[@PeterAttiaMD] The 4 Types of Pain: What Type of Pain Are You Actually Feeling? | Sean Mackey, M.D., Ph.D.

Link: https://youtu.be/ZKEwzjDjoC4

Short Summary

This video transcript categorizes pain into four main types: nociceptive (tissue damage activation of pain receptors), visceral (organ-related, diffuse, and potentially referred), neuropathic (nerve damage or dysfunction causing burning/shooting pain), and nociplastic (central nervous system dysfunction amplifying pain). Neuropathic pain differs from nociceptive and visceral pain in its origin (nerve injury vs. tissue or organ damage) and often requires different medications (anti-convulsants).

Key Quotes

Here are four direct quotes from the transcript that I found particularly insightful:

1. "When you get a stomach ache you can't put your finger exactly where it hurts. you tend to put your whole hand over it and say, 'I'm kind of it hurts here. It's diffuse.' That's because the brain, the spinal cord and the brain have these diffuse receptive fields which expand the area." (This clearly explains the nature of visceral pain and why it's difficult to pinpoint.)

2. "You know who gets credit by the way for making uh I give credit to uh making gabapentin the blockbuster drug? George Clooney." (This is a surprising and humorous anecdote about the popularization of gabapentin, highlighting the influence of popular culture on medical practice.)

3. "There's only a few FDA approved medications for pain, like a handful. So what we've learned to do is to steal borrow drugs from the neurologists, their anti-convulsants, their anti-seizure medications, the gabapentonoids, the taggls and their derivatives, their other anti-seizure medications because they tend to have mechanisms of action that also work on nerves. pain." (This statement highlights the limitations in the pharmaceutical treatment of pain and the resourceful, "borrowing" strategies employed by pain specialists.)

4. "You're absolutely right and I think the verdict is still out in the end. Does no plastic pain stick around or is the problem that in these conditions that we associate with no plastic pain, medical science hasn't caught up to identify a specific peripheral driver. I'm of the opinion it's that latter." (This quote points to the evolving understanding of pain and suggests that "no plastic pain" may simply represent conditions where the underlying causes are yet to be discovered.)

Detailed Summary

Here is a detailed summary of the YouTube video transcript, broken down into bullet points:

Key Topics:

• Categorization of Pain: The video discusses different ways to classify pain, primarily focusing on:
  • Nociceptive Pain
  • Visceral Pain
  • Neuropathic Pain
  • Nociplastic Pain (a newer, less established category)

Nociceptive Pain:

• Caused by activation of primary nociceptors in skin, soft tissues, or viscera.
• Easy to localize; patients can pinpoint the source.
• Intensity is usually well-defined.
• Time-limited, typically resolving with acute injuries.
• Responds well to analgesics like acetaminophen, NSAIDs, COX-2 inhibitors, and opioids (for short-term use).

Visceral Pain:

• Originates from activation of nociceptors in thoracic, abdominal, or pelvic viscera.
• Diffuse and difficult to localize. Patients often describe a general area of pain rather than a specific point.
• Visceral nociceptors don't always respond to the same stimuli as nociceptors in other tissues (e.g., not sensitive to cutting during surgery, but sensitive to tugging or inflation).
• Viscerosomatic convergence: Afferent signals from the viscera converge with sensory systems from other parts of the body.
  • Example: Irritation of the diaphragm (e.g., from blood during surgery) can cause referred pain in the shoulder because the same cervical nerve roots (C3-C5) subserve both.
  • Example: Heart attack pain radiating into the arm due to overlapping nerve innervation.
• Treatment of visceral pain:
  • Typical analgesics may be helpful, but visceral-specific anti-nociceptive drugs are an area of ongoing research.
  • Focus is on identifying and reducing substances that are "winding up" the nociceptors.

Neuropathic Pain:

• Caused by injury or dysfunction of the peripheral or central nervous system (nerves outside the brain and spinal cord, or the brain and spinal cord itself).
• Classic Qualities: Described as burning, sharp, lancinating (piercing), stabbing, or shock-like.
• Examples:
  • Thalamic stroke causing burning pain in half of the body.
  • Radicular pain (nerve root injury) – sharp, radiating pain, often down the leg below the knee (sciatica).
• Treatment:
  • Common analgesics are often ineffective.
  • Anti-neuropathic pain drugs are used, often "borrowed" from neurology (anti-convulsants, anti-seizure medications).
  • Gabapentinoids (e.g., gabapentin) are frequently used. Gabapentin is noted as a poor anti-seizure drug, but a good anti-nerve pain drug.

Nociplastic Pain:

• A newly introduced category representing dysfunction in the central pain processing system.
• Pain is thought to be caused, perpetuated, and amplified by dysfunction in the brain and spinal cord, in the absence of an identifiable peripheral cause.
• Associated with conditions like fibromyalgia, temporomandibular disorders, some chronic low back pain, irritable bowel syndrome, and interstitial cystitis.
• It's noted that Nociplastic Pain may be a large category encompassing everything for which we don't understand the cause using the other three categories. The speaker believes medical science may eventually catch up and identify specific peripheral drivers for these conditions.

General Information and Disclaimers:

• The speaker has no financial ties to the pharmaceutical industry and receives no industry money.