I think it’s important for primary care providers or anyone taking care of chronic pain patients to realize that the central nervous system plays a very prominent role in pain processing. In many individuals, in whom we see that the central nervous system is amplifying their pain, the brain is also amplifying other sensory experiences. If you encounter a patient with chronic pain who also reports that they’re sensitive to the brightness of light, the loudness of noises, odors, or even that they have a lot of side effects of drugs, those are all clues that the person is more globally sensory hyper-responsive. What that should indicate to a clinician is that part or maybe all of their pain is really coming more from the brain than from the area of the body where they’re experiencing pain. This is really important because the drug and non-drug treatments that work to treat pain that is coming from the brain--this would be classically conditions like fibromyalgia, irritable bowel, headache, interstitial cystitis--are entirely different than the therapies that work for pain from damage or an inflammation somewhere in the body. So we refer to these as centralized pain states, in that the central nervous system is playing a more prominent role.
Physicians need to get better at identifying that symptom pattern. It should really be a blinking neon light that some or much of this person’s pain is coming from the brain. It means we have to switch over to some of the drugs that are working primarily in the brain. The older drugs would be some of the tricyclics. The newer drugs would be the gabapentinoids, the serotonin-norepinephrine reuptake inhibitors. Even cannabinoids would probably be preferred for those individuals rather than opioids or non-steroidals. The non-pharmacologic treatment options are extremely important in these types of syndromes because our drugs to treat this type of pain are not as effective as drugs we have to treat other diseases. And some of the underlying pathogenesis of central or brain pain probably is due to some of the sleep difficulties that people have. A lack of exercise can also turn up the volume control in your brain. So think about non-drug therapies like non-drug approaches to sleep hygiene. Be aggressive about just getting people moving and then exercising.