The elephant in the room. Persistent pain and neurocognitive problems.

Moving has always scared me.

I've never been in full control of my body, for some reason I don't know exactly, it's always been stumbling, comes after the mind, gets filled with anxiety, from fear of falling. My diversity in this sense has always weighed on me. A diversity inside, because outside there was nothing different. There is nothing.

Still, there is so much different.

Who knows from outside what you think of me. What do you see. Who do you see.

From inside, you often feel a lot of fatigue. If a certain thing requires a certain amount of effort for a “standard” person, in general I have to do twice as much, with my body and my head.

The inability to control the body, which has dramatically intertwined with persistent pain, inevitably led me to focus on the brain. Read, study, learn, know. Here, my definition as a person, for years, came from there.

I have read many reviews that tell me, my experience, the experience of the symptoms of a person with persistent pain.

A Systematic Review is an instrument of scientific research whose aim is to summarize data on a certain topic, with attention to the sources, which must be highly referenced, to identify all the evidence relating to a specific scientific question.

Finding yourself in Review on persistent pain, on Central Sensitization, always has a certain effect.

Finding yourself thinking about the neurocognitive problems that persistent pain brings after reading a review, however, was excruciating for me.

I have always known (and then read) that persistent pain causes cognitive problems. Finding written black on white, has something devastating: if persistent pain does not matter to anyone, the cognitive problems that pain brings with it, it matters even less, and yet they are there, elephants in a room, which they become, for those who judge you or make you a diagnosis, if you are lukcy, "stressed", or one with a bad slacker attitude if you are not.

This is not a path made of full stops. It is constantly evolving. Because I am evolving. Persistent pain, due to its multidimensional essence, requires me to tell you my own business.

Persistent pain is not something that you are here, he is there and in the meantime you can continue to have your life. He is hugging you tightly, to the point that you no longer understand who you are and who he is.

Well. Now that we are at the point where we understand a little more who I am, because the bulk of the pain has been removed and we can see that I am not a pathological plaintive, which languishes on the sofa waiting for her inexorable fate (that is, what the world evidently believed I was), I can try to deal with this somewhat complicated topic, without feeling like a perfect idiot.

Since 2003, the year in which my symptoms have definitely worsened, I have also started to experience cognitive problems. And this, for a person who identified himself with his "brain", was simply tremendous.

Let me explain: I started having short-term memory problems, the feeling that "I was missing words", of learning, of attention, an incredible slowdown in the speed of information processing. I lived with a perpetual sense of confusion. Health professionals told me I was anxious and stressed. I was afraid of having a dementia principle. In the meantime, my self-esteem was falling apart, and my life with her.

It is not easy to find yourself unable at any moment. Put your ambition aside, abandon yourself to a body and a brain (above all) that do not correspond to you. It means not recognizing yourself anymore, not knowing what to expect, having no plans.

Losing my brain was almost worse to me than losing my body. I've always been an intellectual, not an athlete. Finding myself unable to think was traumatic, frightening and painful. But I "was anxious" and in short, it was right that I stayed in the social rear, because with my way of being, so fickle, I was useful to the world as a wedding favor.

I thought that the anxiety (i.e. what they diagnosed me as anxiety, but I later discovered to be perceptual problems caused by the migraine) and the feeling of incompetence that came with it, had made me lose the ability to be mentally productive (I'm not considering the pain itself, of course). Instead I suffered from persistent pain.

Then I read a few things. With seventeen years of delay.

The basic cognitive processes of the human being are: perception, attention, memory, language and executive functions. All these functions are closely linked to decision-making and the emotional sphere. Each cognitive ability can involve a specific area of ​​the brain or be the result of a network of connections between different brain areas.

People living with chronic pain commonly have cognitive difficulties affecting short-term memory, attention, speed of information processing, speed of psychomotor reaction, higher-order skills such as planning and reasoning, mental ability to easily switch from one task to another, the ability to solve problems.

Although cognitive symptoms are not the primary concern of patients with persistent pain, they can be significantly debilitating and research suggests that it is worth tackling them.

First, cognitive inefficiencies can impact patients' response to treatment. Most of the therapies offered for the treatment of chronic pain require cognitive effort on the part of patients to manage their mood and to understand, remember and complete physiotherapy exercises.

Several mechanisms have been identified that can influence the cognitive abilities of people with persistent pain.

The first mechanism refers to the "limited resource theory", whereby the capacities, in terms of brain processing resources, are preferably assigned to the treatment of pain signals, due to their high biological importance, thus interrupting others cognitive processes.

The second mechanism is maladaptive plasticity. Over time, persistent nociceptive signals lead to structural and neurochemical changes in the nervous system. Changes in gray matter can be observed in the brain of people with chronic pain. These morphological and neurochemical changes that occur in the brain may be partially responsible for the cognitive changes that are commonly observed.

Furthermore, the contribution of secondary factors such as insomnia, fatigue, medications and mood disorders to the experience of cognitive difficulties should be considered, although further controlled studies are needed to clarify the contributions of each factor.

A promising recent development in this field of research is on the possibility of inversion of maladaptive plasticity, with the resolution of pain.

Imaging and neurocognitive studies have shown that pain resolution leads to normalization of cortical thickness and a reduction in cognitive deficit, however it is certainly necessary to understand what can be done to improve cognitive functions, despite the pain.

Certainly educating the patient about the causes and the maintenance of his deficits can be incredibly therapeutic in itself, it allows to legitimize his concerns and to help him understand the reasons for his cognitive difficulties.

After explaining to the patient the probable causes of the cognitive difficulties, the next logical step is to find together ways to better address them, using compensatory strategies. The purpose of compensatory strategies for cognitive impairment is not to repair the deficit per se. Rather, the focus is on reducing the disabilities that can result from those cognitive difficulties.

Compensation strategies may for example include the use of external memory cues, such as a diary or calendar for appointments, a pill organizer so that the correct medications are taken each day, alarms to keep track of time, and others electronic memory aids.

Compensation strategies have great potential and many can be found based on the patient's specific goals.

There is the possibility of carrying out interventions that stimulate altered or underutilized functions, to build or repair neuronal connections through neuroplasticity. For example, if a patient experiences short-term memory problems that cause him to lose the thread of the speech, a "restorative" approach could be to undertake training on memory.

Another solution available can be CBT psychotherapy, which teaches how to manage pain, with positive effects also on neurocognitive functions.

Lastly, movement has neuroprotective effects and improves cognitive function.

The best solution to cognitive problems of people with persistent pain is likely to involve a combination of approaches, individually tailored to the patient's needs based on their profile. There are certainly many translation possibilities in practice.

Everything should start from the recognition of persistent pain as a serious, pervasive, multifactorial problem. The solutions are there. Unfortunately, they seem distant horizons for many. Of course, it is not a valid reason to give up.

What do I do now to deal with all that? I use compensation strategies and try to take it ironically, but it's not easy. It is not easy not to have words, not to remember things, to struggle to move from one thought to another. And this is still tremendously difficult to accept.

But I believe in neuroplasticity and, basically, my path to change my maladaptive plasticity has only just begun. With the body, with that treacherous body that went away on its own, it went well.

Little by little, the brain will also change. He has already done so, after all. And if I lose my words, I can always laugh about it (even if it's not exactly easy for Miss Perfection).

 

Sources:

Optimizing Cognitive Function in Persons With Chronic Pain Katharine S. Baker, BPsySc (Hons), Nellie Georgiou-Karistianis, PhD, Stephen J. Gibson, PhD, and Melita J. Giummarra, PhD Clinical Journal of Pain

 

Stories of electrical systems

The further I go, the more I know people with persistent pain, the more I realize how difficult it is to make people understand how chronic pain is a physiological problem (related to an organic function) rather than anatomical (related to the structure of the body).

We need to see what's broken in our body and, when we find something wrong, we cling with all our tenacity to that thing that, in an ideal body (where ideal would be better "fake"), not there should be, even minimal: that little thing there, becomes responsible for all our pain, even if it is not. But we see and we like this, it comforts us.

Maybe because my pain was abominable, migrant, "referred" not only to muscles and bones, but also to internal organs that were fine, so when it was explained to me that persistent pain is a problem of physiology and not of anatomy, the fact was obvious to me: "Here is an answer, finally".

But it is not so immediate for everyone.

To simplify, we can say that health professionals have a tendency to look for our pain in the building blocks (bones, muscles, etc.), while persistent pain is in the electrical system, in our nervous system (composed of the brain, spinal cord, from the sense organs and from the set of nerves that connect these organs with the rest of the body).

In short, we have a nervous system, which regulates all the functions of our body, and which nobody (none among the health professionals who have not been able to give us a solution) considers.

But how can the electrical system be seen? And how do you know if I suffer from persistent pain and not from an unknown disease that will lead me to the grave (which I know very well is the fundamental question for all of us)?

First of all, to put you at ease, there is one thing called differential diagnosis.

Differential diagnosis is a procedure that aims to eliminate pathologies based on the presence or absence of some symptoms, using a correct medical history, physical examination and various laboratory tests. The ultimate goal is a correct diagnosis. The health professionals you rely on are able to carry out a differential diagnosis, each for their own skills and, in the event of the slightest doubt, they are obliged to send you to another professional figure. If at the end of the process they tell you that you have nothing, you have nothing ... Nothing that will kill you, at least. Forgive me for being honest, but this is the topic.

One of the first things the practitioner will do is ask you to evaluate your pain. In fact, patient self-portrayals of pain are one of the most reliable sources of information and can help understand what kind of pain you are suffering from.

Some simply ask you questions about your pain, while others can use a more formal pain questionnaire, asking you to choose the words that best describe your pain (such as burning, tingling, sharp, dull, etc.).

After that, which seems to be unknown to most, there are tests that a person suffering from persistent pain can undergo. It is often possible to demonstrate a malfunction (or injury) of the nervous system in one or more modalities, by testing the affected areas with different types of touch, the temperature (using an ice cube or an alcohol swab) ... also take note of the presence and distribution of abnormal pain responses. These tests, a professional who deals with persistent pain, should know how to do them and explain to you what they are for, what they tell about your body and your pain.

But the proven proof of my pain?

Well ... All the questionnaires, questions and tests that are made to you are not the result of the madness of your physiotherapist or your doctor, but of the research on persistent pain, which has allowed us to understand how it works and therefore to develop questions and tests to recognize it and diagnose it. Your body, it is not true that it says nothing about pain. In reverse. It tells a lot. The proven proof you have it under your nose, even if it seems impossible to you.

Well ... yes. There are neuroimaging.

Thanks to neuroimaging in recent years it has been understood that the brain of patients suffering from chronic pain shows alterations with respect to function, structure and chemistry.

Neuroimaging is a relatively new technique that uses various methods for mapping the structure or function of the nervous system.

The use of brain imaging and other technologies has led to the understanding that chronic pain is mediated by the CNS ... It remains that the use of these tools as a standard diagnostic tool for persistent pain is inappropriate (according to IASP), because there are no protocols validated and this is potentially harmful to patients.

In short, even if in neuro-images we see, in people with persistent pain, the activation of certain areas of the brain, it is not possible to quantify the pain from the outside.

I can't tell you if you'll ever see pain. But I can tell you that the evaluation of chronic pain is made on the basis of your medical history, clinical examination, questionnaires ... It may seem trivial to you in our medical system made up of a thousand thousand specific tests for everything, but everything that comes to you proposed by a professional who really knows persistent pain, it is the result of research and clinical reasoning (ie the exercise of a set of complex skills, such as critical, reflective, creative thinking), not by chance.

Your body clearly tells the story of its pain. You need to know how to listen and have the knowledge to understand it, above all.

 

Schmidt-Wilcke, T. (2015). Neuroimaging of chronic pain. Best Practice & Research Clinical Rheumatology, 29 (1), 29–41. doi: 10.1016 / j.berh.2015.04.030
Davis KD, Flor H, Greely HT, et al. Brain imaging tests for chronic pain: medical, legal and ethical issues and recommendations. Nat Rev Neurol. 2017; 13 (10): 624-638.

On coping strategies

How does stress work? And what can we do to manage and deal positively with [this] stressful situation?

Semi-serious advice to get serious and understand something more, by dr. Daniele Banquet of Move Physiotherapy - Galactic guide for physiotherapists.
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Have you ever heard of the COVID-19 virus? I think not. But if you try to open some social pages, maybe you will find a little something. After all, not everyone is experiencing a pandemic.

By now we are bombarded by TG, advertisements, newspapers, the Simpsons' forecasts. Everyone, even those who shouldn't, talk about the coronavirus. It is such a particular situation that it is not easy to manage. And the fact that it happened in the social age, makes the period much more complex. Everyone has their say, everyone interprets the data at will, everyone has different experiences. There are those who sing from the balcony and there are those who cry from home. It is just one example of the relativity of experience. Everyone experiences a stressful event in their own way. There are those who despair, who do not find solutions, who do not know what to do and there are those who do not worry about anything (simply because the situation is not clear to them). And it is precisely the stress due to this particular situation that I want to talk to you about.

If in this period you are feeling more pain than usual, you sleep badly, you are tired or you cannot concentrate, do not worry, it is completely normal, your body is doing nothing but reacting to what is happening around you. You will wonder why. The pathways of pain transmission are a bit complicated, but in a nutshell, the stress you are undergoing is altering the central processing and modulation (in your brain) of pain. Negative thoughts, fear, anxiety, do nothing but amplify the experience of pain. Your pain threshold has lowered because the psychological component has altered the balance of the system. What can we do to react to these stressful factors and return to an "acceptable" condition? All you have to do is implement coping strategies. No, not the one you applied to middle school with a classmate. Coping strategies are psychological mechanisms that are put in place by each of us to manage and deal with a stressful situation.

"I don't understand POPO, what did you say?" - Now let me explain.

In a nutshell, when we face a stressful situation, each of us reacts in its own way to be able to face or avoid it. There are those who run away from the problem, or those looking for a solution, or those looking for distractions. It all depends a lot on personality and character. This is not meant to be an excuse to play the Play Station and say "I am implementing my coping strategy".

Now we are all facing the problem of COVID-19 and I ask you a question: "Do you have the solution for this problem?" Do you think it is useful to open all the links where there is an article on how hot water defeats the virus? Or how the mask made with marzipan is better than the one made with puff pastry? Or how a friend's cougar discovered that the virus is actually a conspiracy between the American government and the Lilliputians? Therefore, I recommend the first coping strategy.

Find out, but from reliable sources. The Internet has given everyone the opportunity to express themselves, but this does not mean that everyone has the skills or competences to do it. You can be a good metalworker, or a good carpenter, but this does not make you an expert in virology. Therefore, avoid sites that search for clicks. All they do is fill your head with useless and harmful information. Follow the doctors, follow the ministerial channels, follow the health professionals (not all of them, even in this case there is a need to make a selection).

What other strategies can be implemented? Simple, take care of yourself. Listen to your body and try to understand its needs, if it wants to move, if it wants to rest or if it just wants to be distracted. The only things you can do are those you can act on. Needless to search Google for the new Noah's ark. At the moment it is not expected. I think. Focus your attention on what you can do, on what you can act. Exercise, read a book, play with the dog, cultivate that hobby you abandoned a few years ago, contact your friends, change that light bulb in the closet burnt out since '93. But above all, be positive.

That's right, all these things, done with passion, with desire, and with a psychological predisposition, will make us reduce the perception of pain. They asked us to stay home, we take the time to take care of ourselves. Meanwhile, medicine will run its course, but it needs time. We can only guarantee time if we stay at home. Dedicate this time to yourself that #everything will be fine".

Serendipity (my article on BJSM)

The term serendipity indicates the good fortune of making happy discoveries by chance and, also, finding something that is not sought and unforeseen while you was looking for something else. The term was coined by Horace Walpole in the 18th century and therefore it falls within the category of "author's words".

Serendipity also indicates a typical element of scientific research, when important discoveries occur by chance, while one was searching for something else. In every discovery, as in real life, there is some element of randomness: if the researcher knew exactly what he is looking for, he would not need to look for it, because it would be enough for him to have a confirmation of a reality which he knew already exists.

My life has been progressing this way lately.

I'm not getting things in life, I'm doing something. Well, I'm doing a lot. But I'm making happy discoveries by pure chance. I am following the flow and beautiful things happen.

One of the paper boats I built in the last few months and trusted to the current is an article, which was published in the British Journal of Sports Medicine (BJSM), with the harmless title: Should you first care your ignorance, healthcare professionals? (you can read it by clicking here).

This article was born as a game, as a bet that I would have lost. But no. It has been published.

This article isfor all the people with persistent pain , beated by the genetics and ignorance of those who condemn them to existences that, today, are meaningless calvaries.

This article is for all health professionals looking to make a difference in their daily work, to change our lives, in a world of unprepared who are reputed themselves to be great clinicians and who are not: their ignorance tells us they are not.

This article is not just like any article published in any magazine. It is in the British Journal of Sports Medicine (BJSM): the magazine with the highest impact factor in the world in sports medicine.

This article is peer reviewed. Peer review is a critical part of the functioning of the scientific community, quality control and the self-corrective nature of Science.

All that is written in this article, the incapacity to treat chronic pain, which made me live a tremendous existence for twenty-five years, the discovery of the latest scientific evidence to manage persistent pain, the importance of movement, the uselessness of opiates and anti-inflammatories, the fundamental role of self-efficacy, the pain that is nowhere to be seen, the anger towards a class of health professionals that does not update knowledge, despite the fact that science is evolving ... is peer-reviewed.

So somehow,my story, stops being just a story and just mine. It becomes a weapon to silence fools. Not just for me, but for all patients like me, with an experience like mine. And for all health professionals who deeply believe in the revolutionary change that Science is laboriously bringing to the treatment of persistent pain.

 

This article is really for those who brought me here, building legs, nerves, knowledge, heart. The lists are useless. Those who are in my heart, they know.

 

At the links below you can find two Italian translations of the article.

http://bit.ly/327Z0Pm

http://bit.ly/2q3jhas

 

The pill for persistent pain does not exist

I never talk about drugs. It is a choice that arises from the belief that it is not up to me to do so, in addition to the awareness that drugs are nothing more than a small piece of a great puzzle: those who only place hope in drugs are destined to remain disappointed.
Moreover, the temptation to DIY, especially if you are tired of wandering from one doctor to another, can be high.

But, lately, I am often asked about my medications (no, I will never give you the name). So I think I should spend a few words on it.

The goal, when prescribing pain-modifying drugs, is to enable you to achieve optimal conditions to improve physical function, mood, sleep and ability to manage pain. The name“painkiller”, when it comes to persistent pain, therefore, is a bit misleading.

It is very important to identify the type (or types) of persistent pain you are suffering from (nociceptive, neuropathic, nociplastic), in order for you to be prescribed an effective drug. Otherwise, it is impossible for the drugs to be effective. Indeed, they do you more harm than good. They do not help you with pain and harm your body unnecessarily.

To alleviate a painful manifestation, the use of painkillers is almost taken for granted. It shouldn't be though, if the pain is neuropathic or nociplastic (if you don't understand much about these two terms, I suggest you to read here ). In fact, potentially, the drugs that act on the central nervous system are the proper treatment option for "pain system dysfunctions". These drugs are antiepileptics and antidepressants. The name does not count. What counts is the fact that these drugs are able to interfere with the pain circuit: nobody is epileptic, nobody is depressed, simply, given at low doses, these medications can help to "lower the volume of pain". These drugs have side effects, at least at the beginning of treatment, of which a person must be aware, and they cannot be taken "once in a while". They are therapies, not headache pills. So you need to talk to a doctor who knows not only pain therapy, but the mechanisms of central sensitization.

I emphasize, in case there is a need, that these drugs are not opiates (it is easy to think pain therapy = opiates). Opiates are well known to be ineffective or even harmful for chronic pain. It may also seem us a cool thing to be prescribed with opiates, because maybe at last we feel recognized ("Oh, in the end a POWERFUL drug"). Eww. No. In addition to the development of addiction (so sorry for this pun), exists opiate-induced hyperalgesia, which is defined as a state of nociceptive sensitization, caused by exposure to these drugs. The condition is characterized by a paradoxical response, whereby a patient receiving opiates for pain treatment, may become more sensitive to certain painful stimuli.

And ... What about weed? Uh, weed. Mainstream. In February 2018, the "Canadian Family Physician" magazine published a systematic review of studies evaluating the use of medical cannabinoids. After identifying 1085 articles and keeping 31 relevant publications, the authors came to the following conclusions: there is reasonable evidence to support the use of cannabinoids for the treatment of nausea and vomiting associated with chemotherapy; these products could improve spasticity, particularly in multiple sclerosis. It is uncertain whether cannabinoids are capable of relieving pain, if they do they only relieve neuropathic pain (with modest benefits). However, negative effects (sedation, confusion, psychosis, tinnitus, distorted vision, ataxia, aphasia, dysphasia, memory disorders, psychiatric disorders, diarrhea, dry mouth ...) often occur, to the point that the authors have indicated that the benefits expected must be very high before considering the use of these products.

Pain is complex. Pain is difficult to explain. Medications can help. But don't lose the overview. The goal of a drug, when it comes to persistent pain, is to help you reach optimal conditions to improve physical function, mood, sleep and the ability to manage pain. Self-efficacy is always what you need to have in mind. Find people who can lend you a hand and help you be the real protagonist of your journey to healing. Persistent pain asks us to change our looks. And in these new looks we can find real solutions.

Sources:
Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar;319(9):872–882. PubMed #29509867
A Comprehensive Review of Opioid-Induced Hyperalgesia by Marion Lee, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti, on Pain Physician 2011; 14:145-161 • ISSN 1533-3159
The cannabis paradox Roger Ladouceur, MD MSc CCMF(SP) FCMF, ASSOCIATE SCIENTIFIC EDITOR Can Fam Physician. 2018 Feb; 64(2): 86.
Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis Nanna B Finnerup, Nadine Attal, Simon Haroutounian, Ewan McNicol, Ralf Baron, Robert H Dworkin, Ian Gilron, Maija Haanpää, Per Hansson, Troels S Jensen, Peter R Kamerman, Karen Lund, Andrew Moore, Srinivasa N Raja, Andrew S C Rice, Michael Rowbotham, Emily Sena, Philip Siddall, Blair H Smith, Mark Wallace Lancet Neurol. 2015 Feb;14(2):162-73. doi: 10.1016/S1474-4422(14)70251-0. Epub 2015 Jan 7. PubMed# 25575710

The most important things you need to know about vulvodynia (even if you are a man)

I love Sex and the City. Actually, I never wanted to watch it for years, because it seemed rough and vulgar, but once I did, I fell in love with it. And, in the end, when the series ended, with Carrie walking fresh, happy and proud, bouncing on her heels and on "You've Got the Love" by Florence + the Machine for the sidewalks of NY, I had, and I still have, the feeling that an era was over.

Sex and the City has marked a small revolution, perhaps it will have brought a watered-down feminist instance but. thanks to Sex and the City, women now have a language to talk about their sexual experiences, their friendships, their stories and idiosyncrasies.

Of course, attempts at post-feminist emancipation always remain confined to a world that is ultimately "feminine" and heterosexual, but not too much. In short, I love it. Period. It was a socio-cultural phenomenon that cannot be ignored.

And yet there is one thing I don't forgive in Sex and the City . Season XNUMX, episode XNUMX. Do you remember that certain moment when Charlotte tells her friends that she was diagnosed with vulvodynia and that her vagina is "depressed?" Depressed. The vagina is depressed. The dullest explanation I’ve ever heard . I also went to listen to the original audio, to make sure there were no "poetic licenses" in the translation. No. The vagina is depressed, both for Italians and English speakers.

Fine. My personal experience with chronic vulvar pain, because yes, I had that too, is quite descriptive of the situation. First of all, speaking so deliberately of my modesty, I am actually breaking the first taboo because yes, we don't talk about it, we don't have to talk about it. So my mother, as a good feminist, I think she did some damage, making me so shameless about it.

We live in a somewhat phallocentric society . From a quick search, I notice that the "market" of erectile dysfunction (the only male medical condition with which it seemed reasonable to create a comparison) is saturated, with new studies being published continuously: the references on PubMed are XNUMX, collapsing at XNUMX on the theme "vulvodynia". I agree if you object that, among the papers I mention, there are certainly also low quality articles, but you will agree that, even if you want to make a skim and keeping only those of high quality, there is proportionally no history.

Vagina either doesn't care (scientifically speaking) or is scary. And this complicates things. It's strange, considering that the 16% of the US female population encounters vulvodynia in their lives. If we extend statistics to the rest of the world, the problem is remarkable.

An American study of XNUMX titled "The girl who cried pain: a bias against women in the treatment of pain" showed that, despite the fact that women live pain more frequently than men in their daily lives, men receive better treatment for their painful symptoms . A chronic disease of any kind already has a stigma, but this is worsened if the condition is invisible, explains the UK Vulval Pain Society website. And pain is the only manifestation of vulvodynia.

Imagine therefore a chronic painful disease, without an apparent organic cause, applied to a woman, to the most representative anatomical part of femininity, and you will have created the perfect storm.

I know vulvodynia. It destroyed my existence, made me lose jobs, let me discover the benziodiazepines and self-harm. And, frankly, I never understood anything of it, except that the symptoms, which I had learned to control with breathing and biofeedback, are among the ones have disappeared since I started my treatment for central sensitization.

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Depressed vagina, depressed vagina ... my dear Charlotte, you miss a bit of definition. Not only is our friend V. depressed because she cannot perform her sexual functions, but she is also deeply saddened. From an emotional and physical point of view. Burning pain, often constant. This is what patients who have had the misfortune of knowing vulvodynia report.

In XNUMX the Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia reported the following definition: localized pain (clitoral or labia minora) or generalized, provoked or spontaneous, with primary or secondary origin (recurrent candidiasis), constant or intermittent (menstrual cycles).

Vulvodynia impacts more or less with the normal course of patients' daily life and this depends on its characteristics and how it can be "subjectively debilitating". After all, pain is a projection of our central nervous system and it is up to the individual to determine the intensity or not.

By grace, pain remains pain and a blowtorch constantly present on our most precious treasure, and it affects our lives, of course it does . It affects the perception of our body, how we conduct our lives and how, inevitably, we live our sexual sphere.

"Come on, after all it's just a bit of inflammation, put some cream on, you will surely get irritated with those super tight jeans ... Let's use a little lube honey, you're just a little tired and stressed." Aha, yes, fairy tales.

Vulvodynia is a neuropathic pain. No one is crazy, none is hysterical. The central nervous system changes, becomes sensitive, becomes constantly touchy, that's it.

The damage can be located anywhere in the nervous system: in the peripheral system, in the spinal or supraspinal system, in the brain.

The explanation is "simple": the nervous mechanisms that modulate the sensation of pain are confused and can send the information nociception to the brain in an amplified way; in the same way the brain "can cry wolf" just because something is working too much and too often. Clinically, neuropathic pain is characterized by two abnormal sensory processes, called hyperalgesia and allodynia. In the first case we mean an amplified response to a painful stimulus which is normal in itself; in the second we mean a change in the perception of the stimulus from tactile to "painful burning". It is not a mirage, after all.

Fortunately, these mechanisms begin to be chewed by most: now we consider psychosexual factors a direct consequence of vulvodynia rather than the cause.

The interaction between biological, predisposing, precipitating and maintenance factors, which contribute to the organic and neurogenic damage of the vulva, can interact with psychogenic factors, which always have a neurochemical correlation. Neuropathic pain is basically a clinical diagnosis that needs to be confirmed by reproducible tests or diagnostic tests (to make it short: we must "see pain somewhere" in a diagnostic exam).

It often happens in the studio that patients come with a sort of personal encyclopedia. The famous "doctor shopping", but no one has managed to find something that could be the source of pain: folders on medical files, all negative. The patient is desperate, suffers, but "has nothing", according to the tests. It happens, very often. Until some time ago we were amazed, displaced and frustrated. Luckily, in the XNUMX those great geniuses of the IASP - International Association for the Study of Pain have found the need to introduce a third point of clarification for those who have "nothing" (nothing to be found or to be seen in a laboratory test ). Nociplastic pain. I quote: pain that emerges from an altered nociception without injury or threat of a tissue that may be the cause of activation of peripheral nociceptors or evident injury to the somatosensory system that may cause pain.In practice, there are people who feel "spontaneously". In this case, especially in this case, the psychosocial component plays a fundamental role as an additional activator of the algogenic process by activating the circuit of the dog chasing his own tail.

Rosemary Basano has conceptualized a model that explains, in a circular manner, the sexual functioning of a woman. The context and the mental state are the most important elements of the female sexual cycle. The interlocking rings of this chain are also sexual stimuli and finally emotional and physical satisfaction (orgasm). The mental state of a woman with persistent vulvar pain or a dyspareunia will certainly not be predisposing. Let us consider that we are facing a woman with a superfine mental strength, one of those who is not discouraged: the coital pain due to dyspareunia interferes with the various aspects of sexual function. It directly inhibits vaginal lubrication, causing excitation difficulties with vaginal dryness: orgasmic difficulty, frustration, dissatisfaction, secondary loss of sexual desire and mental excitement with consequent avoidance of relationships.

When the symptom immediately manifests itself as vulvar pain, it is associated primarily with an inflammation of the vaginal mucosa. This then determines the defensive contraction of the levator ani muscles (main components of the pelvic floor) and, finally, the proliferation of the pain fibers. When instead, on intact vaginal muscosa, the starting symptom is the pain during sexual intercourse, the first consequence is the defensive contraction of the levator ani muscles, followed by the blockage of the lubrication, microabrasions by penetration and proliferation of nerve fibers of pain with vulvodynia finally neuropathic. (Graziottin et al. 2011).

Doctor, what can I do?

Natalie O.Rosen in her review sought to investigate, basing on existing literature, what could be the best treatment for vulvodynia. Her conclusion, which among other things also supports the Fourth International Consultation on Sexual Medicine, points out that the best treatment options are: psychological interventions (no, not because someone is crazy, but to learn how to manage pain in everyday life), pelvic floor physiotherapy, vestibulectomy (for the provoked vestibulodynia).Pharmacological treatments can be beneficial and include antinociceptive agents, anti-inflammatory agents, neuromodulators, muscle relaxants.

As mentioned above, there is a clear link between vulvodynia and pelvic floor muscle dysfunctions, which can be translated into hypertonicity, lack of strength and control. The goal of pelvic floor rehabilitation is to restore functionality to muscles and tissues, lower neural tension, improve sexual function.

Manual pelvic floor therapy includes a wide variety of techniques such as stretching, massage and trigger point treatment by acting directly on the treated area and neuromodulating the information that reaches the central nervous system from the periphery. We are going to treat the central nervous system, indirectly.

Retrospective studies have reported significant improvements in referred pain, in dyspareunia, in sexual functions after the application of TENS: a current that is able to close the "gates" at the medullary level that send the altered information of pain to the central nervous system.

Rehabilitation yes, drugs perhaps, therapeutic exercise? The low-load therapeutic exercise, adapted to the individual, has basically the same effect as the neuromodulatory drugs. Exercise makes our body produce good stuff, stimulating it, keeping it alive. Among other things, let's not forget that patients suffering from vulvodynia may be subject to fibromyalgia and other pathologies that deal with chronic pain.

Rehabilitation yes, drugs perhaps, therapeutic exercise yes and a lot of awareness.

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Unfortunately, scientific information, even among doctors, is struggling to spread and the lives of patients suffering from vulvodynia are often an odyssey from one specialist to another, from one therapy to another without any result. If, after treatment, as it happens, because it is not specific to the problem, the symptoms remain, the patient is told that she has nothing and often to go to the psychologist. The diagnosis, therefore, almost always becomes that of psychosomatic illness. Unfortunately it is a rather widespread situation and it often happens that patients find themselves without a cure and with the label of "imaginary invalid". However, some studies point out that the psychiatric profile of women with vulvodynia is not different from that of women with other vulvar disorders.

So we return to one of our usual discourses. There must be a greater awareness of the condition both among health professionals and the general public. Physicians should be better trained to recognize and diagnose vulvodynia to know what treatments to offer, but also how to explain patients their condition.

Perhaps the only accuracy that Sex and the City offers, is when Charlotte's friends respond to her "Vulvo-what?" while revealing her diagnosis. This reaction is too common among ordinary people and even among health professionals. As always, fortunately, there is scientific research, but there is the usual disconnect between research and practice.

Maybe Sex and the City didn't really fail miserably. It did it in trivializing the serious and complicated nature of this condition, but it had the merit, at least, of making people talk about the problem, after almost twenty years (sigh!) from that episode.

 

This article is not one's all me. Half of it was written by Carla Sforza, who helped me make sense of a big black hole in my life. She is one of the "beautiful discoveries" that "Le Stelline" brought, and for which I will never be grateful enough. Carla is a freelance physiotherapist, manual therapist, specializing in rehabilitation of the pelvic floor in female urinary incontinence and chronic pelvic pain. You can find her on Facebook as Fisioelle.

Sources:

"The girl who cried pain: a bias against women in the treatment of pain" by Hoffmann DE, Tarzian AJ. on The Journal of Law, Medicine and Ethics 2001 Spring; 29 (1): 13-27 PubMed # 11521267

2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia by Bornstein J1, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D, ​​Coady D on Obstet Gynecol. 2016 Apr; 127 (4): 745-5 PubMed #27008217

Psychological characteristics and outcome of patients attending a clinic for vulval disease Fenella Wojnarowska Richard Mayou, Sue Simkin, Alex Day on Journal of the European Academy of Dermatology and Venereology, July 2006

Graziottin A, Murina F. Vulvodynia diagnosis and treatment strategies. Springer- Verlag Italy 2011

Rosen NO, Dawson SJ, Brooks M, Kellogg-Spadt S. Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches. Drugs. 2019 Apr; 79 (5): 483-493. doi: 10.1007 / s40265-019-01085-1. PubMed PMID: 30847806.

www.vulvalpainsociety.org

www.nva.org

 

Kinesiophobia state of mind

Kinesiophobia State of Mind.

Once yes. Phobia. Fear of movement. Chronic fear of movement. I've always had it. From what memory I have.

Kinesiophobia is defined as excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability due to a painful injury or repeated injury. Here. I have always had motor difficulties (the sisters in kindergarten did not help), which did nothing but get worse at school, where nobody cared about my fatigue, on the contrary: I found myself overwhelmed by a flow of kids, whose skills motor skills were certainly superior to mine and I was asked to adapt to their standard, without having the means, with catastrophic results. So for me, moving and hurting myself was the norm. I started having the fear of physical education classes, during which, in junior high, I remedied the whiplash injury that caused the lesion that causes the occipital neuralgia, I broke a couple of flexor tendons of the fingers and other various figures of 💩 that I'm not telling (not to mention the apocalyptic fall that paved the way for persistent pain, but that was accidental).

I believe there is little wonder that it has become kinesiophobic. Somehow, my body has always been a traitor. It was normal for me to choose the brain. It was certainly more reliable.

Obviously, over the years, my kinesiophobia has nurtured and made strong of "don't move", which the various health professionals have offered me. I was happy that I was told not to move. The fact is that kinesiophobia is related to chronic pain. Understanding this relationship can be difficult, but it is important in addressing the "dysfunctions" that can "cause the pain cycle". To sum up, the belief that something is wrong with our body, and the belief that avoiding exercise will prevent an increase in pain, lead to a vicious cycle involving avoidance of movement or any activity that could (could, in theory, in our opinion) cause pain or injury. Over time, the inactivity that results from this fear leads to psychophysical consequences such as muscle wasting, loss of mobility, and an altered response to painful stimuli and behavioral changes, which can contribute to perpetuating the pain. In short, a mess: we trap ourselves (unknowingly) even better in the problem.

Immersed in my kinesiophobia, when Luca showed up saying that I had to move to manage the pain, I thought he was crazy (sorry). Because it would have hurt, because I was not able. And it didn't happen that way. What happened was that in my journey I had people who welcomed me. They listened to my fears and, one kg after another, they helped me make it.

So, when I mirror myself, with a barbell on my shoulders, and I see all the intelligence of my body, which only needed its time, not to be overwhelmed by the flow of "others", I don't just feel free from pain, but also from fear and insecurity. And I firmly believe that the modicum of self-esteem that I managed to recover has passed and passes through the tool that I felt less congenial: my body.

My body, which I look more and more astonished.

 

Sources:
Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999; 80 (1): 329 – 339. doi: 10.1016 / 0304-s3959 (98) 00229-2.
Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception — I. Behavior Research and Therapy 1983; 21 (4): 401 – 408. doi: 10.1016 / 0005-7967 (83) 90009-8.
Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015; 20 (5): 1 – 10. doi: 10.1002 / ejp.795.

In search of the lost symptom

"The drug removes the symptom, but it does not help to deal with what has led to being sick. Psychotherapy removes the symptom and allows us to face the difficulties that led to the development of the symptom ".

Mh.

Calm. Let's keep our heads. As a basic assumption, it can work.

Psychotherapy has led to a demand for renewal in relation to a tendentially mechanistic vision, in some way functionalistic, of the human being. However, we cannot consider psychotherapy a panacea for all ills or, at least, not in the case of persistent pain. If psychotherapy has changed the view of the human being, which therefore is not a machine, it seems to have jammed on one of its fundamental premises. Pain is considered as an expression of dissociation from emotional trauma: it seems to be an axiom. But is it really an axiom? Persistent pain challenges it, in a scientific way.

Although there are predictive psychosocial factors (emotional trauma, adverse socio-family conditions ...), these are not a sufficient condition for the development of persistent pain (not all those who have persistent pain, have experienced such conditions): pain necessarily has a demonstrable and verifiable biological basis (including nociplastic pain, for which structural and functional cortical changes are appreciable - the famous pain "which is nowhere to be seen").

If pain is a problem on an organic basis, it is not human to think of treating it with exhausting psychotherapy sessions in search of lost trauma, which may not exist (and often does not exist). Rather, it would be useful to renounce the premise pain = dissociation and stop considering people with persistent pain as sick people: they have a disease, they are not their disease, provided that persistent pain is a disease, rather than a (psycho) physical condition.

Scientifically, neurosciences question the premises of psychotherapy. A person with persistent pain is not a sick person, he is a person who lives a (psycho) physical condition, but he is not to be identified with his problem, with his difficulty, with his painful condition, he is a person who needs to be treated, but not in medical terms: he needs to be accepted, tout court. The aim of “cure medically intended” is to lead to the condition prior to that of the disease: it is often not possible. Psychotherapy, accepted all these assumptions, should be genuinely open to these new demands.

The Science of Pain, is a new science, which looks at an ancient problem with new eyes. It is not possible to think of finding innovative solutions while remaining anchored to old prejudices. Psychotherapy, which at the dawn of the twentieth century became the bearer of a revolution, has the possibility of renewing itself by playing a new and very important role, giving people with persistent pain different looks and alternative tools to deal with their own experiences in a constructive and effective way , detaching itself from the old vision of which we have spoken that, in this case, demonstrates its ineffectiveness.

In the case of persistent pain, intervention on the symptom is not useful, because we act with the idea that it is the manifestation of something, of the famous "repressed trauma", while pain is not the symptom, but the manifestation: if you enter into this perspective you can try to understand how it affects the life of those who live with it constantly and therefore it becomes possible to work at different levels on pain and its manifestations, undermining the idea that there is something to cure, to try rather to understand how it is possible to increase self-efficacy and live well with pain.

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(We chose to talk about psychotherapy, not psychology, because it intervenes directly on the epistemological constructs of the personality and on the functioning of the persons themselves).

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Article written with Andrea Ghirelli, trusted friend, educator, family mediator, systemic relational counselor.

 

Sources:

Chronic pain epidemiology - where do lifestyle factors fit in? by Oliver van Hecke, corresponding author Nicola Torrance, and Blair H Smith Br J Pain. 2013 Nov; 7 (4): 209 – 217. PMC4590163

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here? by Hannah N. McKillop, and Gerard A. Banez2 Children (Basel). 2016 Dec; 3 (4): 38. Published online 2016 Nov 30. doi: 10.3390 / children3040038 PMC5184813

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and Their Efficiency by Kai McGreevy, MD, Michael M. Bottros, MD, and Srinivasa N. Raja, MD Eur J Pain Suppl. 2011 Nov 11; 5 (2): 365 – 372. PMC3217302

New concepts of pain, by Anne-Priscille Trouvina SergePerrota on Best Practice & Research Clinical Rheumatology

Bardolino Chiaretto Bentegodi, 2018

 

Just a (wrong) word

I can seem a cold person, lonely, indifferent and devoid of feelings. Not so: I had to build an armor. Because surviving physical pain has been complicated. So complicated, that sometimes I don't know where I ended up.

It was even more complicated to survive the sense of inadequacy that caused me to fail to heal, despite all my efforts.

Up to about twenty-two, I don't think I was fully aware of the pain. There was, but it wasn't scary. It has started to be so since the summer of 2003, due to the combination of a number of factors, which I can now clearly identify (psychological, social, environmental, biological), but which at that moment completely eluded me.

In that summer, the pain, and a series of absurd symptoms, began to eat everything. I am no longer just talking about musculoskeletal pain and allodynia, but rigidity, sleep disturbances, stubborn headaches, tinnitus, irritable bowel, alterations in the perception of body temperature, tachycardia, allergic symptoms, dizziness, confused head. I felt like a crazy fly in an upside down glass. At that point I, already a loyal customer of countless physiotherapists, started my tours with doctors, who invariably resolved themselves in trips from shrinks or in bankruptcy treatment and consequent iatrogenic damage.

My pain and my "related" symptoms did not go away as planned, not as I expected, and not even as doctors, physiotherapists, osteopaths, chiropractors and shrinks were expecting.

So, at some point, I became the problem. The problem was not the pain, or my symptoms, or the tremendous situation I was in, or the treatments that didn't work. It was not those who treated me that he had insufficient knowledge about the mechanisms of persistent pain. No. I was the problem. And I was told in the face. As if I were hostile to healing.

As human beings, we generally like to think we are prepared and empathetic, but I wonder if we ever really think about the power of words. Because words build worlds. And the ones I heard from health professionals, have shaped my world and my personality.

Looking back, it's no wonder I was so ashamed of having persistent pain. No wonder I felt guilty. Because everything possible has really been done to make me feel inadequate, not so much unable to deal with the situation as directly responsible for its maintenance. I'm not saying it was done deliberately, with the intent to harm, but the result is this.

It makes no sense to deny the complexity of pain by offending the patient, yet it is what happened to me. We are people with persistent pain, not bad people, lying, fragile, incapable, uncooperative, irretrievable, condemned to pain "because of us"; we live in terrible situations, we are forced to adapt to a "standard" with which, frankly, no human being would like to confront: I know that I often say, that I am repetitive, it is just that I want to enter into your head well. Living with chronic pain is not normal.

Considering how important language is for those suffering from pain, any health professional should be prohibited from using inappropriate terms, those that end up making us feel weak, guilty (you'll end up in a wheelchair, just learn to live with it, it's the worst that I've ever seen, you only have Lourdes left) or ineffective (the pain doesn't go away because you don't want it to pass, you're like this because of yourself), crazy (you're doing it too big, you can't see anything from exams). The collection can easily be expanded. These words take us away from healing, first of all. Secondly, they are inhuman. And, in our heads of people with persistent pain, they consolidate a world of ineptitude and guilt.

A key task in pain psychology is to help people learn to reframe their inner monologue so that it becomes more realistic and supportive. Being able to catch and recognize unnecessary or unrealistic impulses is not easy, but this skill underlies many successful adaptations to persistent pain. This insight forms the basis of cognitive behavioral therapy (a form of psychotherapy that aims to change unnecessary thinking behaviors), which plays an important role in helping people live with persistent pain. Living with persistent pain, living well with pain, is a fully achievable goal, I know from personal experience. I would add that it is fully achievable in a context in which the patient is not regularly kicked by health professionals, which still often happens.

If the patient is to be guided towards a greater awareness, the same must happen for those who take care of him: health professionals should motivate people with persistent pain, offering a language that must be carefully chosen in order to take more care of the patient, not to rub against him.

When a treatment doesn't work, it's human to find someone to blame. I would avoid accusing the patient, I have already said that. I would also avoid blaming the clinician (although in this case, I admit, it takes me an effort of mercy, I'm biased). Moreover, by accusing each other, we do not have much to gain. Surely a motivated patient is one step closer to success, and a health professional aware of their limitations will know how to motivate a person, respect them, pass on the right information, when to stop and pass the baton, or choose to inquire.

I don't think health professionals are naturally evil. I believe that once we assume that the "old way of proceeding" we are used to is deleterious, just as we look for new ways for patients to help them reframe their thoughts in order to live well with pain, it must be given greater emphasis on the importance of “communicating pain well” by health professionals.

If patients wish to be helped, I assume that health care professionals want to help, so if we interpret the patient / health professional relationship as a dialectic and not as a match between opposing teams, we could achieve something good for both categories.

There is hope for everyone.

When chronic pain kills

One of the "interesting" things that have happened to me since I started to leave chronic pain behind me is that people have started to recognize my illness. People who had denied it for years, when they saw me go to the gym twice a week, run, treat myself with medicines "never heard of" and literally become someone else, began to think (more than anything else to understand) that I was "Really sick".

At that point, even the most unsuspected, not only began to ask me for information for the friend who is suffering or (even) for themselves, but also to tell me about those acquaintances of theirs who, for years, sought help because they suffered from terrible pain. and that, in the end, unable to find it anywhere, they decided they had had enough.

I had always thought that chronic pain could ruin a life to the point of suicide. I myself had thought about it, for about thirty seconds, in the summer of 2003, looking at the pavement from the second floor of the house. Now I had some more empirical data, which wasn't just about me.

Surely it is not pleasant to talk about suicide. It's not a topic to talk to. But generally, problems are not solved by ignoring them.

We, of chronic pain, kill each other. I don't feel like turning a blind eye.

In fact, unless there are specific underlying pathological conditions, chronic pain "in and of itself" does not die. It is possible that a predisposition to cardiovascular disease develops, probably caused by the prolonged anxiety and stress to which those suffering from persistent pain are exposed, but this is a condition that can be managed with the appropriate strategies.

Other factors related to increased cardiovascular risk, cancer and lung disease, often also affecting chronic pain sufferers, are too high BMI, inactivity, poor diet, but they are all factors related to lifestyle, which suffers the effects negative of a series of prejudices on chronic pain (in particular the need to reduce movement, which is deleterious), not on chronic pain itself: by improving the lifestyle, one returns to "normal" ranges.

In short, I don't think I have to explain here what it means to live with persistent pain but, to summarize, it means carrying a load of pain that, in the long term, physically and psychologically is simply devastating. First the body is stolen, then the psyche, sometimes the whole. If he eats it. It takes life. Point. And you can get to contemplate suicide.

Suicide rates are more common among people with persistent pain.  Risk factors in this population can generally be conceptualized in terms of two categories. The first includes factors that are not limited to pain patients but are associated with suicidal tendencies in general. The second category groups specific risk factors for people with pain. Some of these are difficult or impossible to change, such as the duration of pain, or where the body is affected. Others, such as the intensity of pain, the tendency to catastrophism, functional interference, poor self-efficacy, can be improved with appropriate interventions (and this could be considered good news).

Although rarely discussed, suicide in people with chronic pain often occurs. There is no concrete data on how many people with chronic pain die by suicide every year. But there are some assumptions. It is believed that on about 40.000 people who succeed in their suicide attempts every year in the United States, at least from the 10 to the 15% are people suffering from chronic pain. The truth, of course, is devilishly difficult to understand with certainty (I don't want to dwell on dissertations on the subject, but we don't have the data of people who don't leave letters explaining their motives and often it is not possible to frame opiate overdoses as intentional acts, etc.).    

Since individuals with chronic pain are at least twice as likely to report suicidal behavior or commit suicide, it is of the utmost importance to identify which risk factors contribute most to the increased risk of suicide. There is strong evidence that chronic pain itself, regardless of type, is an important independent risk factor for suicide. The only socio-demographic factor found associated with suicide in individuals with chronic pain is related to unemployment and disability. Depressive symptoms, anger problems, harmful habits (e.g. smoking, alcohol abuse, illicit drugs), adversity in childhood or adulthood, and family history of depression or suicidal tendencies have all been identified as general risk factors.

Regarding pain-related factors, sleep problems, low mood, concomitant conditions of chronic pain, and more frequent episodes of intermittent pain, all were considered to be predictors of suicide. Unexpectedly, the characteristics of pain (e.g. type, duration, intensity, severity) and physical state do not appear to be related to suicide risk. Psychosocial factors (for example the sense of mental defeat, the tendency to catastrophism, despair) are more significant, associated with suicidal outcomes.

A large number of these factors are susceptible to change through targeted intervention, underlining the importance of comprehensively assessing chronic pain patients at risk of suicide, while also incorporating a suicide prevention component into chronic pain management programs.

The plight of chronic pain patients, and their potential link to suicide, is unlikely to improve until the chronic pain epidemic is genuinely taken seriously by implementing truly effective strategies that do not rely on prehistoric treatment of the problem. .

People living with chronic pain are the reason why increased care funding is needed to manage chronic pain, at all levels, starting with the training of health personnel (and others). The weight of pain often exceeds the human will to live, too often not because research is lacking, but because of a dramatic lack of skills on the part of those who should take charge of the health of patients, who are left to themselves, lives without lives, in which the pain leads to a disintegration of the lived, of the relationships, of the personality, with very serious repercussions, which should no longer be ignored. 

Sources:

When pain kills - chronic pain and chronic diseases by Chris Williams on Body in Mind read it here

The Painful Truth, by Lynn Webster

A Nation in Pain. Chronic Pain and the Risk of Suicide by Judy Foreman on Psychology Today

Chronic pain and suicide risk: A comprehensive review, by Melanie Racine Neuro-Psychopharmacology and Biological Psychiatry PubMed # 28847525

Testing the Interpersonal Theory of Suicide in Chronic Pain by Wilson KG, Heenan A, Kowal J, Henderson PR, McWilliams LA, Castillo D on Clinical Journal of Pain PubMed #27768608

Remission From suicidal Ideation Among Those in Chronic Pain: What Factors Are Associated With Resilience? by Fuller-Thomson E, Kotchapaw LD on The Journal of Pain PubMed # 30979638