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The Complexity of Pain Management: Part 2 with Dr Mark Donohoe

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The Complexity of Pain Management: Part 2 with Dr Mark Donohoe

Continuing on from where we left off in Part 1, we are joined again by Dr Mark Donohoe, to continue the discussion on the complexities of managing pain in our patients. 

In part one, Mark discussed how pain is defined and perceived. Today, we take the discussion further into how the brain and body perceive pain, and how the power of the mind can be used to conquer pain, from getting off addictive painkillers, to breaking the pain cycle naturally.

Covered in this episode

[00:40] Welcoming back Dr Mark Donohoe
[01:25] Rethinking prescription painkillers
[11:05] Post surgical pain
[14:35] The power of the mind and how it perceives pain
[24:57] Does pain exist if you can’t express it?
[29:58] Low dose Naltrexone
[33:19] Using the mind to break the pain cycle


Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us again in the studio is Dr Mark Donohoe, who earned his medical degree from Sydney Uni in 1980. And he worked around the Central Coast of New South Wales honing his medical skills where his interest in integrative medicine sparked because patients just weren't fitting into the boxes of diagnoses and treatments, which were drummed into him in medical school. Mark is considered one of the fathers of integrative medicine in Australia. And he's been the vanguard for patient health throughout his whole career. And today, we're going to be talking more about pain. Welcome back to FX Medicine, Mark, how are you?

Mark: Well, I'm well. Pain part two, who could resist from pain part two?

Andrew: Now we discussed quite a lot of generalities with regards to pain sensation, pain amplifiers, anxiety and things like that, stressors. But this week, let's get into more specifics of how we can help these patients, so treatments and other adjuncts.

Mark: Yeah. Which also implies we've got to have a concept of what we're trying to do. So it's all very well to say pain but remember, the medical profession has been all about pain, it's, you know, opioids and cannabis. There are traditional things which have been used to relieve pain for centuries. And what medicine has done is thought, well, we know things that block the perception of pain, we know things that block the nerves that bring pain in there, let's use those and bring pain under control. And it was much more of a minefield than we thought.

So we're reconsidering...in the medical community, we’re reconsidering what pain is. It's only in the mind. Pain can only be perceived by the brain and the mind, and so a lot of the talk has turned away from what you would remember, I do certainly, as gate control theories and the idea that everything happens at the spinal level. Until it's perceived, pain is either not there,  or not distressing.

And so there's two different aspects of pain control. One is can there be less pain? And the second one is, can there be less attention to pain, which works exactly the same way? So if you don't experience pain, whether the stimulus is there or not, the non-perception of pain is relief. And I think that we're moving from that, “Let’s give oxycodone, codeine, tapentadol…” we have a lot of tools. And generally, they've turned out to be very bad news. Why? Because you have to escalate the dose over time, people become dependent, withdrawal responses are terrifying for people.

And now I think we're moving back to a much saner idea of what are the things that we could do that will get you to respond to pain in a different way? And I think that's the big turnaround. And that opens the door for non-medical practitioners. Because as you would know, S8 drugs are not only...the S8 being the potential for drugs like oxycodone, morphine...

Andrew: Dangerous drugs.

Mark: The S8s are...even GPs hesitate to just keep on writing scripts for them, but they're prescription only. Whereas changing the person's perception of pain falls much further back into the area of natural health care. Pain has been with us forever, as long as there's been humans, and we found ways around it.

Andrew: I have to ask you a question regarding codeine. You've mentioned the S8s and, you know, codeine is now an S4, all codeine scripts, and then the stronger ones are S8s. Prior to February of 2018, many of these up to, what is it, 15 milligrams...

Mark: Fifteen milligrams.

Andrew: ...per tablet were...

Mark: Over the counter.

Andrew: S3 or S2, which required a pharmacist to dispense them, or were just available upon request. I have been told...I never knew this, I’ve been told that these, up to 12 milligrams per tablet, so let's say 24 milligrams per dose, was ineffective anyway as an opioid, and that you needed the higher dose found in the always S4s. The drugs that were always on prescription of a doctor that you require that higher dose to have a pain-relieving effect anyway. And my thoughts around this are twofold.

One, how come there was never anything in the news? You know, we covered dextromethorphan and guaifenesin and all those sort of things about being ineffective. Never was this covered as being an ineffective drug. That's number one. Number two is this. If we've had such an opioid problem and those drugs were, "ineffective," then the opioid problem was not from those drugs. The opioid problem was from prescribed opioids.

Mark: Yes. I think this is a recognition of our sins of the past in the medical community that we created problems that became unsolvable problems. It's not the first time, I mean we did it with the benzodiazepines, before that we did it with the barbiturates. We are a profession addicted to quick results, short-term gains, clear benefits. The person says, "Thank you, yes, I'm sleeping now, I'm not anxious now, I'm not depressed now, I'm not in pain now, " and we tend to think of job done, how could there be anything wrong with that?

And I think you're right, that what we've done is we've developed a group of drugs whose short-term benefit was paid for by long-term dose-escalation, dependency, withdrawal effects. Just to go on codeine, I think it's worth saying it, dose equivalent 30 milligrams of codeine, which was the doctor's prescription, the S8 level, 30 milligrams of codeine, in most people, converts to around 4 milligrams of morphine, its literal conversion. So it's codeine is the ineffective, morphine is the effective. There are a solid 15% of the population, my wife being one, for whom codeine does not convert to morphine but has different pathways that can lead to psychotic-like episodes, ineffectiveness over effectiveness. There are ways...

Andrew: Nausea.

Mark: Nausea. And certainly, when you get into those doses, pretty well everybody gets constipated. The gastrointestinal motility goes down. And so again, as doctors, we thought, “well, we've got to solve that.” So we go to tapentadol or other drugs that we thought, well, this will have a little bit less of an effect on constipation. So we were fiddling the dials a little bit for probably 20 years.

Andrew: Or heaven forbid, dextropropoxyphene. 

Mark: Yes.

Andrew: Oh my god, what were the doctors doing?

Mark: You sound like you've had experience in this particular area yourself.

Andrew: A travesty, but anyway. And still available on the Australian market.

Mark: So I think we've got to at least mention in passing oxycodone. Oxycodone, terrifically effective for very short-term management of pain, but capable within a week or two of having it of developing a dependency, which is almost impossible to break. And so let's put this in perspective. I have a practice where, say, pain of fibromyalgia or chronic pain syndromes are very, very common, which is why we're talking about it today. The people who come to me who are on 12 codeine twice a day, so 24 of the 30-milligram codeines, were up around about a gram of codeine a day and changing it down, the person, I couldn't...

I tell you about in Adelaide a person has taken four years to come down at the highest rate they possibly can. Highly motivated to get off it, but it's taken four years to bring it down to just four a day. That is the kind of dependency problems that we create with the drug. She didn't need it. And interestingly there, she's doing a laser therapy right at the moment, which is allowing her to more rapidly reduce it. So using a kind of musculoskeletal low-intensity laser...

Andrew: Photobiomodulation.

Mark: That's right.

Andrew: #EmrysGoldsworthy.

Mark: Right. So you know, I am unconcerned because I, like everyone, we all fell for it. Valium works, yes.

Andrew: Sure.

Mark: Codeine works, yes, for most people. And if it doesn't, there's certainly another one there that will work. The cost of it, we see years later and we think all the pain must be worse. But probably is not that the pain is worse, it's that we have blockaded the opioid receptors around the body. We've caused secondary complications with the gut, nausea, vomiting. And then they don't work and the question from the person is, "Well, what's next?" And that, I think, is what we're addressing right now that, yes, we have good short-term answers, but they were never going to work in the long term. And I think that's where the national prescribing service is good. Don't take your short amounts and assume that they work for the long term. That should be tattooed on every doctor's forehead. What I do in the short term will work...

Andrew: Problem is they wouldn't read it.

Mark: In the mirror in reverse. What I do in the short term will work but it is not a long-term treatment. Proton pump inhibitors, you know...

Andrew: There's an argument going on about those at the moment, it's a cracker.

Mark: Yes. But we are good for short term and what we fail to do is think, is that a sustainable long-term thing? And so what we're talking about today, I think, is what are the things that have the evidence that they're sustainable that do not induce tolerance, do not induce withdrawal responses, can we find a different way? And I think the talk for pain has turned way back to, do you know what, we produce our own natural pain relievers, we produce our own cannabinoids, we produce our own endogenous opioids, we are good at producing it.

But what we do with symptomatic treatment is prevent that process from happening. We load up the opioid receptors with drugs that stay a long period of time and don't allow for our own bodies to respond in the way that they may otherwise do. And we don't address core issues of the anxiety about pain, the anxiety that a person will experience pain is often worse than the pain itself. And that anxiety is itself experienced as pain. So the opening up of pain research really comes back to say yes, look, literally pain is all in the mind. And you can take mindfulness approaches, you can take drug approaches, there are a variety of things that are not going to end up with the same problems that we had in the past.

Andrew: I'm reminded of a recent paper, this is mid-2018-ish, talking about melatonin plus or minus gabapentin just prior to lower back surgery, reducing the need for pain relief after surgery, vastly different pain scores. And it was either/or, it wasn't GABA plus melatonin. So one could just use melatonin. And it was immediately prior to surgery, which is an interesting perspective from the anaesthetics point of view.

Mark: Anaesthesia is being rewritten in a sense. Basically, all you do with anaesthesia is induce a type of unconsciousness, but the body still responds at the biological level. When you cut the abdomen, when you poke something through the belly button, the body still experiences the trauma. The brain does not experience the pain, and brain is effectively asleep. But the body response is the adrenaline, the cortisol, they go crazy during surgery! And that is a threat response that the person afterwards has to deal with. So we think surgery, bang, get in, anaesthesia, don't feel anything, wake up the other side, go home and everything is great.

Andrew: Really like racing heart and things?

Mark: Yeah, you get...

Andrew: During surgery?

Mark: No, they control that. 

Andrew: Yeah.

Mark: Everything’s controlled during the surgery. But my point is there is a threat response, there has been penetration of a cavity, there has been damage. 

Andrew: Yeah.

Mark: And the body's response percolates on well after the anaesthetist has gone home to bed, and well after the surgeon says “job done.” So, plenty of my patients...here's a really good example. Remember we use adrenaline for haemostasis. 

Andrew: Yep.

Mark: The injection is given. 

Andrew: Yep.

Mark: The injection of adrenaline is very effective at closing up blood vessels. It is also very effective at telling nerves, "My god, adrenaline has absolutely saturated you."

And in the area of the head and neck, the trigeminal nerve goes berserk with some people when adrenaline is used. Dental surgery, for example, they experience long-term problems after that. The whole escalation of the responses, we think the trigeminal nerve, which is the sensory nerve of the head and neck, says, "Good God, something just penetrated my mouth and took a tooth out." And the brain just goes berserk saying, "Well, we're not going to have that threat happen again." And so people become utterly sensitised by a single injection of adrenaline to control bleeding during dental surgery. Same happens with abdominal surgery.

Now the problem is it happens only to a minority. And so we don't have a good concept of what it is that sets one person up to experiencing ongoing pain, ongoing threat response on the other side, and the experience of, say, normal sensation, light, photophobia as pain. And that has taught us a lot about it's not that there is a threat, light doesn't hurt you, but photophobia hurts. 

Andrew: Mm-hmm.

Mark: What is going on in the mind of a person for whom photophobia is happening is an escalation of sensory experience. And we now call it central...I get this wrong every time. Central sensory sensitivities, CSS.

And so now the mindset of medicine is changing to say, oh, the stimulus is coming in all the time, it's the same as it was before, but the way the mind pays attention to it is, “I think there's a threat out there”. And we as animals respond to pain, what we perceive as pain, we withdraw from, and there is probably a safety mechanism in that.

Andrew: Just going back a bit to the surgery aspect. When you were talking about that stress response remains afterwards. I mean, we experience pain after we wake up, we're in recovery. You know, we've just had abdominal surgery or something, let's say laparoscopy.

Mark: Right.

Andrew: And that's when you experience the pain, and the wound needs to heal. Now, what I find interesting when you were just describing that was an example of hypnosis where it was actually in front of us in our psychiatric nursing class. And the psychologist hypnotised a few guys and girls out the front. And then, in this one guy, proceeded to stick a needle in between his index finger and his thumb.

Now, normally when you stick yourself with a needle it wilts, it sort of hangs off your skin and you go, "Ow," and pull it out quickly. This did not wilt, he stuck it in. 

Mark: Mm-hmm.

Andrew: So it was sitting there upright in his hand, he was perfectly fine, there was not a budge, not a twitch. 

Mark: Yeah.

Andrew: After the session, he removed that. And Andrew came up to us later and we were saying "Give us a look at your hand." You could see the dot in the middle with penetration with a slight little bit of blood, nothing seeping out, and then the white pile area around it. So there was an inflammatory type response…

Mark: Yeah.

Andrew: …but no residual pain. I don't get that.

Mark: Ah, for the good old days…

Andrew: I don’t get it!

Mark: …where you can experiment on students in the front row as well…

Andrew: Yeah, I know!

Mark: …that probably wouldn't be allowed right now.

Andrew: Ah, you got no idea what the rest that happened. But I don't get it, like why do you not recover and experience pain afterwards?

Mark: I similarly have seen these things. So things that have bothered me are, I've seen acupuncture...

Andrew: Have you seen UFOs too?

Mark: I've seen acupuncture work with surgery and with painful stimulus and relieving low back pain with meridian treatments. I've seen...we also, in medicine, had our college of GPs and the whole hypnosis thing of just standing there and saying, "You have dipped your arm into a bucket of cold water," and it comes to here, and immediately the arm goes white in that area. 

Andrew: Right.

Mark: So we don't think of conscious control, it's not in a dermatome. And then putting needles in didn't cause bleeding, your hammer is coming out of the bucket, and as the blood spread down there...

Andrew: It's bleeding.

Mark: ...the bleeding came out of the wound. 

Andrew: Wow.

Mark: So I think these are just hints that we think of the controllers, literally, you know, the nerves from the spine going there and the nerves coming back and there is little feedback loops and that's how we manage it. There's something much, much deeper that is going on with the mind's perception of circumstances, self-protection, and it didn't fit any known biomedical model. So yes, when water goes...you put your arm in ice water, there's a stimulus and we say okay, here, the blood vessels shut down. here they don't. But if you draw a finger around it, and say here and here, there's no nerve that controls that, it's the whole of the arm. The vascular system, below the perceived point, does precisely the same as it would as if it was actually immersed in ice water.

But these are lessons about how can it be, that we've taken the very literal approach, there are pain receptors here, they feed up to here, the thalamus filters out some of them, but the rest, it requires magical drug therapy or herbs or, you know, some approaches? And I think the move now is since pain is all perceived in the mind, and disability associated with pain is perceived in the mind, the far more sensible thing is to invoke some of the biology, some of the biochemistry of the body to do the job itself. And so we have endogenous opioids, the endorphins, the met-enkephalins, all of these things floating around in a soup, trying to allow us to distinguish what's a pain that is a threat, or is injury, or is damage that we should do something about, and what's a pain which is a perceived threat, which does no harm or injury?

This, I think, is where we get stuck a little bit as doctors is, a person comes to a hospital, abdominal pain, we examine. If there's no literal cause of the pain, we send the person straight home, usually with, you know, four oxycodone, "Just take the oxycodone and the pain will go away." We're obsessed with this idea that there's real pain, which is organ-specific, receptor-specific, trauma happening, and if we as doctors don't catch it, then bad things will happen. And as soon as we've made sure that bad things won't happen, we lose interest in pain. After that, it's just, "Oh, take a codeine, take a panadol, take a something."

Andrew: Yeah. We have a pill for that. Yeah. Take it.

Mark: And the change is, well, how do you cope with when normal sensory perception becomes painful perception? And I have a practice in this area with chronic fatigue, fibromyalgia. People are chemically-sensitive, noise-sensitive, light-sensitive, the whole sensory system goes on alert the whole time. One theory of this type of disorder is, your exhaustion is because the radars are on 24 hours a day, 7 days a week. And if you are always looking for the next perception of threat, and the body converts that to pain, then we talk about, "I feel pain." Where do you feel it and why? It's not where. It's, "I feel pain." 

Andrew: Yeah. Yeah.

Mark: It’s a global sensation. 

Andrew: Yep.

Mark: And if we can tone that down, if we can say, "Well, there's a way of bringing pain back under control of inducing your own endorphins, your own cannabinoid system." If we've got ways of triggering that, then we have a method of being able to say, "Look, the threat is over. What we're trying to convince your body to do is to understand that the threat is over." And sometimes we're wrong, you know, sometimes we get the pain out of the way and then we find out there actually is damage going on. But most of the time, it's that the body escalates, says, "Where the hell is the next insult coming from?" And the way that's non-specifically perceived is this concept of pain.

We try and tie it down, we press on muscles in fibromyalgia and say, "Does that hurt more?" and you put standardised pressure on it. But it is a global sensation of increased pain in areas where we can find no pathology, and that's one of the big challenges, what's the tools that we should use as practitioners to either induce the body to reproduce its own anti-pain, pharmacology? Or what's the technique that we use to distract and change the way the mind perceives and understands a stimulus? And that is just a fascinating area. As doctors, we still turn back to drugs, you know, low dose amitriptyline, low dose naltrexone, we're still using all of those because we're addicted to the idea of you take a pill or you take an injection and that's the way that things are fixed.

Andrew: Yeah.

Mark: But the opening up of mindfulness, meditation, distraction, giving people who've got arthritic pain just things to do in their nursing home so they're not sitting in the same position every day with nothing else to play on the mind except the pain. When all that's left in your life is pain, then, of course, you experience pain. And pain is...I think we call it half psychic and half real that yes, you've got old joints that are grumpy and they will be sending stimuli to the brain. And if you've got nothing else to do with your life, that's all that fills the space.

Andrew: So there's a couple of quandaries here. One of them is, of course, the resilience if you like, of the patient. If they're one of these stronger types of people, they don't need this issue because they don't feel pain because they don't attribute anxiety to it. You know, a colleague of mine's husband just smashed, and I mean mashed his thumb. And he's just like "Wrap it up, we'll get to the hospital later," sort of thing, "I need to work." Whereas me, I'd be hurting from a splinter. So there's that issue about the caregiver having to not pick your battles, but having to sort of gauge how hard you have to work.

Mark: Yes.

Andrew. And then, of course, there's the practitioner's perspective, they're busy, how much time have they got? You've got somebody that's in "a lot of pain…” 

Mark: Yeah.

Andrew: …now you have to assess what else is going on in that person's life that they're focusing on or experiencing that high amount of pain? How long have I got to delve into this? You know, I can understand, I can fully understand why somebody would choose a pill.

Mark: I know. And we are a society, I think, which has come to expect that there is a pill for everything and pain should be easy.

Andrew: Both patient and practitioner, I can understand both sides.

Mark: Absolutely. And it's breaking that nexus. You know, you talked about resilience. It's absolutely true. I have a 75-year-old farmer from way up West, I won’t identify the area…

Andrew: You were telling me about it.

Mark: ...and he fell over broke his back. They, you know, basically pieced it all together. And he then went back out onto the farm a week later to look after the horses to get back into the farm. And they eventually had to put him in a full-body cast. He went back to the cast, went out to the horses again, fell four meters and broke his back again, and still stayed with the horses. And it was just, to me, the remarkable story...

Andrew: The horses were shaking their heads going, "Oh, here he comes again."

Mark: Yeah. The remarkable story is that by any objective measure, this is a person that should have been in agony…

Andrew: Yeah.

Mark: …but he had a farm to look after. He's 74 years of age at that stage, looking after a farm by himself. It is remarkable what motivation and a desire to do something which you identify as who you are. And for him, like most farmers, they hate doctors, they hate us. And for very good reason, it’s like, "Let me get back to work, please, you know, what am I doing here?"

He went through things that I would have just imagined should have been disabling, life-threatening disability, and did not experience it. And he didn't experience it because there was another life that no matter how actually painful it was, that other life dominated the experience and changed the way the pain was perceived. I asked him over and over, "What about you broke your back? The spine looks like it's been through a little macerator, it doesn't look like a spine." And he's "No, no back pain."

Andrew: Okay, so let's take the other side. And obviously, we won't be mentioning names or any identifying material here. But let's talk about a patient who is in a lot of pain…

Mark: Yeah.

Andrew: …experiencing a lot of pain, and have you discovered that there's a lot of work to do with their mind?

Mark: Yes. As a doctor, and as any healthcare practitioner, you have to make sure that the pain does not signify damage that you should know about and do something about. And so I think that in medical circles, that's not all that hard to do. If there's an acute abdomen, we're pretty good at picking that up.

Andrew: There's an assessment.

Mark: If there is, you know, the pressure of a subdural pain of headaches, the person's had a fall, we do a CAT scan, and we pick things up. And so not by any stretch am I saying there's no stimulus from the outside. What we're trying to distinguish is, is there a threat which is worsening where the pain has a very good value of stopping you doing something that would otherwise get you into more trouble?

And I think that we're pretty good as doctors at just what happens to my pain patients that turn up in hospitals, examine the abdomen, examine the head, do an ultrasound, make sure there's no pelvic pathology inside. Not, "There's no reason for your pain." The next question of the person is, "So what do I do about the pain?" And in the doctor's mind, it's like, "Well, actually, isn't any pain, but you think that there's pain and that is..."

Andrew: But that means there's pain there.

Mark: Yes, that's exactly right.

Andrew: You know, I've heard patients who have said, "You know, I was disgusted because the doctor said it's all in the head." Well, technically, he was actually right.

Mark: Yeah, every pain is all in your head. Every pain is on the mind because failure to perceive pain is an anaesthetised patient, you can't perceive it. And so as far as we're concerned, if you can't complain about it, there is no pain. And so this happens to locked-in people as well, they can't say anything. They can perceive pain and tell you after they've come out of that locked-in phase, "I was in agony and no one did anything about it."

Andrew: Oh, these are the people under anaesthesia that...?

Mark: No, the locked-in meaning the people who are...completely because of infection of a nerve, virus in a nerve. They sit there in hospital, we've all done it as a medical student, the person is looking like they're unconscious there, in sensory terms, absolutely fully conscious and cannot move a thing. 

Andrew: Right.

Mark: They can't talk, they can't respond. And the reason every medical student's been through it is you get taken there and they say, "So what do you think about this person? What do you think...?" Every student, “Oh, I think they've had a swa…” "Would you turn off life su...?" "Oh, yeah, I'd turn off life support.” This person is lying there conscious hearing everything…

Andrew: Everything. Yeah.

Mark: …being said and cannot even flicker an eyelid. So we know that if you can't express it, no doctor or practitioner thinks that there is any pain. What we've tried to do is stop the people expressing that there is anything about pain, so numb the nervous system far enough and pain can be dissipated to the point where yes, you're semi-conscious not really participating in life, you're bummed out, but you're not complaining.

So we do understand that until it is appreciated as pain, there is no pain. And if we're going to move this forward, what we need to understand is that pain can come from normal sensation. So when people with fibromyalgia, chronic fatigue syndrome, post-viral syndromes, trauma, post-traumatic stress disorders, the normal sensory input, the visual input, auditory input, olfactory taste, these become distorted in a way where the person's perception is “that is a threat.” The threat response becomes translated to pain in the mind. Do opioids work? Absolutely not. They just don't touch that kind of a pain.

Person still complains of pain, but what we're seeing is central sensory sensitivity, the escalation by the body to do something to avoid further threat in the future. And the job in many of those cases is to bring that central sensory sensitivity down back to a level where they say, oh, it actually isn't threatening, it's not cancer, it's not trauma. It's not a heart attack when it's chest pain. And to bring it back to a level where we say, okay, we doctors know that there's no heart attack, that everything's working fine there. But you still have chest pain in the apprehension of heart disease, how do we manage those kind of pains?

And I think that's the area that's interesting. You know, we now are using....as I said, in the medical armamentarium, low-dose amitriptyline. Amitriptyline started life as antihistamine.

Andrew: Yeah.

Mark: And then as an antihistamine, it was found that at high enough doses, people felt less depressed, so it became a tricyclic antidepressant. It's now reborn as low-dose Amitriptyline having an effect on pain perception, and the ability to switch that off, and without many of the side effects of the high-dose tricyclics. So there are worthwhile tricks knowing about. Oxytocin is being used more and more. How is it that oxytocin turns off pain? It's a nasal spray of oxytocin they use for pain relievers. 

So changing the way that the mind perceives the whole of the world around you also seem to be effective. And there's one that I wanna talk about it even though it is a bit arcane, this thing of naltrexone. Naltrexone is used to break addictions to alcohol, to break the cycle of opioids, to effectively block the receptors of the opiate receptors around the body in order to stop the drugs that people are taking, often illicit drugs or prescription drugs...

Andrew: And used in SIBO as well, yeah?

Mark: It is. But it's used in a particular way. At low doses, there was this magical thing of the pain of various medical conditions was disappearing when underdose was done. And so at about a 10th to a 20th of the dose of naltrexone, called low-dose naltrexone, it works like magic in more than half of the people who complain of this chronic pain and sensory sensitivity. And it seems that the answer, at present anyways, it does it because it's got a short half-life, you give it before bed, it blocks the opioid receptors. The body goes, “Hey! I'm not getting pain relief during your sleep hours," and ups your own endorphins, ups your own opioids that the body produces. So it's a trick to induce the body to think there's a shortage of pain relief while you sleep so that in the morning afterwards, you are flooded with endorphins, the same stuff that the runners go for.

Andrew: I got a question about it's the dose, or it's a 10th of the dose. Why is it a 10th of the dose? Why isn't the 10th of the dose, the dose?

Mark: Well, that's because...

Andrew: And the other one 10 times the dose?

Mark: ...low-dose naltrexone...So the short half-life means you take it at night and it's gone in the morning… 

Andrew: Yeah.

Mark: …so that it's not blockading those receptors. The body every night says, "I've got to escalate my own opioids," and they have a long half-life that runs right through the next day.

Andrew: But if a 10th of the dose worked, why are we giving 10 times that dose?

Mark: Well, the 10 times of the dose is for different things. So if I'm on oxycodone and I really want to get off it and I take naltrexone, or if I'm an alcoholic and I want to break alcohol, naltrexone blockades the beneficial effects. So at the high dose, it lasts the whole day and the high dose, the point of it is to have it there the whole time so that you don't get any benefit, any high, any good feelings from any of the things that you would otherwise be addicted to. So it's used at the high dose for a different purpose.

What I'm saying though is if you can trick the body into thinking, while you're asleep and while you don't need pain relief, that there is a shortage of protection against pain, the body releases its own chemicals on autopilot and that's what doctor's love. That you give a dose of something, which is somewhere between, say, half a milligram and 4.5 milligrams instead of the 50 to 100 milligrams, and a whole different system kicks in. It's not that it's the best thing to do but it doesn't have dose escalation. And when people come off it, they go right back to where they were in pain. 

Andrew: Right. Right.

Mark: But there's no dose escalation, it's not an addiction to it. And you can then sometimes get people to do the exercise that allows them to produce the opioids themselves. So a person relieved of pain and their perception of pain will then take on activities and distractions and life becomes not just focused on pain, but “what else can I do?"

And I think that that pathway of if you can do something that is not harmful, if you can introduce mindfulness to a person, if you can introduce yoga to some people so that there is, you know, movement of the body, breath, these things are vitally important to regaining a sense of control of the body. You can break a pain cycle, and if you can break the pain cycle, you can start to bring people back to what a normal life would normally blockade their pain. 

Andrew: Yeah, yeah.

Mark: Living life, being at the beach, seeing the grandkids, they are all impossible when you're in agony. But as soon as you can break that pain cycle, these are the things that displace pain. It's not rocket science, it is really, you can break pain, pain stops being the dominating sensation of the body. And I think that's what we as practitioners can encourage people to do. It's not is it in the body or is it in the mind? The good news for a patient is we've said it's not organ damage. That's great news, that's not bad news. Your pain is now much more manageable because we don't have a rotten liver, we don't have a heart that's about to run short of oxygen and kill you.

Once we've done our job as doctors, we tend to leave people to fall off the other edge. And they say, "But they don't understand, I'm still in pain." And if we just went that extra distance to say, "Here's the things that you can do to blockade that pain, really simple, maybe low-dose medications, you can use prescriptions as long as you're not building a future of dependency." If we can do that, then the next step is to take them back into life and the distraction of life and the things that, once pain is gone, fill your mind, don't leave the room for the pain.

And I think that's what I've learned that it's not mind or body, all pain is mind. All pain, there is no other kind of pain. But that pain can be seeing a scene, you know, that pain can be experienced by hearing a loud noise. We're not trying to blockade sensation, we're trying to bring the person back to where that balance between stimulus and response is back in the balance of a normal person. If any of us are normal.

Andrew: Just a little point about the dependence. Depending on the drug, depending on whether it's an opioid or ice, is depending on how quickly you knock out that reward system if you like. How quickly or how long does it take to regenerate receptors so that you can actually experience reward or have pain relief?

Mark: Right. So first step is most of the people that I see that have been put on pain relief and believe themselves to be dependent upon that pain relief. How do they know that? Because if they forget a dose for a day, they feel the pain all over.

Andrew: The escalation requiring more, you know, how long does it take to get them off? And does it actually regenerate receptors so that in the end they don't need as much?

Mark: Whether it regenerates receptors, what I'm really saying is our idea of receptors in the periphery for pain… 

Andrew: Yep.

Mark: …was always pretty flawed. We had this idea that they were pain receptors, and they're really small, unmyelinated fibres, and they travel on up and they give them nonspecific secondary pain. The idea there is if there is tissue trauma, you don't want to knock any of those out, they should be there for tissue trauma. And if you cut yourself, if you're bitten by something, if your hand goes in a fire, you want there to be pain as a learning experience, and there's value to that.

So normal pain response is, ideally, what we want. We don't want people not turning up to hospital with acute abdomens because they've taken so much codeine that they don't feel anything. We depend on pain for the signal for when to intervene medically. What I'm saying is having excluded biological medical causes of pain that we really need to take action about, the next step is to reduce the sensitivity of the person to the stimulus that is causing the pain.

Now, that also requires going back in the history. Lots of people, you do find traumatic sexual abuse, you find all kinds of things in the past history, which keeps on turning doctors on to say, "Oh, it's all psychological," or, "It's all physical," or, "It's all..." There are things that set the stage for sensations that are normal to become painful sensations. And it happens with everybody, we all have our emotional tug points where we feel nostalgia, we feel pain for a particular set of circumstances, it usually relates to something in our past. So we can do something to go into a person's history, doctors don't have much time to do it, but there is always something in the history that says, and here's where it escalated.

And that aha moment happens all the time. If you take time to talk to a person and say, "Before you got sick, before you got pain, what was happening in the six months to a year before?" Almost always you find out that there were traumatic events, there were sensory events, there was a car accident, there was something that has just escalated the perception of pain. Knowing that doesn't fix it. There is, you know, work done by psychologists to go back and revisit it and to desensitise it. But knowing it means that the person now has a hook to hang it on to say, "Okay, I understand that's where it took off." Now, the next question is, how do I unhook that, there is, the trauma is not around?

You know, my least favourite thing is cognitive-behavioural therapy but it works in some people to bring that to cognition. So is it pain or is it a revisiting of some sensation, which I'm now calling pain, and that escalates it itself? So I think that we can, as practitioners, delve back into “is there a point in your history where escalation occurred?” Knowing that, we sometimes get a very good sense of what to do. And I'll go with ones where people get chronic abdominal pain after antibiotic therapy, lots and lots of antibiotics, out the other end, they get bloating, stretchy pain. And that is a pain, the sensation and pain in the gut is a real thing, but there's no pain receptors in the gut, there are stretch receptors.

Andrew: Yeah.

Mark: So some people will say, "I bloat and it's uncomfortable." Other people will say, "It is agony," and it appears to be exactly the same stimulus. What do we do there? Give them probiotics, work out what is going on in the gut, treat their SIBO if there is, you know, a SIBO issue. We still do our natural and medical healthcare, we still fix the things that may be the origins of the stimulus. But just because you fixed it, doesn't mean the person is pain-free. The body remembers the insults, it has a radar out for where's the next tick is coming from.

And the second job is take that away, bring people to an understanding that the problem is fixed and the pain does not need to be perceived anymore. And here's techniques, low-dose naltrexone, low-dose Amitriptyline, mindfulness, yoga, breath. There's a lot, a lot of ways around that. But we need to separate what is medically necessary to know. Don't want a naturopath to miss a heart attack by saying, "It's all about the trauma of your childhood," when a person is running out of oxygen.

Andrew: Yeah, yeah. No.

Mark: So the ability to discriminate, what do I need to know from pain? And when I'm convinced that all the things I need to know as a practitioner, I know, what's a technique that I can now use to de-escalate that hyper-sensory response, the thing that the person is describing as pain? I ask all the time, "Does it feel like stabbing pain, lightning, a toothache, what kind of pain?" And the thing about these types of pain is it's not any of those. It's non-specific, it is painful, you know, when sound hits, I withdraw. And that's the point of pain. The point of pain in many ways is where damage is happening, withdraw, don't do any more with it.

Andrew: Yeah.

Mark: Once we know that the damage is not happening, then the re-education of that nervous system is able to be done. There is an ability now with the new way we're thinking about pain, oxytocin. We even have cannabinoids now, very, very good at triggering the other part of the nervous system. And pain relief from cannabinoids is proving exceptionally effective now that we have medical cannabis available. So the tools increase, what we're sitting back thinking about cannabis for though is plenty of people in medicine are saying, "We thought opioids were okay too." But let's see if there's a dose escalation. Let's see if there's dependencies. Let's see what happens with cannabis. I have a little more feeling that cannabis is going to be safer and that the dose escalation does not occur from experience that I've had so far, but it's still up in the air.

So if we can move from pure pharmacology, what do we do to bomb you out to stop the pain, if we can move from there, back to here's how to dissociate pain. Once we know it's not medical, once we know that organ damage isn't occurring. Once we know the threat response is just a radar that stayed on too long at too high a sensitivity, the tools for reducing that radar and bring it back under control are quite doable.

There's pharmacological approaches but I'm much, much happier about the grandparents that come back and say, "My arthritis has gone out." The knee still looks a little bit swollen, nothing's changed on the x-ray, but they don't experience pain, they're out with the kids, they're at the beach. That's not pain anymore even though the trauma is there. We can't do much about the arthritis necessarily, we are…our job is to relieve suffering, and these are the tools of relieving suffering.

And I think that's the point for our listeners is, as practitioners, it's not is it medical or is it not medical? It's pain, is it perception? Can we work with the medical messages appropriately, and then can we move on to the de-escalation of it so that now quality of life is improved, and as it improves, pain disappears as an absolutely normal process in life.

Andrew: Salient and experienced words from a caring physician. Dr Mark Donohue, thanks so much for taking us through. You know, I mean, this is a real conundrum, caring for patients in pain, it requires a bit of checking in on oneself as well.

Mark: It does.

Andrew: So thanks.

Mark: It does. And as physicians, the whole time, we're trying to weigh what good could we do by relieving pain against what harm? And I think this is a new opportunity to do good without the harm.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.



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