Chronic GI pain is one of the hottest discussed topics in the functional gastrointestinal disorder world and a topic I have been speaking on a lot lately. And it is clinical challenge that makes the importance of effective physician-patient communications and a biopsychosocial approach so vital to quality patient care.
During the ROME Foundation AGA Institute Lectureship at DDW 2014, Understanding and Treating the Brain’s Contribution to Pain, I stressed, along with my colleagues, that pain is a normal human experience and some people are hardwired physically, emotionally or both to progress to chronic pain states.
The ROME Foundation AGA Lectureship was valuable for clinicians, especially those working with functional gastrointestinal disorders due to the overview of what chronic GI pain entails, the various way to manage this pain and why. The various treatment options included several complementary therapies focused on the mind-body connection, such as cognitive behavior therapy and hypnotherapy; as well as pharmacological options, specifically antidepressants.
Irene Tracey, PhD, the Nuffield Professor of Anaesthesic Science and director of the Oxford Center for Functional Magnetic Resonance Imaging of the Brain at Oxford University, U.K., explained how the brain affects chronic pain.
The central nervous system addresses pain with a “good cop-bad cop” approach, she explained. The bad copy is pro-nociception, which leads to widespread, whole-body pain in humans. The good cop is anti-nociception, which reduces sensitivity to painful stimuli. Anxiety and depression are amplifiers and sensitizers of pain, and they both exacerbate the pain experience, Dr. Tracey added. Her research and that of others has shown that individuals can control their own perception of pain, especially when distracted from focusing on the pain. And because both emotional and physical factors are involved, the treatment for chronic GI pain may include pain medication and behavioral interventions.
Laurie Keefer, PhD, AGAF, associate professor of medicine, psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine in Chicago, IL, described four behavioral interventions commonly used to deal with the depression and anxiety associated with chronic pain.
Cognitive behavioral therapy is a treatment approach that assumes that the perception of pain affects behavior and that fear of pain directly interferes with function. Therapists teach patients how to confront the pain directly, that suffering should be anticipated and that emotional and behavioral avoidance of pain is the reason they are disabled.
Another behavioral intervention is hypnotherapy. Hypnosis creates a focused state of awareness and shifts attention away from the negative emotions the patients are experiencing. It has been used to treat a variety of medical conditions, including irritable bowel syndrome (IBS). Dr.Keefer noted that one study showed that post-hypnotic suggestions are critical in reducing the patient’s attention on negative emotions.
I addressed pharmacotherapy for chronic abdominal pain during the session and explained that even though a variety of drugs are used to treat chronic pain syndromes, most are used off-label. However, it is important that clinicians understand the the various options available to their patients and the mechanisms of they work in managing chronic GI pain.
Antidepressants are commonly used for functional abdominal pain disorders and functional GI disorders, such as IBS and functional dyspepsia, and there is a clinical rationale to using antidepressants. hence, the reason, I encourage gastroenterologists to become familiar with the use of antidepressants if they are dealing with chronic pain conditions. One of the messages can tell your patients if they say they are not crazy, not depressed, say that the brain and the gut are hardwired. Drugs used for the brain will affect the gut as well.”
Tricyclic antidepressnats (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs) may be more effective than selective serotonin reuptake inhibiotors (SSRIs for chronic pain because they work on serotonergic and noradrenergic systems, whereas SSRIs are primarily serotonergic in action. Other medications used to treat chronic abdominal pain include the antidepressant mirtazapine, the hypotensive agent clonine and the anxiolytic agent buspirone. The antipsychotic agent quetiapine may be used for anxiety, while the Alzheimer medication memantine may affect the development of chronic pain.
Again, I encourage clinicians to understand the brain’s role in chronic GI pain, and be open to learning more about the various therapies, including those outlined above, as they work with their patients in managing their chronic GI pain.