For 20 years, Dr. Vania Apkarian has dedicated his research to the study of pain and how our brain perceives that experience. More recently, his focus has shifted to how chronic pain develops in injured patients and how to better treat those affected. It’s a good thing too, because chronic pain impacts 1 in 5 Americans and costs society around $500 billion a year to manage. That alone is enough to catch the attention of the medical and scientific communities. However, not only is chronic pain widespread, but it’s also widely mistreated by well-meaning physicians who prescribe opiates as a one-size-fits-all solution for pain management. It’s no wonder we have an opiate epidemic on our hands as well! But Dr. Apkarian seeks to shed light on the source of chronic pain with his research and develop treatment solutions that provide a better quality of life and quality of care for patients.
The Art of War
In his prolific masterpiece The Art of War, Sun Tzu encourages his reader to know their enemy. If I were to summarize my conversation with Dr. Apkarian it would be that we are losing the battle against chronic pain because we don’t understand our enemy at all. Acute and chronic pain are different. Any doctor worth their salt can make that distinction. But few actually treat these conditions differently. Oftentimes, chronic pain patients are presented with a slew of opiates to dull the pain that puts them at high risk of developing an addiction. But Dr. Apkarian suggests that if we really understood the neuroscience behind chronic pain, we would be committed to discovering better treatment options.
A foundational discovery of his research is the fact that acute pain and chronic pain show up in different areas of the brain when observed demonstrating that the brain perceives these types of pain differently. While acute pain is perceived as an external stimulus, chronic pain has more of an introspective perception and is associated with the mesolimbic circuitry that deals with emotions, motivation, and learning. This is significant because if acute pain persists, that mesolimbic circuitry pushes the cortical circuitry to reorganize connectivity resulting in a chronic pain state for the cortex and the patient. Meaning chronic pain quite literally rewires your brain to cope with a constant negative emotional state.
The long road ahead
My first question for Dr. Apkarian upon learning this information is “Are these changes permanent?” Can you reverse the effects of long-term chronic pain? His answer provided both encouragement and a sobering realization of where we are at in the effective treatment of chronic pain. Yes, some of the changes caused by chronic pain are reversible. Things like meditation and multimodality management tools can restore some of these functions. But we are not yet in a place where there is a “magic bullet” solution or drug to solve chronic pain. Dr. Apkarian reminds us that these are HUGE circuitry organizations being reorganized and whole cortical function properties being redefined by this prolonged pain experience. We are just beginning to demonstrate these processes and understand how to manipulate them. The future looks bright, but it’s still a ways off.
What Dr. Apkarian needs the medical community to understand in the meantime is that much of our current interventions for chronic pain issues are a part of the problem. Prescribing opiates at will for an issue that lives in the learning and behavioral part of the brain is training patients to become addicts. Or that cutting neural tissue has just as much probability of causing chronic pain as it does curing it. This is not an easy fix and will require a delicate and deliberate touch until the science catches up. The question he poses is “Can we identify for a given patient what is the optimum route? And can we get to the point where we can actually cure these patients as opposed to managing them?” He believes so. But he also recognizes that it’s a long road ahead.