By Dr. Forest Tennant and Ingrid Hollis

As 2021 comes to a close, we wish to summarize what we personally consider to be the greatest issue in pain management. Physicians have observed for centuries that some chronic pain conditions are not only more severe than others, but some cause excruciating, constant pain that casts the poor suffering individual into a humbled, bed-bound state.

Unfortunately, throughout the past half-century or so, many concerned parties, whether intentional or not, have tried to lump all pain patients into one category, saying they all have persistent or chronic pain. This has led to calls for “one size fits all” treatment and inflated statistical figures on the number of pain patients who need help (i.e., 50 or 100 million Americans).

The Real Issue

Chronic pain has traditionally been defined as pain that continues past the normal healing time for an injury or disease, which is about ninety days. There has been no generally accepted separate classification as to the severity, constancy or periodicity of pain that lasts longer than 90 days. Consequently, chronic pain surveys and statistics always include persons with the common, mild to moderate painful afflictions such as bunions, carpal tunnel, fibromyalgia, headaches, TMJ, irritable bowel, back strains, plantar fasciitis, and mild neuropathies and arthropathies.

Cries of undertreatment of these common chronic pain problems ring hollow, since every community has a plethora of medical practitioners, pharmacies, health food stores and fitness centers that tend to vast number of persons who have these common pain problems.

It may also be why all of the recent lobbying and advocating for “chronic pain” doesn’t seem to connect with the body politic, because the vast majority of chronic pain patients are getting adequate care. This is not to say that treatment for their common, mild to moderate conditions can’t be improved, or that their treatment isn’t needed.

The real issue, however, is that there is a sub-set of chronic pain patients who develop what can justifiably be called “complicated chronic pain.” Most have tried a plethora of treatment options but are left with severe, constant pain that has a specific set of pathologic complications. It is this group that is undertreated, poorly understood and needs advocacy, attention and treatment for their complicated chronic pain.

The Complications

The hallmark of complicated chronic pain is constant pain which is associated with cardiovascular, metabolic and hormonal abnormalities. Complications include hypertension, tachycardia, glucose elevations (pre-diabetes, and diabetes), and adrenal-gonadal hormone deficiencies including cortisol, estradiol and testosterone, among others. These complications can lead to heart attack, stroke, heart failure, autoimmunity, diabetes, obesity, depression, dementia and other health problems.

Thanks to modern research and science, we have a better understanding of why some unfortunate individuals transform from a mild, periodic chronic pain, to a constant, ferocious and disabling pain state. We now know that injured or diseased tissue from whatever initiating cause can generate bioelectricity that may enter the spinal cord and brain -- the central nervous system (CNS) – causing destructive inflammation that damages critical tissue sites that normally eliminate or control pain.

This development is called “neuroinflammation.” The transformation process in now often called “centralization” or “central sensitization.” Some pain specialists prefer to call complicated chronic pain “neuropathic pain.”

We Need a Name

A syndrome is a clinical state in which one pathologic defect causes multiple abnormalities and symptoms. Hence, we recently began calling the complicated chronic pain state the Intractable Pain Syndrome (IPS). The term intractable was first used by British physicians in the last century who championed treatment of severe incurable pain. The term intractable is now used in some laws and is in popular use in some pain circles.

There may be a better name than Intractable Pain Syndrome. Maybe we should just call it “Complicated Chronic Pain.” Regardless, understanding that inflammation can develop in the CNS and cause complicated constant pain is essential, as these patients need a different treatment approach from the more common, uncomplicated chronic pain patient.

Going forward into 2022, we define Intractable Pain Syndrome as “an inflammatory disorder of the central nervous system that causes constant severe pain and is associated with cardiovascular, metabolic and hormonal complications.”

Furthermore, we will advocate that this tragic syndrome be understood, and that its proper treatment demands not only symptomatic pain relief, but specific treatment of the disease that originated the syndrome, along with specific treatment of its complications. 

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on intractable pain and arachnoiditis. Ingrid Hollis chairs the editorial committee of the Tennant Foundation Research and Education Projects. She is also a family caregiver and advocate for those who suffer from rare diseases and intractable pain. The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.