We have to try some fairly startling chemistry in order to find the right support for our weird and wacky systems. It’s not a joke — but it can be a circus.
Years of nursing — in home care, acute care, HIV care, emergency care, all sorts of things — and, of course, the independent study I wound up doing along the way — most of the time, having no health insurance of my own, because being full-time at one facility was intolerable so I spliced together several part-time jobs in order to keep my mind working — where was I?
Oh right — getting safely off of problematic medications, which I’ll call “detox” for short. We usually think of hard drugs or alcohol when we say that, but the underlying mechanisms and the affected structures are the same. Logically, it works.
I could bore you to tears about the metabolic work of detoxing, but I won’t. I’ll drop in a brain-dump I just did for someone who has had to come off of Lyrica, the most fashionable med for CRPS right now (look here for the background on its fame), and — like many! — has not been able to recover former thinking, memory, and personality. Hopefully, it will return in time. In the meantime, helping the body clear out the last of the med, thus reducing the background strain, could help.
One thought before proceeding … it’s old news now (at least from 2009, Çagla Eroglu et al.) that Lyrica kills new synapses. In other words, if you get that blank, stupid feeling when taking Lyrica or Neurontin, it’s not imaginary.
This class of meds actually works by slowing down the rate of “excitement”, or activity, across the synapse. It does so in a way that prevents further synapse formation. Normally, new synapses keep forming throughout life. Making use of that fact is the best way to battle age-related brain diseases as well as chronic pain.
There is a ton of dense “science-speak” surrounding the fact that the very thing that makes it work short-term or for occasional use, is the very thing that makes it problematic for chronic and long-term use. That’s a complex issue. The precise nature of this activity has only become apparent over time, and medical science hasn’t really figured out what to do about it yet. Meanwhile, buyer beware.
This is going to take a few more years to shake out. In the meantime, keep a diary of what works and what doesn’t, and how goofy you seem to be. Note where your meds change. Look for relationships. Talk to your pharmacist and your doctor. Keep them in the loop, even if you — or they — don’t always agree.
We and our care teams need to work together, and as the patients, the burden of managing that falls on us.
Don’t overthink that — if it’s working for you and you don’t notice the deficit, then think carefully before switching. It’s not that those who do well on it should change, it’s simply that such a med does not belong on the first line of treatment, but in the second or even third. Less synapse death is better, usually!
The point of putting gabapentin/pregabalin in the second or third line of treatment is that, if the other stuff doesn’t work, then those who need Lyrica will still get to it, after trying the meds that’re less likely to be problematic.
Anyway, here’s the brain-dump on detoxing from almost any med, with some special notes about this tricky class.
BTW, this works for narcotics too. In that case, be especially diligent about easing slowly onto the liver-cleansing stuff, because you don’t want to clear your opioid receptors too fast for your body to cope with. “Easy does it.”
If you’re interested in suggestions, I sure do have some. I had to get off Neurontin, Effexor, and a few other heavy-duty nuisances, and I used to be a nurse and helped an awful lot of other people deal with this…
If you’re not interested, I understand, I don’t mind, and please just ignore the rest of this 🙂
[I left that in because it’s important to realize that not everyone on a support group wants advice — some just want to vent.]
Normally, going off of one major med is part of a larger task of re-adjusting the whole medication picture. There are 3 important elements to this process:
Clearing out the old med
Trying something different
Firstly, of course, lots of hydration (yes, the bathroom trips are work, but your blood, lymph, and skin do need the fluid to clear things out, and your brain and spine need more water to rest upon when they’re suffering.)
So, as you reach for your water, here is the rest of my riff on detoxing from meds.
Clearing out the old med:
The point is to clear the old stuff out of your system. This means supporting your body’s “housekeeping department” — liver, kidneys, blood, lymphatic system, skin.
SInce gabapentin dissolves itself readily in fat, it hangs out in your system. (Every cell wall and every bit of white matter in your body uses fat. It’s not optional.)
Your kidneys take the burden; your liver doesn’t seem to do much to it, as most of the drug is excreted unchnged. That doesn’t mean your liver doesn’t have to deal with it as it passes through, though. (Fat-soluble drug in a high-fat organ.)
These are both blood-rich organs, so that’s why the artichoke and dandelion (root in tea, or leaf in salad) can be useful — they support the liver’s detox work. Also, milk thistle seed (silymarin) is in the same category as artichoke. I’ve always used whole seed and ground it fresh, as thats cheap (except for being hard on the coffee-grinder) and works gerat with no side effects, but extracts and preparations are available too.
Any one of these (artichoke, dandelion root, dandelion leaf, milk thistle seed, silymarin) is fine. Whatever works for you.
Check with your pharmacist!
Check with your pharmacist before adding this stuff to your day. There are meds which these cleaner-uppers can interact with by cleaning up the liver. For instance, if you’re on chemo, save this for after you’ve finished the chemo and are rebuilding yourself.
A good pharmacist knows this, and can check scientifically-developed references for more info.
The other aspect of clearing the med out of your system is supporting the “mopping-up” part of the housekeeping team — your blood and lymphatic systems. Green tea, echinacea (mix it with lemon & honey to make it tolerable), melon (fruit or juice), and citrus are all good for this. If you can find citric acid from fruit rather than corn, that can do a good job too. (There’s something odd about the corn-based citric acid — it tends to trigger indigestion and gastritis in the vulnerable much more than the fruit-based citric acid does.)
Any of these (green tea, echinacea, lemon, lime, melon, citric acid) are good, not only for helping get more water into you, but for helping your lymph and blood to “scrub between the cracks” and pull the rubbish out from your cells and clear it away.
Lymphatic support: start gently
Start slowly and work up, because you don’t want too much backlog clearing out at once. If you start at a high dose of green tea or echniacea, you can wind up with swollen lymph nodes, because your body can detox faster than your lymph and blood can wash it away. Give it a chance and work up gradually to a therapeutic dose.
Start at one cup of green tea or echinacea a day, and work up to 3 times that. See how you do and let your body adjust for a few days or a week. Then go up to 4 times that original dose. Give this a month or six weeks (your call) and taper off again if you want to.
Drink up 🙂
For lemon or lime water, melon and melon juice, and of course seltzer, you can drink as much as you like, as long as the citrus is well-diluted and doesn’t give you any trouble.
Citric acid and lemon or lime are best used with plenty of water. Using an intense concentration can irritate the stomach. (These also help prevent kidney stones, btw.)
Just like the artichoke/dandelion/milk thistle seed — check echinacea and citric acid with your pharmacist before using them.
If it’s okay to use echinacea with your other meds, then remember to either go off it after 6-8 weeks total, or, if you find you need to stay on it to keep the channels flowing, then remember to take a week off every month. Your body needs a break in order to keep responding to it. Echincacea is not for ongoing use unless you’re being followed by a good herbalist who’s comfortable with your complexity. (If getting the Lyrica out of your system is the only thing you need it for, then one round like this should do.)
Or you could just…
As I look back over this incredible screed, the simplest thing might be to find a nice herbal “detox tea” and start with one a day, go up to 4 a day, and leave all these details to the nerds!
I hope you can get clear of the Lyrica and find the right pharmaceutical/dietary/physical/mental support for you.
Shifting to a different med for neuro pain:
The mixed-SNRI class of new meds has had the best statistical results of anything so far tried, according to the first few years of studies. Mine saved my life (Savella) — it helped that I had a fibromyalgia diagnosis, and Savella was developed and tested on fibro, so insurance would cover it. It cuts my fibro pain by 90% but it also cuts the CRPS pain by almost as much.
All of the so-called “anti-depressant” classes have been found to be statistically useful in treating neuro pain. Why? Because what they really do is stabilize the messenger molecules.
The most profitable market for this is depression, but our central pain means that stabilizing the messenger molecules of neurogenic pain (regardless of emotional pain) means that we hurt less and function better.
Tricyclics (also good for sleep) and some SSRIs have had results that, statistically, are about as good as Lyrica. The real breakout med for long-term neuro stabilization for pain and dysautonomia is the new mixed-SNRI category, though.
There are also meds in other categories, such as bisphosphonates (again, take care of your liver and kidneys) and a class of heart meds called statins. Low-dose naltrexone and ketamine infusions are other options from the anesthesiology side. They usually require qualified specialty care to try, especially the ketamine.
If pain is localized (say, to a foot or a shoulder), then topical treatments can be terrific. Voltaren and Lidocaine patches are a great help to many. Compounding pharmacies can make up special concoctions tailored to your specific needs, containing any of the meds mentioned in the last few paragraphs.
I’ve used the word “statistically” a lot here. That’s because scientific method only tells us what the general trend for a group of people is. Statistics mean nothing in the case of the individual. What matters in the clinical setting — that is, what matters in the lives of individual patients — IS the individual. Therefore, the medical science is only a guideline, telling doctors what to start with and where to go from there.
We are all guinea pigs, because the subtle and comprehensive nature of the nervous system, and the way longstanding CRPS and other central pain diseases disrupt it, means that the only way we’ll know what works for us is to try things and see.
Your doc should take a deep breath, take a good look at your whole picture, and work with you to figure out what works for you.
Please be clear that THERE IS A WAY FORWARD. I’m certain of that. It’s just a question of finding the right way for you.
Best wishes and I hope you get a good solution soon!
After talking with patients, doctors, and loved ones — and, as a trained observer, carefully noticing the changes in posture, expression, and tone as I’ve done so — I’ve arrived at the following conclusion. I realize it flies in the face of current accepted usage, but there are some things wrong with current accepted usage, and I don’t mind saying so.
/SeeYarP’Yes/ is not that hard to say.
No, it’s not proper to call it CRiPS unless you yourself have it. This is partly because “crips” is a term of abuse for disabled people and using the term for a particular set of disabled people won’t change that, and partly because Crips is the name of a violent organized crime group originating from Southern California. Neither is an appropriate form of address for those who have the most disruptive and intransigent pain disease known to science, and can’t perpetrate violence because of the devastation it wreaks in their own bodies.
Those who have this disease sure don’t need to be subliminally messaged with either association.
I understand that young docs are being trained to use the term in order to remind themselves that it is, in fact, a disabling disease. My view is that, if you’re smart enough to graduate from medical school, you’re smart enough to remember that disruption of the central nervous system can be pretty freaking disabling, in CRPS as in spinal injury or Alzheimer’s or anything else that disrupts the normal structure, chemistry, and behavior of the central nervous system.
The fact that the current name focuses on “pain” is a problem of nomenclature, which will change again as it often has since the year 1548 when it was first described by Ambroise Paré, father of forensic medicine and physician to the French court at the time. (Look him up — great guy. Prefigured that outstanding physician and gifted schmooze-meister Dr. Silas Weir by over 300 years.)
CRaPS, as in the game of chance, is not recommended. It sounds like a vulgar term for bowel excretions, which is — if possible — even more inappropriate. It’s certainly a “crappy” disease, but having said that, it’s time to move on and not keep reminding someone that they feel (and believe they look) like shit.
Of course your CRPS patients say they don’t mind. Check the power differential; their ability to bear to live is in your hands, doctor/loved one, so they’re highly motivated to be nice and go along with anything that doesn’t involve an immediate threat. They want you to feel good about them, so they will laugh along with you, however unreal it feels.
Have some decency — don’t call them or their disease CRiPS or CRaPS, even if they say it’s okay. They don’t need to feel any worse than they already do.
The CRPS patients can call it whatever they like, because only they know how bad it really is, and have the right — and need — to cuss it now and then.
/SeeYarP’Yes/ is not that hard to say. It’s only 4 syllables, like “pain diseases” or “really bad day.” It’s 20% shorter than the word “dehumanizing.”
This moment of intellectual — and emotional — honesty has been brought to you by a nightmare I woke up with this morning. My nightmares are a direct result of my disordered central nervous system, which can no longer process things normally and has to roil around and tear up the pavement in between the constant push-back and re-organization that takes place in my waking state.
It’s pretty crappy, not to mention crippling. But I rise above it, yet again, as I intend to do every day until the day I die. I sure appreciate anything others can do to avoid making that harder.
I’m now attending a weekly meeting of fellow pain patients in the area. It’s very good. A few things came up which I felt confident to share with the group and am now sharing with you, because the body of info is so useful… even if it’s only connected “under the hood.”
Pain care in the western New England region
Here are the local resources I can (to some degree) recommend. Those of you from other states and regions, please feel free to make recommendations in the comments! 🙂
Baystate Pain Management
There’s a Pain Management Center in Greenfield, MA, which I never knew about. It describes itself as “interventional”, meaning their focus is on procedures and injections and the like. (This means they aren’t currently doing much with the material mentioned in the Readings heading, but that may change in time.) They also provide PT and acupuncture, the latter only at the Springfield site. https://www.baystatehealth.org/services/pain-management-center
The Springfield site is the old home of a doctor I’ve mentioned before and don’t want to mention again. I noticed they don’t list staff on their current web page, but I do intend to follow up and learn a bit more about their current practitioners.
My doc, Lloyd Saberski, is intellectually conservative, and will do nothing that has a fair chance of hurting the patient. (Since I tend to be more gung-ho, I consider his approach a necessary complement to mine.)
There are a couple of other specialties (stem cell treatment and a weight-loss thingy) attached to the clinic, which is probably how they stay in business despite putting something as rare, time-intensive, & low-paying as advanced pain diagnosis at the center of the practice. I have never had the least hint of being nudged towards either of those; rather, Dr. Saberski specifically mentioned once that stem-cell treatment was still an immature modality with only a few conditions it was proven for, and that it would be totally unsuitable for me. Despite my poundage, he has never mentioned weight-loss, not even with a glance.
Readings on brain plasticity, with guidance on pushing back
I consider this the best lowdown on trauma gets put in place into the brain & body (and why this shows that Worker’s Comp and the insurance industry are specifically trying to destroy us, so don’t buy their evil story about you): “The Body Keeps the Score” by Bessel van der Kolk
It’s pretty science-y, so feel free to start with other authors like Pat Ogden or those listed below.
He’s a doc who developed central pain in himself, realized the current medicine on it was, um, let’s call it ill-informed, and eventually turned his extensive study on the subject into accessible material for the rest of us. He’s a good story-teller with an eye for the compelling detail that makes his point. He has two books out, both of them excellent, informative, and inspiring, avoiding all the usual pitfalls of physicians who like to write. He stays on topic, refers to the science, defers to the patient’s experience, and each side-trip turns out to be relevant and interesting.
I now mentally push my pain back up my spine and squish down on the pain regions in my brain every time I think of it 🙂 Week 2 — 4 more to go! Read more from him to understand what that’s about.
Credited with developing one of the most-recognized techniques (called EMDR) for accessing the neurobiology of distress and reprogramming the mind/body response to it. Some of her work is very clinical, and some of it is designed for anyone to pick up and use for themselves. Be aware that EMDR techniques tend to be multi-stage processes, and the “at home” techniques involve a little advance work to set up your mental safety-net. (I did that during my designated meditation time, which I use for any solitary mental healing work.) With that done, you have a lot of options later for catching yourself and quickly restoring your ability to cope.
An outstandingly practical person with tremendous insight and depth, she is one of the founders & leaders in the field of understanding how ghastly experiences interact with the brain, and how the individual can get consciously involved and get back in control of these systems.
Note: These last two skillful practitioners produce, not only video clips and their defining books, but also accessible articles, textbooks, narratives, and workbooks for both professionals and patients. This provides many ways to get into their information, whatever your sensory learning mode and attention span, so you can see what works for you.
A lucid speaker and explainer with many videos and a couple of books, especially (but not exclusively) for brain-science nerds. He co-authored several additional books that turn his theory into practical tools and techniques to use in real life. He focuses on hot issues for painiacs and those who love us: re-training our brains to identify and embrace the feeling of safety, developing healthy relationships in spite of twitchy brain responses, and re-developing our neurological coordination so we can get back in charge of ourselves.
Multiple access-points to get to the same root issues of healing our neurobiology
These brilliant practitioners have come up with different ways to access and engage with our natural neurobiological wiring, in order to manage our own brain and body responses better. Many of them focus on trauma recovery rather than the ongoing disruption of central pain etc, but, where that’s the case, I mentally edit for ongoing “trauma” (which ongoing pain is, strictly speaking), and I find considerable insight and useful techniques there. Great stuff. Also, if you’ve had awful things happen in your life, you may find a useful healing approach in one or more of their works.
Resources & info in this blog
I’ve been keeping a blog for ~9 years, though the earlier years got lost in a move. (Just as well; I was flailing.) Questions I could probably bore you to tears answering in person…
As I say elsewhere in this blog, it’s a bit of work to generate the first set of documents, but maintaining them is easy, and the payoff in personal poise and doctor response is tremendous.
Why is sitting in a moving car for hours so rotten?
Oh, boy, let me tell you what I’ve found about this! I think of it as 4 main issues, each of which I’ve developed ways to mitigate for my own case:
Our skin (where all those peripheral nerve sensors hang out) is hardly moving and half of it is pretty much unable to breathe, due to the mechanical pressure of our limbs against our bodies and the seat against our backs & thighs.
Hungry skin, with cellular & intestinal metabolic waste building up, no way to flush itself, with unhappy sensors, makes for serious discomfort.
I find a good song and dance & gently gyrate in my seat :))
Believe it or not, cars (especially American cars, sadly) are made of plastics that release molecules, which is called outgasing. Most plastics (including fabrics) outgas, meaning that molecules evaporate off the surface and escape into the atmosphere. These aren’t body-friendly molecules. Variously, they may interfere with endocrine (hormones) and aprocrine (sweating) activity. Many are neurotoxic, capable (depending on individual factors) of reducing impulse control, spiking irritation, and triggering emotional and physical pain. (Many of the studies around this have disappeared from the web, which somehow doesn’t surprise me. Sigh.) This lessens as cars age, but doesn’t go away as long as there is plastic, car fabric, foam, treated leather, varnish, etc, in the car.
The vehicle itself compounds all the skin stuff, and adds a constant low-dose exposure to neurotoxins.
Even in cold weather, I roll down all the windows every hour or so and purge the air in the car.
Our joints are not able to move much. The position, with the hips rotated slightly back, the shoulders reflexively rolled slightly forward to compensate, and not much room to do otherwise, is an unnatural position to be strapped into. It reduces ordinary motion, CSF/lymphatic flow, and nerve transmission, especially through the hips and spine. Our joints carry a lot of sensors, including those for blood pressure and balance; having them stuck in one position (while we’re breathing outgas, of course) makes the sensors unhappy, contributing to that general sense of yucky unpleasantness.
Unhealthy stasis in the joints, spine, and circulating body fluids, including CSF, lymph, and blood. This contributes to a central (brain & spine based) body-unhappiness.
When I’m driving alone, I stop every hour and, at least, stretch and move until I feel okay, or do t’ai chi/qi gong/yoga if I feel safe enough. When I’m being driven, we stop every 1-1/2 to 1-3/4 of an hour. We usually stop for 20-30 minutes, unless we’re in a real hurry, in which case it’s 15. I don’t tolerate less.
Mitigation bonus: stopping this often means I can get potty breaks, making it easier to stay hydrated and up on my electrolytes — which makes everything more bearable and significantly reduces recovery time.
For many of us, vibration is a problem. It certainly stimulates the nervous system, especially in the spine and feet, and wherever you’re touching the structure of the car.
Whether vibration itself is obnoxious or not, car vibration is irregularly irregular, having no consistent pattern whatsoever. This means my brain/body has no chance of anticipating or compensating for the rhythm of it, putting my body in a constant state of jolt. I find it exhausting, and it pushes up my dysautonomia as well as my pain.
Central stimulation in a relentlessly irregular vibrating pattern can be really harsh.
I adapted the inside of my car to reduce my exposure to seat outgas, improve airflow to my skin, and cut steering wheel and seat vibration to manageable levels. I also chose my car carefully to get maximum smoothness & good shocks in the first place.
To cut a long story short, I wound up with insufficient medication before my next pain doc appointment, and had to cobble together my full dose by using 3 smaller-dose tablets. Periodically over the last month, I’ve been peering quizzically into my bottle and wondering if all those little pills were going to last long enough.
Late last week, I finally had few enough that I could count them. (Due to perceptual issues, looking at a lot of little identical objects makes my eyes swivel, and I can’t keep track of them, even if I pull them out a few at a time. They appear to dance and swim without any help.)
Well, I had a problem. I couldn’t parse what to do about it because I didn’t know who to ask. My pain doc had been a bit more high-handed than usual at my last appointment, so I didn’t expect sympathy there, especially as it implied his math was wrong. I knew my GP would feel understandably uncomfortable prescribing a med he didn’t know well and didn’t normally use, which was normally prescribed by a high-flying specialist in a narrow discipline. That’s a lousy position to put a GP in.
So, regardless of the record heat and shocking floods elsewhere, New England has been cooler than usual, perpetually cloudy, with the Spring rain pattern (3 days and nights of constant rain, one and a half days of sun, a day or two of mostly clouds, 3 days and nights of constant rain, rinse and repeat.) This does tie in — really.
The reason it ties in is because summer gives me my recovery time, which involves sun and warmth and outdoor activity. 3 months of sun, warmth, and outdoor activity is what makes me strong enough to endure a New England winter.
It was so gloomy and chilly this summer, we dug up the money to go to California to recharge our bodies’ batteries. That didn’t go according to plan at all. As some of you know, I had viral meningitis from the day after we landed to 2 days before we left.
So, not much recovery, just a whole heaping helping of extra damage to recover from!
Then, of course, I had a relapse 10 days later, just in case I was getting too perky.
This summer has left me with a brain that’s just not up to par. So, rather than doing my usual thing of targeting the issue and parsing its components and figuring out what solution solves most of the elements, I … froze.
I started cutting the third of the 3 little pills in half, and taking two and a half, so I could buy a little time to think. Since that works out to my normal summertime dose, I didn’t question it much. It occurred to me, just as I’m writing this, that it has really crippled my ability to think, so that was not my usual problem-solving level of skill. Sigh.
I honestly can’t remember how I wound up on the phone with my doctor’s office on Friday. Wait, after 5 minutes’ cogitation, I do: I hadn’t heard from referrals my primary doc was supposed to have written 2 weeks before. Usually right on top of things, he had documented that he intended to make the referrals, but forgotten to enter the orders to do so.
The compassionate office lady asked how I was, and it wasn’t until then that I said, “Actually, I’m kind of in a bind,” and explained about the meds. To my complete lack of surprise, given how things have been going, it turns out my primary doc is on vacation this coming week. She left a note for whoever’s covering for him.
Since then, of course, I’ve been trying to work out whether I should call during the weekend, when coverage is even weirder and less accountable, or wait until Tuesday and the first day of business this week, and try to coherently answer the question of why I didn’t call sooner, and hope and plead to get my meds from someone who doesn’t know me and is working too hard to feel for one more sad case.
So … I’m froze.
Meanwhile, my feelings and my disease-driven propensity to worry paralyzingly, are all honed to a ridiculous edge. Once my pills get past the cannon-ball feeling in my stomach (almost past the half hour mark; 15 minutes to go) I’m going to do an hour of meditation, which I expect to roughly track the pattern of the meditation I did during the meningitis episode: 20 minutes of pure inward flail, breathing quietly while my mind and emotions just went off like a carton of firecrackers spilled on a brush fire; then, once that calmed down, my thoughts chased each other like frantic squirrels for another 20, not slowing appreciably until the last 2 or 3 minutes; then 10 minutes of one or two issues or ideas holding fairly still, allowing me to turn it over until it’s transformed into something peaceful by the pure attention; and then the rest, finally, gradually, moving into a pure and floating calm.
They say that one should meditate for an hour every day. If you don’t have the time for that, make it two hours. I hold this as a constant goal. Sadly for me, I can normally only push myself to sit down and shut up like that when things are so bad all I can think to do otherwise is scream.
I need to work on that.
This was going to be the year I learned to meditate and do t’ai chi pretty much daily, no matter what level of peace and calm there was in my life. I’m embarrassed that, even at my age, I still seem to need some chaos to let me bring enough pressure to bear on myself that I’ll do these key self-care activities at all.
Something to mull over in the contemplation stage of some meditation!
With the kind consent of the friend mentioned, I post the following exercise in “radical presence”, or staying sane in spite of the craziness…
Bubbles of thoughts are rising through the viscidity of my mind, drifting from side to side, now tending one way, now tending another.
Feels like a relapse of that FUO (Fever of Unkown Origin, although there’re more vulgar interpretations of that acronym too) that looked and acted like viral meningitis. This time, I have a thermometer so there’s something I can document. It’s less than a few weeks after the first case, so this is not good.
So far, though, no vomiting!
While recovering (barely) from the first bout of this, I met with one of my excellent friends, the one who’s going to make decisions for me if I can’t make them myself. We first met during one of the most effective times in my life.
She spent much of the recent visit picking up after me, getting the tea I forgot, making sure everyone got fed — the ideal hostess, really. Too bad that was my job. I was a good small-party hostess at one time.
For obvious reasons, given her impending status as my health care proxy, I need her to be able to tell me how I’m really doing. There was a time when full anesthesia and industrial forceps were required to make anything that wasn’t kindly and flattering come out of her. She’d almost rather lose a limb than lose her manners.
So, testing the waters, I asked if she found me a bit daffier and more disorganized than I used to be.
I’m so proud of her. She gave me a somewhat verbose “kind of” … then gave me an eyeball-to-eyeball gaze of love and torture, which I’m pretty sure meant, “It shreds my being to see you like this, but somehow I have to breathe and keep going, and I promise you I will, no matter how hard.”
Such a friend can’t be described, only experienced if you’re insanely lucky.
I rarely look back. There’s no future in it. However, the memories I usually keep firmly in the rear-view mirror haunted me for days, as bright as if they were klieg-lit.
Teaching her to run effectively under the redwoods. She was a quick study, all right. I was getting sick, so the fact that she could lap me in less than a year is probably not something I should feel too bad about.
Trying very hard to talk her out of medical school, which I was pretty sure would embitter her extraordinary sweetness and distort her self-effacing diligence. In the end, it gave her mind and heart a stronger shape.
Researching and working together on user interface guidelines, which made most senior engineers effectively beg our blessing on their designs — as they should!
What it was like to ask my quiet, courteous friend a music question, and have her snap upright, point snappily to a chair, and snap, “Sit.” Then give lively, passionate, 20- to 40-minute illustrated lectures on music theory that enrich my life even now. (I did much the same thing for her health questions.)
On a related but more self-oriented tangent, remembering what it was like to keep over 230 threads of information going simultaneously in my head, switching threads from meeting to meeting and file to file. I tracked the early course of this disease by when the number of thought-threads went down. I was “laid off” when I could only maintain about 90 different threads in active memory. I was crushed by that figure.
Remembering what it was like to run through the redwood glen at dawn, the scenery and birds staging a daily spectacular just for me.
The last walk I took on the mountain tops, when every bit of exercise just made things worse, but I had to say goodbye to the wild open spaces.
The curling breezes change direction again.
The wasps are too quiet. I turn my head to follow them and warn them away, and the world seems to slip off its stand then right itself again, and the quiet singing in my ears rises to a sharp chord then slithers down again.
Having a frying brain is like living in a hallucination at times.
This post is a little diaristic, but it serves a purpose beyond easing the pressure in my head. You’ll see.
The hundreds of little mercies that keep me going cluster around. The air here is delicious. The trees are fluffing their leaves in the curling breezes. J is quietly rattling around inside, scared in his ignorance of my illness and memories of losses, but keeping a good face on and making sure that I hydrate. The birds are mulling the possibility of rain, but it will hold off a few hours. The sun strokes my head with a long hand.
I breathe, and the world settles down.
A few days ago, I had a wonderful insight about the way that many bits of my past are getting referenced in the present somehow, and how, rather than highlighting my staggering losses, they fit together in a way that draws me onward.
That’s all I can remember, though. I think most of the ideas poured out of me last night as I sweated with the fever I forgot to document.
Drifting first one way, then another.
Must remember to inhale when getting up. It’s the only way to keep my head from wanting to explode, and clutching it doesn’t really help.
Normally, a good idea like the past-reaching-forward-and-propelling-the-present would come back to me with sufficient prompts. Not the way things work anymore. Once it’s gone, that’s it, it’s gone. I’ve learned that the hard way, over years and years.
However, do I need to remember the examples and details? Or do I just need to remember that feeling of a rising tide lifting my weary, worried ass?
Just because I don’t understand how it all fits together, does it stop being real?
Medicine is real, neurology is real, and I defy absolutely anyone to say, hand over heart, that they really, REALLY understand those. Yet, they are real just the same.
I’ll allow myself to be carried onward by the memory of the idea, even if I can’t remember why it made sense.
For now, it’s time for more lie-down and seltzer.
Small moves. Just like steering a sailboat. Small moves get you where you need to go, without steering wrong. Now, seltzer. Later, rest. Then, we shall see.
Remapping and the primitive brain are key concepts that come up often for people with chronic pain — though we don’t always know it. These underlie some treatment strategies that seem, at on the surface, anything from absurd to cruel from the perspective of the stressed patient. They also underlie a couple of those chronic misunderstandings between medical people and non-medical people, which are especially painful when the non-medical person is a chronic pain patient. I hope this will go some way towards creating better communication between palliative-care doctors and chronic-pain patients.
First, I’ll go over a few fundamentals. Naturally, I’ll translate the dense stuff into Plain English.
Basic brain structure
The brain has sections which have different jobs, but communicate intensely with the others. It’s impossible to view them either as entirely separate or entirely connected; they’re simultaneously distinct, and inter-linked.
Providers, I’m going to oversimplify. Be warned.
The hindbrain, or medulla and cerebellum, manage the business of pulse, respirations, and the kind of moment-by-moment activities of survival we don’t even think about. The cerebellum and cerebrum take in information about our environment, check for reflex response, compare it to learned and instinctual information and decide what to do about it. The cerebral cortex is where we start thinking we’re in human territory, because this is where much of our actual thinking takes place, linked into deeper structures in order to turn into words and deeds. Our thinking brain is very much in the minority and, whether it knows it or not, conscious thinking only happens on top of a great deal of unthinking response which has already happened.
That’s the key, right there. The thinking brain is never isolated, even though we sometimes act as if it can operate alone.
Think about the meaning of the word “objective”, then think about how that can possibly apply to thoughts and perceptions channeled by a mind that’s driven by unackowledged forces at inaccessible levels. Objectivity is only an aspiration, not a rational goal, but that’s too often forgotten or ignored.
When scientists forget this, it explains a lot about conventional medicine’s blind spots, certain doctor-patient miscommunications, and many crucial limitations of scientific method.
When the rest of us forget it, we’re already reacting on the basis of the primitive brain’s unthinking push. We lose our capacity for any objectivity right when we need it most.
The central nervous system (CNS) is “plastic”, a term in Medical Jargon which means that it morphs and changes to meet the requirements of whatever the CNS thinks is going on.
To be more precise, the CNS doesn’t change the shape of its cord, lumps, and lines, it changes the tasks (and pertinent chemistry) of sections of cord, lump, or line, when ongoing survival seems to call for it. The term for that morphing of purpose and chemistry is “remapping.”
During fetal and childhood development, the brain and spinal cord develop into certain chunks, and those chunks learn to store and pass along information and signal responses in predictable ways. Sounds, colors, sensations, Mom’s face, Dad’s scent, sibling’s voices — these all get processed in, stored for future reference and retrieval. The information finds its home in the CNS while the brain and spine build roads and rails to carry the signals on.
In Medical Jargon, this arrangement of storage and signaling is called the brain map. Unlike most other disciplines, in neurology, the map IS the territory, and mostly it works pretty well.
Therefore, a healthy brain has a normal map of the body, including how it signals normal needs and how to meet them. As the body, signals, and needs all change, the map gets re-drawn, and that’s how the brain and spinal cord get remapped.
This is appropriate in the developing years and in times of great change when we need to adapt. Brain plasticity is important and exists for good reason. However, in chronic pain, especially with central sensitization, it goes overboard.
Thanks to the remapping that happens with chronic pain, the pain signals can’t stop because the chemicals that carry the signals change, so the old pathways aren’t even accessible to them. You know how trains can’t use roads, and cars can’t use railroad tracks? It’s a bit like that. Your spinal cord/brain has blacktop where it used to have rails.
In central sensitization, it means that normal signals — excitement, touch, sound, lights — can get processed, not just as emotions (wow!) or touch (hey!) or sound (oh!) or light (ah!) signals, but as pain signals (ow!), because the brain’s remapping means the normal ways of processing feelings, sensations, etc., have been partly overwritten — sometimes completely erased. It’s all pain, showing up right there in the spine and brain; pure, gruesome pain. It doesn’t come from anywhere in particular; it’s just the essence of pure pain.
Yeah, it sucks.
This is why people with chronic pain and central sensitization get so quickly overwhelmed by things that used to be fun, like music, parties, dancing, socializing, and so on. The inputs, however delightful themselves, just get shunted into the “pain” tracks right in the central nervous system.
It’s not about not wanting to have fun! It’s about not being able to bear the unnaturally high price, which is so high the fun is usually lost.
When a normal person sees one of us at a party or other event, it would be totally appropriate for them to fall to their knees in admiration and gratitude, because our level of dedication to the events we do attend is truly special.
Not that anyone ever does, nor are they expected to … but it would be perfectly appropriate if they did 🙂
The primitive brain’s role in all this
The primitive brain is one of those terms that changes meaning depending on who’s using it. So, to be clear, I use it here to mean the parts of the brain that don’t use words a lot, and that underlie all the parts that do. Very simple.
Since pain is a survival function, it has deep roots in the primitive brain. This is kind of too bad for us, because once we understand the concept of remapping, we want to learn how to re-remap, so we can push our brains back closer to normal. The catch is, this is all rather intellectual, and pushing back on pain’s remapping means that the re-remapping needs to target a lot of primitive brain, which is primal, not intellectual. The approaches that have been developed reflect this. They’re hard to keep up with, because they don’t always appeal to our higher personality characteristics. (That is, they can be repetitious, trivial-seeming, and dull.)
Let’s take a look at the underlying concepts here, so the ways we communicate with the primitive brain make more sense.
The primitive brain relies heavily on nonverbal cues. Take a look a few paragraphs back, where I was discussing how sensory signals turn into pain. I’ll repeat the section here:
…emotions (wow!) or touch (hey!) or sound (oh!) or light (ah!) signals, but as pain signals (ow!)…
See what I did there? For each type of signal, I made a pertinent sound, and drew attention to that sound by adding an exclamation point. I was totally talking to your primitive brain, there.
Most of us find we talk more easily with people who don’t have arms crossed or brows lowered. That’s the primitive brain noticing the lack of withdrawn or threatening cues. Body language is 90% of visible communication, just as tone is 90% of audible communication, and it’s rarely noticed by the cortex at all — it’s primitive brain stuff, and humans respond as reflexively as Pavlov’s dogs.
Color (for those who can see it) sends powerful signals to the primitive brain.
Interior decorators may suggest painting the marital bedroom red, because red makes the primitive brain tend to feel passions more strongly and this can improve the sex life.
Some prisons use grey (which is depressing, and slows people down) or pink (which tends to promote calm. The nice theory is, it’s the first color we saw, as light penetrated mother’s stomach wall while we were in the womb. The mean-spirited theory is, it makes grown men feel like little girls; rather than learning to control their impulses, they get emotionally emasculated. Not corrective at all.)
Here’s a classic example of good intentions: In 1991, the administrators at my hospital decided to paint the walls of our HIV unit yellow, in a conscious effort to cheer the environment and counteract the depressing nature of early-90’s existence with HIV. They should have involved caregivers in the choice of shade… after only a year, the one they chose looked just like the serous fluid oozing from a skin ulcer. Still, they meant well.
Movement is powerful. The movement we see around us and what we do, ourselves, gets plugged in very deep indeed. Movement involves the most primitive parts of our brains. Because so many of us become limited in our movement due to central pain disease, what movements we do make, and even observe, become even more important, more concentrated.
Very primitive indeed. That’s why these things can be so effective.
Putting several primitive-brain cues together: food, pills
Eating is comforting to the central nervous system for all sorts of reasons, one of which is that taking something, putting it in your mouth, and swallowing, is something we first experienced before we were even born. Also, eating good foods and taking effective medicines makes us more capable and less miserable, because of what happens afterwards to our chemistry — a powerful reinforcement of that primal reward.
The sensation of feeling better is even more compelling when being alive is unbearable at baseline.
Freud went to town over this instinctual action, but he wasn’t completely wrong.
Putting hand to mouth and swallowing is one of the most powerful primitive-brain signals we habitually engage in. (Realizing this makes me think about how I eat, fidget, and generally do hand-mouth things. I’ll be less mindless about those actions — at least for awhile — and try to give my primitive brain its due.)
This is where we get to one of the things that seems so cruel from the patient’s point of view, but makes perfect sense to the doctor seeing it from the brain’s point of view. I didn’t really get it until mulling over my recent visit, so those of you who’ve seen me saying something different before, I apologize for not having thought it through. They might not be wrong!
This was not easy to write, but for the reader, who doesn’t know what’s coming until you read it, it could be triggering. I want to insert a reminder to my fellow painiacs, for whom black-and-white thinking is very easy to fall into… Take a breath, let it out slowly, and keep in mind that there are no absolutes here, just lots of context and a few guidelines. This can be pretty tough material, but you are way, way tougher.
What we can do about this
Now that we have some idea just how powerful the primitive brain is, how easily it remaps itself once central sensitization takes hold, and how powerful the act of taking and swallowing things that make you feel better is …
Ideally, think long term
We can see why, when doctors don’t want us to ramp up our daily meds when the pain gets worse or to become too regular about taking our breakthrough meds, these things worry them. It’s too easy to program the primitive brain in pain. They see it as powerful signaling that sets the brain up for needing an outside chemical push whenever it starts acting up.
Pain patients come in all sorts, but can broadly be divided into the passive care recipients and active care participants. The latter tend to have much better prognoses and quality of life, but the nature of bitter central pain tends to suck everyone down into the former approach now and then.
Thus, the doctor has no way of knowing if the patient in front of them is currently able to be an active participant and do their disciplines first, or if they’re sufficiently overwhelmed and disabled to just reach for a pill (ow! — mmm!).
None of us is immune from mental exhaustion. However appalling their terminology may be, good docs’ instincts are founded on caring for our greater good, even when we can’t think that far ahead.
Unlike acute pain, life with chronic pain requires us to take more than one approach at the same time. (Insurance doesn’t much respect this fact, which makes it all the harder to manage!) We aren’t expected to recover, unlike those lucky so-and-so’s with ordinary acute pain, so we have to think in terms of having a life while thinking ahead to being able to live the rest of our lives in a bearable state.
This means that all of those primitive-brain approaches and re-remapping tools — eating well, keeping moving, mental rehearsal, coloring, internal arts like meditation and yoga — PLUS individually tailored pharmaceutical therapy and occasional procedures — have to be part of the picture.
Doctors can help us, but they can’t save us; we have to do as much re-remapping as possible, and contribute as little as possible to the pain’s remapping. We aren’t talking about a couple of days or even a couple of years; we have to be able to keep life as manageable as possible for however many years or decades we have left.
The painiac’s barriers to success
Considering how devastating it is to think that we’ll most likely be dealing with this all our lives, our own brain-care requires us not to think about that, because so much perfectly rational despair is waiting when we do.
It requires thinking years ahead on every aspect of our treatment. This is more than usually hard for us to do, becuase thinking too much about this aspect of our future is so counterproductive in other ways.
Nobody’s brains are set up to stay detached and rational when our nerves are running riot with pain signals and our bodies are just exhausted with it. It’s okay if this seems insanely hard, because it IS insanely hard.
This is not a normal situation! We’re rational people stuck in a complex web of relentless, irrational challenges, and we are obliged to prioritize our current survival. Just do your best! It’s all you can do!
Personally, some days, getting out of bed and doing my tea-snack-pills routine is all I can manage, and I have to be glad of that. (Things could be worse.) I realize that, good as my disciplines (and consequently my perspective) are, they aren’t always up to the job of keeping this mile-high view. Also, I’m a brain-hurt human, and I can’t necessarily keep track of all the myriad things I’m supposed to do.
This is why I seek out and travel to such astoundingly good doctors. I need them to DO what I can’t, as well as to KNOW what I don’t.
Taking more pills and feeling better is powerful retraining. Yet… There are only so many pills in the world, only so many chemical boosts that can do any good at all.
What a set-up!
Built-in pain control and building up tools
On the other hand, remember that we have other tools available to us. For one thing, the brain/spine complex has many ways of managing pain and distress which can be leveraged by a conscious and determined owner of that system. These ways, from the descending inhibitory pathway to oxytocin, endocannabinoids, and endogenous opioids, can be consciously operated and can be nudged by what we take in and do. (Go ahead and google the heck out of those terms. I don’t have enough spoons left to dig up the best links.)
They take practice to master. Not surprisingly, developing these skills can be repetitious, trivial-seeming, and dull.
Just like building a muscle, it takes work to build — rebuild — and keep on building — the ability to counter pain in ways that use what your body has already got.
Letting the primitive brain slide into taking a pill for increased pain as Plan A or B puts the kybosh on those other methods. They wither, like unused muscles.
The pain patient is left with fewer and fewer alternatives, as the years go on.
Yeah, that REALLY sucks.
The one member of the doctor-patient team who isn’t currently losing their mind to disabling pain has the perspective to think ahead, and to realize that NOT retraining the brain to go with “pill as Plan A” is crucial to ongoing survival.
They aren’t always tactful about it, of course (!). They learned it in terms of Pavlov’s dog, and nobody likes being compared to a slobbering animal, so the usual explanation is deeply offensive. I hope they’ll figure that out and start using terms like “primitive brain” and “primal reflexes” and so forth, rather than “operant conditioning”, let alone “Pavlov’s dog.” Sigh.
This conflict of ongoing needs and current distress often winds up painting the doctor-patient team into a corner: the patient’s desperation may lead them to remap their brain to need something it can no longer make for itself, while the doc is not able to communicate real concerns effectively (between their own language gap and the patient’s neurological chaos) but winds up patronizing the patient to a standstill.
Where to go from here
So, when your doc says, “Don’t pill up,” this is why. They’re worried sick that you might be reaching for pills as the easiest fix — just like most normal people do. Just as they do, when they’ve got an infection or allergies. These days, reaching for a pill to solve a medical problem is the normal thing to do. That’s why it’s a natural assumption for them to make.
I know my readers are a lot better informed and more skilled at self-care than most people. So, if you find yourself having this kind of conversation with your doctor, pause a moment, take a breath, exhale slowly, and explain:
You understand the concern about screwing up your body’s reward-signaling,
You’d like them to know you’ve been using your alternate methods for days/weeks/whatever, and
The pills were the last ditch effort.
That’s exactly what breakthrough meds and med increases are for — last-ditch efforts when our home remedies and personal strategies can no longer meet our minimal requirements.
You may have to say this every time. (I do.) That’s okay; it shows they think of your survival before they remember their manners. These docs are seriously worried that you’ll wind up beyond the ability of modern medicine to do anything for you. (We want docs who worry for us!)
Some of us wind up there anyway, as we’re all well aware from our networks. Our best bet (though there are no guarantees) is to explore, discover, and refine the set of non-pharmaceutical management techniques that offer each of us, individually, the most manageable level of trouble/expense which give us the best results. We’re all neurologically different, so we have to develop our “toolkits” on the basis of what works for ourselves.
Suzanne Stewart (among others) at National Pain Report, intelligence diligently applied;
For the multiply allergic or drug-problematic, Taming the Beast, out of Canada, for more on home management and strategies that are as nontoxic as possible, discussed as pleasantly as possible.
These blogs all discuss strategies that are compatible — or at least not incompatible — with current science.
In the end, what tools matter to you is what tools work for you. You don’t owe anyone any explanations for those. It’s your body, your life, and you who have to face the consequences of every strategy used in your case. Might as well own it.
Other “ancillary” or “alternative” therapies
Once you include strategies and therapies outside your doctor’s bailiwick, it’s not fair to ask the doctor if they think it will help. They’re already doing what they think will help. Conventional mainstream medicine names these techniques with terms that specifically put them off to the side, because that’s where they believe these things belong, so it’s normal and appropriate for conventional practitioners to have a bit of trouble making sense of them.
For the pain patient, these strategies are likely to take more time and attention than conventional care, but only because they are so necessary to living with central disruption and pain.
As long as these therapies don’t disrupt or interfere with your medical care, then the physician’s opinion is not relevant; your experience with that therapy is.
This brings us to a form of intellectual integrity which many well-educated people have trouble with. Ready? Here goes:
Others’ belief systems are not relevant to your personal experience of less pain and greater function.
Even if the “others” are care providers, and even if their belief systems are based on the current state of our limited and ever-changing model of science.
The only proof we need, here at the sharp end of reality, is what kind of good something does, and what kind of bad it doesn’t do, for the only body we’re in.
If it helps, doesn’t hurt, and you can access it, success! It’s in your toolkit!
Below is a short table of “alternative” therapies and modalities I’ve used with success, with annotations about what I learned about how to make the most of my benefit from them. (With apologies for the weird formatting.)
Essential. Our brains are the most susceptible organ in the body to deficits. Air, food, and water underlie everything our brains do. Immune activity in the gut is becoming a hot issue for study, as the results can be multi-system and devastating. Nutrition is the first and most important step, in my view, to managing a life with serious illness. Eliminating or reducing immune triggers, maximizing nutrition within your practical limits, and being able to absorb and process your food, are key to getting your body to work right again.
As those of you who’ve checked the science know, nerves can’t work without mitochondria, and mitochondria can’t work without antioxidants. The only known preventive strategy for CRPS is vitamin C in frequent small doses for 2 weeks before surgery and 3 months after surgery or trauma. Vitamin C! So yes, nutrition is the base of everything. This also means, beware! Nutrition can interact and have side effects. Brassicas and soy can deplete the thyroid. Co-Q 10 interacts with Lexapro, a common neurochemical modulator used for central pain and depression. Check with your pharmacist.
The practitioner needs long experience to avoid accidental damage, plus specific training and experience with central sensitization. (I use LAc’s with over 20 years’ experience.) Patient needs realistic expectations and a pragmatic list of attainable goals: anxiety control, sleep/wake improvement, temp/sweat stabilization, digestive support, wound healing, whatever your practical concerns are.
Acupuncture is extremely sophisticated. Its methodological groundwork was being laid before my European ancestors even figured out where babies came from. Because of that sophistication, experience counts, because some of what they evaluate is very subtle. Inappropriate acupuncture can make local or central pain worse, so do be mindful and pay attention to the care you’re getting.
Can be GREAT for pain. It’s more “tunable” than many practitioners realize. If you have dysautonomia or suspect any other form of central disruption/transformation/sensitization, be sure to tell them: “Use SHK, and lots of it. CKR can be bad for central nervous system disruption.” Their likely reply is, “But Reiki goes where it’s needed; it can’t hurt.” The response to that is, “Reiki gets attracted by need. However, more than a touch of CKR can be like warming hands by pouring burning fuel on them. SHK is more stabilizing, and that’s what’s effective. CKR is great for a final ‘coat’ afterwards, but not for the main treatment.” (CKR and SHK are different “flavors” or “types” of Reiki energy.) I figured this out with the assistance of other Reiki 2 practitioners and other centrally sensitized volunteers. It’s absolutely consistent, both for in-person and distance work.
Level matters. A Level 1 practitioner normally needs to work on only themselves. If you have Level 1, consider working towards Level 2, as the rewards can be considerable. Level 2, 3, and Master practitioners can send transformative Reiki. Many massage therapists are also Reiki practitioners.
Therapeutic Touch ™
Came out of the nursing profession from a nurse-scientist who got some initial studies funded. Blood tests were so good it was unreal. Usually done by RNs. Usually helpful with pain, digestive problems, mobility, and wound healing.
May be available in-hospital, sometimes through private practice. Sometimes massage therapists get cross-certified in TT.
Be prepared for some rudeness if you tell people you use this. Its principles are founded on quantum physics (something called “signal propagation”) and conventional medicine still depends on Newtonian physics, which is 600 years old; predictable, but limited. Anyway, I strongly recommend getting competent, qualified help in working out what works for you. Hypericum perforatum is widely used for nerve pain, but it can go either way for us. It used to help me significantly but now my body flips it about half the time and it makes the pain dig in, so I no longer use it. Ignatia amara can help calm that emotional storm that comes with too much stimulation, surprise, or pain. It also eases my bursts of panic. I get great results consistently. I use Arnica pills for soft tissue trauma (which, for me, is a body-wide event), and heal in 1/4 the time with about 1/6 the pain of what happens when I don’t! Many have great results from Rescue Remedy ™; for me, it just calms my mood, but for my housemate, it brings her blood pressure down from the sky and cuts her pain. We’re all different.
As with Reiki, some say that “it can’t hurt”, but that isn’t correct for the centrally sensitized. Keeping logs of how you respond to each remedy is an excellent idea. Your diligence can result in a handful of outstanding remedies that help you enormously and very quickly.
These are the precursors to conventional mainstream medicine. Therefore, they’re a double-edged sword. Assume that everything interacts with something in conventional medicine (except possibly chamomile); know your interactions for what you use. Everything has side effects, although, with that said, whole herbs tend to buffer their own bad effects better than purified extracts. Freshness matters; potency varies. This means that, if you’re interested in the potentially vast bouquet of beneficial herbal support available, either start when you’re young and healthy with a great teacher (as I did) or find a very experienced practitioner with experience treating central sensitization.
Expect to do a lot of homework researching brands and regions and preparations, in your own defense. The market is huge and very aggressive. You are your own guinea pig, so keep track of effects, doses, potency (which you’ll have to figure by color, scent, and taste) if you’re wildcrafting or growing your own. Be wise with your herbs, and they can reward you.
Do your due diligence
As the blunt hints in that table suggest, there is no such thing as a free ride or a guaranteed fix — not even any such thing as “It can’t hurt you!”, especially when central sensitization is part of the picture.
Given all the side effects of our meds, the mistakes by highly qualified physicians, and the errors in surgery, not to mention the rank company of practitioners like Scott Reuben who get rich by urinating in the well of science, these characteristics of not being harmless don’t distinguish “alternative” methods from “conventional” medicine at all, from the patient’s point of view. It’s all risk, and nobody bears it as much as we do.
The obvious corollary is that there are highly qualified practitioners of these therapies too. There’s no substitute for good training and lots of experience, so look for those who’ve studied their disciplines long and hard, and remain enthusiastic about their field. These are the ones who can provide the best help and guidance.
Another handy fact is that there is a lot more information available on these therapies, at a much greater level of detail, to the determined pain patient. We don’t need medical school access or memberships costing thousands we don’t have, to access articles and reports (not to mention extensive fluff and pretty pictures) about physiotherapy, massage, TT, acupuncture, and any herb you care to name. Good resources for checking interactions with medication and devices are there with a little digging. The vocabulary and style is far more approachable. A bit of common sense and occasionally a friendly nudge from a cohort can help us screen out most of the rubbish.
After that, it’s back to trial and re-trial and lots of notes, the reality of patient-hood, which is based on empiricism out of necessity: WHATEVER WORKS FOR YOU IS WHAT MATTERS, NOT WHAT ANYONE BELIEVES “SHOULD” WORK.
As with medicine and surgery, the final sanity check and the final decision is up to you, the patient. It’s always up to you.
May our brains and spinal cords become more stable, less reactive, and ever closer to normal!
As the title hints, it’s been another fascinating visit with my pain diagnostician.
His current working diagnosis is fibromyalgia, which he characterizes as being capable of throwing some hairy curve balls (my terminology, not his) including the growing litany of food sensitivities, which solves a major problem in my mind.
Thyroid disease can also trigger the symptom complex that otherwise gets tagged “fibromyalgia” (more on symptom complexes in a minute.) I mentioned that I’ve had my thyroid checked several times and last year came up with Hashimoto’s (meaning my immune system is attacking on my thyroid.) Since I developed the first symptoms of this central sensitization around 16 years ago, it seems not like a precipitating event; since “normal” thyroid activity is not the most meaningful term, I’m not sure it’s irrelevant. I guess I’ll learn more as we go on.
He’s also checking my hemoglobin A1c to check for underlying blood sugar instability. I’m always happy to check that. Also B12 (pernicious anemia etc.) and D3.
Now we come to the fascinating (and crucial) distinction between a symptom complex and a disease. Both are used as diagnoses, but they mean different things. (Yes, I’ve used the word “disease” indescriminately here, for simplicity.) Medically speaking, a disease has a cause that can be targeted, what you might call a diagnostic end-point. A symptom complex doesn’t have that level of targeted responsibility for the illness; it’s a consistent set of symptoms that cluster together often enough to get a diagnostic label, which takes some doing.
Here are the two scenarios.
On the one hand, you’ve got someone with a lot of pain, funky guts, sensory reactivity, and normal labs. The doctor (we hope) rules out any other possible cause, and decides the diagnosis is, say, Fibromyalgia. This is a symptom complex, because it’s described in terms of what it does to the person, not in terms of specific pathogens or organs as the causative thingy. (I’m tired; thingy will do.)
On the other, you’ve got someone with a lot of pain, funky guts, sensory reactivity, and thyroid labs that are out of whack. Further examination of the thyroid discovers specific thyroid abnormalities which can be treated. With treatment, the symptoms subside or even disappear. The diagnosis is the disease of hypothyroidism, with a diagnostic end-point in an organ (as in this case) or pathogen.
CRPS/RSD, Fibromyalgia, and some other hideous conditions are symptom complexes. This is used by some as a reason not to “believe in” those conditions, because they aren’t “real.” This is intellectually dishonest, but it does no good to tell them that; assuming that a lack of diagnostic end-point equals lack of ill-health is blatantly absurd, but this is a reality we must contend with. It’s a drawback of having such a flexible language as English, where the same word can mean different things from one context to the next: in Plain English, disease and illness are interchangeable, but in Medical Jargon, they’re definitely different: disease means specific diagnostic end-point, illness tends to suggest a pathogen, and condition is the catch-all term — but is used more for things that really aren’t diseases or illnesses. Another example on a hot issue: in medicine, narcotic refers specifically to opioid analgesics; in law enforcement, it’s a MUCH wider term, encompassing any substance that legislators have decided is not legal. In courts, the meaning of the term has to change depending on who’s involved, which has to be weird.
No wonder there’s confusion around anything medical. What a setup, eh?
This brings us to the physician ethical structure this doc works with, and where it fits into this patient’s worldview. You can almost hear me purring comfortably from here.
He speaks of himself as a Palliative Care specialist. Most people think of Hospice when they hear palliative care, but it’s wider and simpler than that. It means this physician has chosen a field defined by the fact that his patients will probably never recover. That’s what palliative care means: keeping the patient as comfortable and functional as possible, for the rest of their (probably, but not necessarily, truncated) lives.
Yeah, pretty darn special. How many of you who see pain docs hear them use the term “palliative care” naturally and fluidly, without wincing and scuttling on? It’s a little thing that means a lot. It makes me realize I’m seeing a doctor who CAN be there for the long haul, if need be. Someone who would NOT throw me off with the very natural cringe of frustration and failure most docs feel when they can’t save you, or when you’re in the final downhill slide and they can’t face you dying. He can take that strain without failing me. That’s rare indeed.
Palliative care is the very heart of chronic pain care, and I couldn’t face that myself until today.
So now I just have to die before he retires…
I’d like to go over his approach more, but the fog is descending; it was an early morning and I’m paying for it as usual. I’ve got lots of notes, though. It’s great food for thought, so, with luck, I’ll come back to it.
My pain diagnostic specialist is elegantly opinionated. Fortunately, he acts out the distinction between being opinionated and being rude about it.
We talked over a few things today. He’s still researching my past exposures to uranium, which he has a hard time believing wouldn’t have lasting effects.
He spent a lot of time combing through the idea that evidence-based medicine (in the sense that doctors use the term, not the sense that insurers do, where it means “how can we treat this as cheaply and barbarically as possible”) is really the best and least scary thing out there. Because, data.
I mentioned Dr. Scott Reuben at this point, and he owned that the scientist-practitioner does have to practice with integrity for the science to be meaningful.
He went on to say that the miracle cases that wind up in the literature leave physicians panting to find the next patient who shows up looking just like that case, so they can try the miracle. Doesn’t happen much, and so, there winds up being a paucity of data on rare cases (like mine) that meets the criteria of medical science as he sees it should be.
In the end, as always happens in conversation with a physician who has intellectual integrity, we found ourselves in the cleft stick of modern science:
While statistical probabilities indicate the best chances of success for groups overall, it has two glaring weaknesses, even in ideal circumstances: statistics depend on copious data, which aren’t always obtainable; and statistics mean nothing in the case of the individual.
Thousands of individuals are studied in order to come up with meaningful statistics. Of those individuals studied, how many respond to the treatment at the level of the group’s statistical probability? How many patients in real life will respond at that level? Pfft. All the statistics do is tell you how much of a crap-shoot a given treatment really is; it doesn’t tell you how well or badly it will do for you.
Last Friday, I saw my allergist/naturopathic MD at Northampton Integrative Wellness. He’s exploring mold toxicity, which sure hits all the hot issues I deal with. It doesn’t meet Dr. Saberski’s mental criteria, as I suspected, but that’s okay — I don’t need Dr. Saberski to follow up on it. I need someone like the docs at Integrative Wellness, who have the relevant background and tools, to follow up on it.
Because of my own experiences, I don’t necessarily assume that a well-educated, well-respected, well-published physician necessarily has a lot of intellectual integrity. However, I’ve come to the conclusion, through our conversations and his decisions along the way, that Dr. Saberski’s entire being (at work) is oriented on intellectual integrity.
We may not view things the same way, and he may not be thrilled at everything I do, but the fact is, he shouldn’t have to be. He’s delighted with my good results when I get them, and if this mold toxicity thing pans out and the treatment goes well, he’ll be truly elated for me — and will keep my chart on file, just in case I come back later.
I find it HUGELY relaxing to have such a resolute scientific conservative with such ferociously diligent, relentlessly inquisitive intelligence, which is completely balanced on intellectual integrity, on my case.
All I have to do in relation to the standard science is let him do his job! I do not have to educate this one — quite the reverse! I savor our conversations and make extensive notes, because he always has something to teach me. (Today’s exciting topics: what makes me NOT look like CRPS; the Flexner Report in history; how anesthesiologists, who have the diagnostic training of a spaniel, wound up running pain clinics — another stupid consequence of US insurance companies; and how the nociceptors and immune signaling in the skin are all entangled into being one thing. Woot! Fun stuff 🙂 )
That, frankly, has been unheard of for most of my time with this illness, whatever it turns out to be. I’m well and truly rid of the fearful weight of using my rare full-brain times to try to stay one step ahead of the risk to my survival and management that every doctor visit can be.
I can use my full- and even three-quarters brain time to study up on the stuff he can’t be interested in. For one thing, the vocabulary and writing style is usually less klunky and demanding. For another, that is supposed to be my job.
Patients should figure out what they can do for themselves without making things worse, so I’m happy to do that.
Now, I’m going to find out more about mold toxicity, methods and treatments, plus what data do exist on what to expect from those treatments and what they do in the body. According to my current info, the main researchers are Shoemaker on one hand, and Nathan and Brewer on the other. My allergy/naturo doc is leaving, so I’ll have to start with another one at the same practice. This means I’d better prepare, so I can move the conversation forward a little faster than usual. That means being able to speak her language in regard to what we’re looking into.
I find it’s best to impress doctors right off and for the first several visits, and then, if I’m having a bad day another time, they have a meaningful bar to measure against, and they don’t lose respect for me or dump me into that “just another whacky pain patient” mental garbage-can. I work hard to make visits as useful as possible, as regular readers know.
I’m also getting ready to do another massage intensive. Looking forward to that! It’s pretty uncomfortable for a couple weeks (arnica pills 6c and 30c, and Advil Liqui-Gels, are essential pre- and post-massage medication), but the payoff could be so spectacular. I’m tired of the downward slide and intend to crank up the functional level one way or another.
Winter bit me pretty hard. It’s time to start biting back.
I switched to a new insurance company that might provide dental care. I haven’t tried them on that yet, but I will. It’s on the agenda for this year.
They want to pre-authorize my main neurological med, Savella. This is the main med that keeps my pain under some kind of control most of the time. If it weren’t for Savella, I’d simply not have survived the past 5 years.
Somehow, the pre-auth requirement has thrown my pain specialist into a tailspin. He wrote a prescription (although I had refills) and mailed it to me, then asked me to come in to see him (2-1/2 hour drive, involving an overnight stay to be there in the morning, which is when his office hours are) in order to discuss this, before he’ll initiate the pre-auth paperwork.
I could get testy about that. It would be so easy.
What I did was refer, by date, to the first visit, when we discussed that first for 10 minutes. I guess his notes from that got lost.
This is where I stay off the computer for a day while I calm down, remind myself that it would not actually be in his best interests to throw me into a bottomless lake of fire, and it would probably not be in my best interests to beat him to it and kill him first.
When you have a brutal pain disease, and you have a med that works enough to let you have a life beyond fighting for the next breath and waiting for the lack of food and crazy stress hormones to kill you, and there’s a situation that threatens to take it away, the consequences of losing the med mean that life will descend into a level of hellishness that most people can’t even imagine. Thus, those of us who’ve found a med that works for us, enough to let us eat and move and think and speak — we get pretty intense at the prospect of having that med taken away.
This is not addiction. It never was. It’s true and valid need. Big fat difference.
Funny how it’s easier to believe when we’re not talking about narcotics, isn’t it?
> If you’re serious about managing the narcotic disaster in this country, you have to let yourself remember that both addicts and painiacs NEED TO BE PATIENTS. They both need CARE. Neither they, nor their doctors, nor their communities, are served by being turned into CRIMINALS.
> REHAB WORKS, when properly funded and designed. THAT is how you get addicts off of contraband drugs.
> PAIN MEDS WORK, when appropriately prescribed and used. THAT is how you keep pain-patients functioning as well as their diseases permit.
> There is some logistical overlap at times, but ADDICTION AND PAIN TREATMENT ARE NOT THE SAME THING.
> However, BOTH NEED TO BE MANAGED BY CLINICIANS, NOT POLITICIANS!
Okay, stepping off that soapbox. Feel free to copy/paste the whole blockquote as much as you like.
So, anyway, I’ve calmed down about my doc’s curious response to doing a pre-auth on my longstanding pain med.
This is really important: from here on, I’m talking about MY ANXIETY, not MY PHYSICIAN’S REALITY. This is pretty normal and natural, and I’m leaving it in as a straightforward demonstration of what my brutally nervous brain can do to in the grip of PTSD from decades of questionable care. So, here’s the anxiety-driven, defense-at-any-cost response. (For more on the reality, check my future posts on his doctoring.)
I remembered he’s a geek. More than that — he’s an ubergeeknerdyguy who’s been a high-end specialist for a very long time.
Geeks are brilliant in their particular slice of the world, but can be surprisingly insecure and nervous about stepping outside it. Also, sudden changes can be surprisingly disorienting to them. (Those of us with ANS problems can sympathize.)
Things that might rattle an ubergeeknerdyguy about this and set off mental alarm bells:
My med was covered before, but now it needs pre-auth. Why? /dingdingding!/
My diagnosis was wrong, and it’s possible that my treatment will change, but we don’t yet have enough info to decide what’s next. Feels like change is coming upon us too soon! Not enough information! /dingdingding!/
Winter. Nobody over 35 is at their best here in the winter. /dingdingding!/
Obviously, to those of us who don’t inhabit the intellectual stratosphere, the first 2 issues are pretty straightforward (1: Cuz American insurance is funny like that. 2: Doesn’t matter — stay the course until there’s reason to change) and the 3rd is just life.
To an ubergeeknerdyguy who’s accustomed to controlling outcomes that nobody else can bear to deal with, it’s too much uncertainty to handle at long distance.
So, I’m getting my documentation ready:
I’ve got another copy of the letter from the ins. co. explaining they just want pre-auth.
I’ve got the current formulary showing that Savella is covered.
I’ve updated my supplement matrix showing the changes for the winter, which does 2 things: shows I’m really working on this “being functional” thing, and that I’m taking my chemistry seriously, not being passive and expecting him to do all the work.
In fact, the last point is so useful, I’m going to link my matrix here for anyone to crib from:
Now my secrets are out! 🙂 You can now see exactly which brands I use and what I find that each thing does for me. (And, if you count up the number of capsules and pills this makes, you also know why it can take me over half an hour to get my pills down!)
The first column shows changes (represented by a delta sign at the top). Docs LOVE being able to see at a glance what’s new and different.
Blank spaces are shaded out. This makes it obvious nothing’s intended to be there. (Common sense is not the same as intelligence, remember. Be as clear as possible.)
I put notes at the bottom putting it all in context.
My neuro supplements went down when I got my antioxidants dialed in to reflect the results of my blood tests. In other words, balancing my antioxidants really helped my brain!
My neuro supplements, along with everything else, have gone up to mitigate the brutal effects of cold and snowy winter.
This is not the time to make changes. Having said that, I’m not opposed to changes — just not now. (It’s good to explain, courteously and clearly, what your boundaries are around treatment.)
Detailing those changes tells the doc that I really do pay attention to what I’m taking in. I’m not a faddist; I’m diligent and determined to manage this as well as I can. Just from this one document alone, that’s reasonably obvious. Displaying this characteristic (or set of entwined characteristics) helps my doctors take me more seriously.
The real fun of this symptom complex: trying to keep others taking me seriously even when I realize I’m in such a panic my brain explodes. Woot!
I have written about dealing with careless, ignorant, detached, and outright bad doctors, which is needful and — given the many problematic layers of living with chronic, intransigent pain — appropriate. However, I’m also a nurse, and I really do see things from both sides.
You’re both right.
Having said that, I normally have to pull for the patients, because only one person in that exam room is definitely NOT paid to be there and is NOT on duty, and it’s the one seeking care.
Patients need more advocacy, partly because few of us have the vocabulary to make our real needs and issues understood, and partly because the mere label “patient” instantly drops a person out of the realm of “real human being” in the minds of providers. If you’ve ever seen, or been, a doctor or nurse who needs medical or surgical care, you know darn well how your erstwhile colleagues speak to you differently from how they did before — but still more humanely than they do to most other “patients.”
Being labeled a “patient” is damning. You become a thing, a self-steering talking object, with only a surface resemblance to “real” people. Your main appearance in the eyes of the system, and, at some level, of those who work in it, is as a collection of problems. Your main purpose is to respond to treatment and go away cured.
Chronic intractable pain syndromes become zero-sum games from this standpoint, because pain is inherently demanding — even thinking about pain is painful!*1 — and managing these disease states rarely involves being able to “go away cured.” So, from this institutionalized standpoint, chronic pain patients are set up as failures from the start, because we can’t do our job — go away cured.
Explains a lot, doesn’t it! This unfortunate fact is simply one more thing to work around.
Those of us with intransigent pain syndromes are lucky in one respect — we have interesting sets of problems, and intelligent doctors find that intriguing! Appealing to their curiosity is often more effective than appealing to their humanity, because it gets them where they work best.
A nurse who’s a patient
It has taken many years of painfully humiliating introspection for me to come to terms with this basic dehumanization of patienthood. I was a good, solid, compassionate nurse, but I did not treat people who came under my care the way I would have treated my friends or relatives if they were in my care.
Many reasons for that. For one thing, the profit-driven scheduling doesn’t allow time for anything more than slinging meds and essential care; spending too much time with one patient means putting other patients at risk.
Beyond that, there’s a primal survival reflex involved, because there are things nurses have to do for patients that would be unbearable to do to a friend or relative.
We have to do all of them, thoroughly and without flinching, because they need doing in order for that patient to heal; and we still must be able to come back to work the next day. So, we create a little distance that we can do the work from.
Patients are Other. When they become too human, they can quickly become embarrassing, and every human on earth cringes away from what’s embarrassing. (Just as every human on earth cringes away from what’s painful, and this explains why we tend to get abandoned by our friends and by the system when our pain becomes too obvious for them to bear. That, in turn, is why we get so crazy-good at minimizing the appearance of being in pain; we don’t like the abandonment, and we don’t want to hurt those around us anyway.)
Speaking as a patient and long-term survivor, starting from the underdog position is a terrible position to negotiate your ongoing survival from.
So, I spend most of my time advocating for and educating my fellow patients. They’re the ones who need it most.
However, once in awhile, something hits me, and I feel a point needs to be made.
Doctors (and other care providers)
This article is a good little anecdote from the ER, my old base:
And that, right there, is the juggling-act providers have to do. The decent ones, which is most of them (really), put their hearts on the line every day, knowing they’re imperfect and doing their best anyway.
When I was doing something intense, like dressing a complex wound or teaching someone about their disease or (obviously) coding someone, that patient was the most important person in my life. I threw everything I had, with all the control and skill I had, into the moment-by-moment demands of their care, the whole time that they needed me.
That patient was my life.
Then, whether they lived or died, I had to arrange what happened next, clean up the mess, and leave the bedside, only to go to the bedside of someone who needed me perhaps just as badly in a wholly different way.
No matter what had just happened, after all that effort and dedication, I had to leave it behind and be ready and focused to correctly identify and move forward with the next patient’s tasks.
So, yes, I rarely came off as a fluffy cuddle-bear (which I tend to do at home), and a lot of my responses could be pretty formulaic, but when the chips were down, “he [still] wasn’t my child.” He, or she, or they, was my whole world.
Being able to turn away from that intensity is what makes it possible to turn back to it at need. That’s a tough thing to deal with when you’re on the wrong end of it, when you’re not the one dying on the table or getting your insides pulled about. You know you matter, and want to be treated as if you do. That’s right and proper. It might be too much to ask of a full-time RN. (There is definitely something weird about that.)
Nurses are the bedside providers. Physicians are the directors of care, deciding who goes where and why. They’re accustomed to deciding what happens, and expecting others to make it so, so that the patient can get better and go home.
Chronic care is always a long game, sometimes a waiting game, and doctors are dealing with people who simply can’t do what the doctor’s expensive education said was the doctor’s job: “send them away cured.” This means that the chronic care provider is also set up as a failure from the start, as some have found the grace and integrity to express. *2
This must be a special kind of tricky to learn to deal with, so it doesn’t surprise me that not many otherwise good-hearted people, who go into medicine for laudable reasons, don’t always manage it with the tact and decency that chronic patients (rightly) expect.
In that case, it’s not a bad idea to find a way to waft this article their way… It’s not judgmental, and it provides much food for thought, for physicians and patients alike:
As a side-note, one strategy I find useful for getting through the thing-ness of being a collection of probl– er, a patient, is being as pleasant and amusing as possible. This creates a safe-zone of humor while drawing the provider in past the boundary of “thing-ness” I’m reflexively put in. The wry, black-nailed, hangman’s humor of living with something so vile and refusing to let it win, coming out in my burbling and whimsical-sounding tones, is probably sufficiently unexpected to blow categories out for the moment anyway.
If I can make them laugh with me (while checking me out with a puzzled “are you serious?” kind of glance) I’m halfway to being human in their eyes, and still being treatable. Then, I just keep up with my due diligence (timelines of care, understanding my treatment options, studying up on things we’ve discussed, etc.) and — with the exception of one doctor out of two dozen, who I thought was a buffoon in any case — my relationships with my doctors have been remarkably good.