麻豆传媒

WE FIRST knew something strange was going on when Clare, my wife, was given intravenous morphine in the emergency room. She had excruciating pain in her ribcage and back, which had started months earlier and was getting worse. At its peak, she described it as feeling like somebody had thrust two swords between her ribs and was prising them apart.

Morphine gave no relief. The doctors were baffled. Clare spent five days undergoing tests. She was eventually discharged with a diagnosis of complex regional pain syndrome and a bag of powerful antidepressants, sleeping pills and anti-anxiety meds.

She didn鈥檛 have complex regional pain syndrome. I looked it up and the pain was in the wrong place. But it took another six weeks to find out what she did have, during which time her physical and mental health declined alarmingly. I eventually secured a consultation with the complex pain team at University College Hospital in London, who told us she had nociplastic pain. It was a non-deteriorating condition, we learned, and it was manageable.

The team鈥檚 leader, Fausto Morell-Ducos, explained that nociplastic pain is the 鈥渢hird category of pain鈥�. The first is nociceptive pain, which responds to an injury or inflammation. The second is neuropathic pain, caused by damage to sensory nerves. Both are created by the brain as a defence mechanism against further injury. The brain assesses signals from the damaged part of the body and transmits instructions back to the site of the damage that generate an appropriate level of pain.

Nociplastic pain is when that system goes wrong, a state known as central sensitisation. The brain鈥檚 pain centre becomes hypervigilant and responds disproportionately to minor injuries or inflammation, converting them into excruciating pain. In some cases, there is no nociceptive pain at all, but the brain still sends out extreme pain signals. Negative mental states, such as anxiety or tiredness, can also be converted into pain. In Clare鈥檚 case, the pain led to anxiety, which led to more pain, in a vicious cycle of torment.

Reclassifying pain

Nociplastic pain was only of the in 2017. There are several subcategories, including fibromyalgia and chronic primary musculoskeletal pain. The latter is what struck Clare.

Estimating prevalence is difficult as many people with nociplastic pain have one of the other categories of pain, too. But according to in Montreal, Canada, it could be as much as , with women more likely to develop the condition.

Pain specialists believe there are two routes to nociplastic pain. One is bottom-up, where an 鈥渙rdinary鈥� pain trigger balloons beyond all proportion. Clare鈥檚 started that way, with an injury. The other is top-down, where there is no obvious trigger. 鈥淚n this context, we believe that the primary abnormality is centred in the nervous system,鈥� says Fitzcharles.

Doctors aren鈥檛 widely aware of nociplastic pain and struggle to understand it, she says. 鈥淎s physicians, we like to do a test that can direct us to a diagnosis. It鈥檚 really challenging to see a person who looks completely well, the examination might be 100 per cent normal, but that person complains of a silent suffering.鈥�

Treatment options are limited. There is no magic bullet; no drug, surgery or talking therapy can quickly reverse it. Clare was prescribed antidepressants, which are the only . They helped, for a while.

鈥淢anagement is very challenging,鈥� says Fitzcharles. The main focus of treatment is non-pharmacological interventions, such as mindfulness meditation or small bouts of activities that bring joy, designed to reprogram the pain-obsessed brain back to its default settings. NICE also recommends cognitive behavioural therapy and acupuncture.

Clare practised mindfulness and tried to find fragments of joy. She liked to be in nature, to go swimming and have foot massages. We did as much of those as she could bear, but these often led to flare-ups. When that happened, she was bedridden, in excruciating pain and ruminating on her predicament. The hole she found herself in became an abyss. She came to believe she was beyond help and attempted suicide three times. She finally completed it in August.

That is thankfully an unusual outcome 鈥� most people at least regain some quality of life, says Fitzcharles, though most will continue to endure some pain and have flare-ups. Up to 20 per cent of people with chronic pain conditions have suicidal thoughts, and 5 to 14 per cent go through with them.

It is too late for Clare, but there is hope. Neuroscientists are starting to understand how the neural circuits go awry. Pharma companies are working on drugs. 鈥淭here鈥檚 so much wonderful work going on, which will hopefully lead to new treatment strategies,鈥� says Fitzcharles. It cannot come too soon.

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