walks into the Neiman Marcus store with your credit card heading to the Gucci or Louis Vuitton section of the store with a fully lit nucleus accumbens, hell-bent with a mission to kill your credit limit?
Imagine that you are nicely ensconced at home watching the game in your favorite easy chair. You suddenly get a warning of the impending credit disaster on your home monitor. You quickly press the button of your mobile TES device you secretly had implanted in the brain of your significant other during the recent blepharoplasty and voila. Next thing you know, your significant other is heading to the sports store down at the mall to get some better beer mugs. Now that is science dammit. (Please notice how gender sensitive I was in this narrative and never said “she” or “he.” I had to turn on my own TES to shut down my anti-politically correct center in my prefrontal cortex while writing this.)
By now, you must question, “What the hell is the point he is trying to make here?” Frankly, I do not completely know. But I do know this. It isn’t just about preserving credit limits and getting some cooler beer mugs. It is about neuroscience and the last frontier.
Can we possibly change the “mind”? Give a patient a “mind” transplant, perhaps? Remember that the only arbiter of your surgical outcome is the cortex of the patient. It does not matter how excellent the job looks or how cool the X-rays look. Just a little flicker of neuronal electricity flowing through some large fraction of 100 billion neurons in the wrong direction and poof — “Houston, we’ve got a problem.”
Homun Culus, PhD, a neuroscientist at a very prestigious university in Israel, invited me to his lab to show me his latest concoction. “Look at this,” he pointed to a pile of white, semi-crystalline powder sitting on top of the tray of a lab scale.
“What is it?” I asked.
“L-methyl-3-ferritin-acetyl oxidase.”
Now I am thinking that is neat but what is it? As Dr. Culus patted his rotund abdomen getting ready to respond, I started thinking how much he looked like Santa Claus with his long white beard.
“We call it LMFAO for short but it is an optogenetic compound that has all the properties of 5-HT (serotonin), dopamine, norepinephrine and MDMA. Once implanted intraneurally, by using different spectrums of light, we can selectively trigger what ever neuronal activity we want in every center of the brain we wish in order to treat anything from Parkinson’s disease to severe depression.”
Instantly, my first response was “When can I get some?”
Santa, I mean Dr. Culus, threw his hands up by his side in disgust, and responded, “Probably never in the United States given the hurdles to get approval by the FDA.”
Now I am thinking to my self about how much easier it would be to take care of patients with chronic pain if I had some of this magic powder and some different colored flashlights. “Is it expensive to make?” I asked.
Culus fired back, “About $12 per dose. But by the time it gets through phase 5 clinical trials and the FDA new drug application process, it will be priced somewhere in the $25,000 per dose area.”
What About The Role Of Cognitive Behavioral Therapy In Pain Management?
Pensively thinking about the sad ramifications of not being able to get some of the magical powder, I felt despair. Culus picked up on this quickly from my body language and quickly added, “But you have something already close in the U.S. to LMFAO.”
“What?” I quickly blurted.
“You have CBT (cognitive behavioral therapy) and laughter.”
“Really?” I shot back. “Is that all?”
“Very powerful stuff”, he replied. “You just do not know enough about it and how to sell it to your patients.”
So on the flight back from Israel, I had Wi-Fi and time, and started doing some research. Let us talk about laughter first as that was what I started researching. Everyone knows and probably has read Norman Cousins’ Anatomy of an Illness. The essence of his tome delineates his journey through his own illness and how there is an emotional interplay with physiological homeostasis and that there truly is a mind-body connection. In fact, it turns out that there is even an Association for Applied and Therapeutic Humor. Now they probably have a CME meeting I would like to attend.
Okay, so as Martin pointed out in “Humor, Laughter, and Physical Health: Methodological Issues and Research Findings,” there may be no increased longevity with greater humor, but there is substantive evidence that laughter can increase pain management.1 In fact, if you do a PubMed search, you will find a mere 18,337 articles that have been published on the subject in 2015 alone. The complete search has more 80,000 articles. (I wanted to put all the citations in the bibliography but knew that the esteemed editors did not want to have a 700-page blog. Funny how restrictive those guys have been with me over the last five years.)
Now what about cognitive behavior therapy? Think of cognitive behavior therapy as nothing more than changing the way patients think about their condition and how to cope with it.2-4 The way you think about something has huge ramifications in how a patient perceives his or her disability. Perhaps you are in clinic one day and see a patient who has an obliterated ankle joint from a horrible car accident. Looking at the X-rays, you start shaking your head. You see more plates and screws in there than what they have down at the local hardware store.
Then you happen to ask what is bothering the patient. “Oh,” the patient says, “I have this painful area between my fourth and fifth digit.”
“Well, what about the ankle?” you ask.
“Ah, that’s been buggered up since 1985 when I ran the Ford Pinto into a tree after a night of partying and I just live with it. It hurts me sometimes when the weather changes.”
Now think about this for one second. If this patient had been the victim from someone else, rather than his own stupidity, would there be a different mental take on this? Maybe. My Vegas odds maker boys tell me it is a “no line.”
So for 2016, why don’t we have a resolution to prescribe some LMFAO and think about some cognitive behavior therapy, and see if we can’t make more people better!
Happy holidays.
Financial disclosure: I have no interest in the fictional Israeli company that makes the fictional cool powder.
