Rethinking Chronic Pain

There are many ways to separate members of the human race. One seems to be the tendency toward addiction and chronic pain. The majority of people in this world have little inclination toward controlled substances. They may binge drink alcohol in college, but tend to move on with life. This is the person who gets #30 pain pills from the surgeon after a procedure and only takes four or five.

There are others that are much more likely to end up taking narcotics (like percocet and vicodin), benzodiazepines (like xanax and ativan), stimulants (like Ritalin and Adderall) and other medications with abuse potential. Most physicians have a subgroup of patients that are taking or at least requesting combinations of these pharmaceuticals. These people often smoke cigarettes and consume excessive alcohol through adulthood. They are more likely to have chronic pain in the form of headaches, neck pain, back pain and muscle pain. Some are diagnosed with the chronic pain syndrome fibromyalgia. For years, I have noticed that these individuals will often have other first degree relatives with similar tendencies.

When it comes to the individuals prone to substance use and pain, I would guess the majority of people believe that genetic factors (nature) play a minor role and that environmental factors (nurture) predominate.

There is an unstated presumption that those struggling with addiction and pain are somehow weak-minded. They are looking for a good time. They just need to suck it up and get on with life like the rest of us. For those who understand mental health, this isn’t the case at all. People use/abuse substances to get relief from anxiety, depression, pain and other difficult issues. For them, the time they are high or otherwise impaired can be the only time they have relief and are without physical and emotional pain.

I am starting to wonder more and more about a single genetic anomaly that may predict this differentiation point among people: MTHFR. As I noted in an earlier blog, about 40% of people have a genetic anomaly that leads to moderately reduced activity of this crucial enzyme and 10% of people have severely reduced activity. How could this one enzyme lead to both pain and addiction?

Dopamine is the chemical associated with reward and addiction. Dopamine affects brain processes that control movement, emotional responses and the ability to experience pleasure and pain. Optimal functioning of the MTHFR enzyme within cells is required for a person to have adequate levels of methylfolate. Methylfolate is a precursor in a series of complex biochemical pathways that leads to the production of many neurotransmitters including dopamine.

On the pain side of the equation, we can focus on a substance called glutathione. Glutathione is a powerful antioxidant made in high quantities in our bodies. It helps with detoxification of damaging substances. Glutathione naturally reduces inflammation. MTHFR and mehtylfolate are involved in glutathione production.

There is research as well that glutathione is important for the production of something called nitric oxide. The substance nitric oxide helps dilate blood vessels so there is adequate blood flow to the muscles and other tissues. Might this mechanism explain some of the muscle pain that many feel in chronic pain syndromes like fibromyalgia? Possibly.

Why, you might also ask, does this seem to be a modern problem? People in the past didn’t seem to have as many problems with headaches, chronic pain, fibromyalgia and substance abuse. Maybe they were just tougher?

With MTHFR, it’s not only the genetics, it is reduced MTHFR enzyme activity in combination with environment and lifestyle. The factors that make MTHFR more relevant now include stress, chemical and toxin exposure, a devitalized diet and others. Stress is high for Americans, no one really questions that.

A study done showed the average American has over 200 chemicals in their blood stream and soft tissue known to be cause health problems.

The American food supply is a mess. It has been estimated that 80% of all food consumed is processed. People are cramming in crappy food on the go so they can work more, keep their jobs and buy a third TV. The staples of the American diet are beef, pork, chicken, corn, soy and wheat.

There are now many books, videos and documentaries that expose the mass produced versions of these foods as low quality. Read The Omnivore’s Dilemma if you want an eye opener. For a simpler introduction to our pitiful food choices, watch the documentary Food, Inc.

To this point, each person I’ve seen in the office with a personal and family history of mental health issues, substance abuse and chronic pain that I’ve tested has been MTHFR positive.

Sorting this out, would be relatively easy. A start would be to identify this subset of people with low quality of life from substances and pain and do the MTHFR blood test. We would compare the frequency of MTHFR anomalies in this group with a control group in the general population. Someone needs to fund this study and about 100 others to clarify the impact of MTHFR and, even more importantly, to help figure out optimal ways to manage the problem. Bill and Melinda Gates where are you?

References: Harbrecht, et. al. Ann Surg. Jan 1997; 225(1):76-87 Glutathione regulates nitric oxide synthase in cultured hepatocytes.

Andrew Lenhardt, MD

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