The first thing that comes to mind when I read your post is the "misdirected problem solving"-model as proposed by Eccleston and Crombez in "Eccleston, C. and G. Crombez, Worry and chronic pain: a misdirected problem solving model. PAIN®, 2007. 132(3): p. 233-236." Check that article out and see if it is any help to you!

You may also find some answers in a recent paper in the Clinical Journal of Pain of the fear-avoidance model: the next generation (Crombez et al., 2012). This paper takes a motivational/goal account of (pain) behaviour and daily (dis)functioning. it attempts to integrate/overarche the fear avoidance model and the misdirected problem solving model,

You have to take into account exactly what is motivating the person--and that is not always simple. Financial gain including disability insurance is often the least of it. I have found most often people want to be acknowledged for the pain they are having and they want sympathy and comfort and some kind of physical contact like a pat on the back or the hand.

i like Dr. M Sullivan's work on perceived injustice - this might be quite applicable

Your observation makes perfect sense from a motivational/self-regulation perspective on pain behaviour/coping. Actually, we are currently investigating this kind of ideas. In a recent experimental study (Van Damme et al., 2012, PAIN; "No Pain No Gain"), we have shown that when individuals have the choice to perform or avoid a pain-evoking task, they avoid this task less when it has some motivational value to them than when it has not. Also, participants' behaviour is clearly less driven by fearful thoughts about the pain when the task has motivational importance. Of further interest is a study (Schrooten et al., 2012, PAIN) showing that attention to pain-related cues is substantially reduced when engaging in a task that has motivational value. So this suggests that when people engage in behaviour that is connected to relevant personal goals they may be better able to ignore pain and are more distracted from their pain, as a result of which they feel less disabled. Other papers related to this issue are Van Damme et al., 2010 (Neuroscience and Biobehavioral Reviews) and Verhoeven et al., 2010 (Pain).

Thank you so much for your thoughts. Is there any research to suggest that the ACT (Acceptance and Commitment Therapy) model could be applicable?

It strikes me that it's the combination of pursuing something that has personal value and remaining aware of, but undistressed by, the pain experience that defines these people. At this point in my study (classical grounded theory) I'm not attempting to explain *how* these people develop their approach, although that is clearly the next step, but it is evident with all of them that remaining committed to doing what is important to them prior to the onset of their pain is a characteristic.

It suggests that to help people who don't cope as well is less about developing a wider repertoire of coping strategies, but far more about helping them identify what is important (valued) and supporting them to remain committed to achieving it.

This is a central feature of pain, one that has not been well illuminated. Biologically, a starting point is "aversion," a complex neuropsychological function that has been partly explored in addiction studies, since it is roughly an inverse to "craving."

As others have pointed out, it is very interesting that these results mirror the molecular-imaging and animal studies which have demonstrated the important role of the opioid and dopamine systems in modulating both pain and pleasure and the interaction of pain with the reward centres of the brain focused on decision making (Leknes and Tracey Nature Reviews Neuroscience 9, 314-320 April 2008). Further research suggests that pain and reward processing may potentially interact and subsequent models have been developed ( Talmi et al The Journal of Neuroscience, 18 November 2009, 29(46): 14617-14626). My research found that (in patients with chronic pain) a patient's focus and belief structure around their activity levels and limitations was an important predictor of higher functioning rather than their actual physical activities. I think your research raises some very interesting questions around the interactions between beliefs and behaviours and its effects on pain.

Could a motivational account explain how people who participate in body piercing, body suspension and other painful activities cope with their experience? To me there is always the element of context - both goal pursuit as well as social support and purpose. It occurs to me that it's a combination of the meaning of the pain, the value of the goal, and the capacity to persist that is modified by social factors such as the immediate presence of those supporting the concept of coping, and community values and expectations about that type of pain. Has this been integrated into any existing models?

Next to the degree of interference of pain (or absence) with respect to activities also the matrix short/long-term pos/neg consequences of their activities may be at stake. Distress may be the result of both.

Ahh - exactly what I mean about motivation! The goal is to have social connection and the "high" from endogenous opioids etc which helps to overcome the usual anxiety and avoidance. Any model of pain and behaviour should at some level help to explain how people do cope with their pain in this sort of context, shouldn't it? And what about those who use pain in the context of sexual arousal?

Maybe we can collaborate to do such ressearch in Indonesia. Here is many people who get pain.

I am studying about pain in labor. Even the women reach highly score of NRS, most of them stay to calm. My result showed that knowledge of the women is important thing. They didn't know that labor pain can be managed effectively. They thought that as a women who deliver the baby, pain is needed to push the baby out. I think race and ethnic also have role, as some references mention but my study is still running, I have not found it.

The research I've looked at regarding pain in labour suggests pain behaviour is quite variable between women (I'm teaching Psychosocial & Cultural Aspects of Pain). I think because it's known to be short-term pain (with a known endpoint - a baby!), it's possibly easier to deal with in some respects than the ongoing persistent pain that the people I have been researching. And yes, I've found similar research showing ethnicity, cultural and knowledge aspects influence pain experience and pain behaviour also.

Yes, pain caused by diseases may different. This kind of pain could interfere with the psychosocial condition. Patients who have good support system may have effective coping

I've just picked this up. I think that the basic point about pain (Pat Wall noted this many years ago and alludes to it in his wonderful book 'Pain: the science of suffering') is that it always occurs in the context of other activity / motivation. Until recently we've only studied pain per se but as Stefaan van Damme has noted, he and others are now working within a motivational conflict framework. Putting it at its most basic pain 'asks' a question - 'what are you going to do: pay attention to me or get on with other stuff?' In most lab experiments we find difficult to develop powerful 'other stuff' that can capture attention and behaviour in preference to pain - see work by Stefaan, Geert Crombez and Chris Eccleston.

The other part of this is consideration of the 'other stuff'. That will I think prove to be complex when we look at the real world dynamics of how people regulate their behaviour (or perhaps I should say how events and motivation regulate behaviour). There are several aspects to this but it's helpful to think of appetitive and aversive motivation. If you find pain threatening both of itself and because it brings you closer to other unwanted (anti) goals, then it may be very difficult to disengage from pain-related activity and to (re)engage in positive, appetitively rewarded behaviour. We've done work on pain patients views of both their hoped-for and feared-for selves (i.e. their values and goals). We know that if your major focus is pain removal and your belief is that you can't become what you want to be then your distress level is high. We don't know how the positive and negative aspects of the self inter-relate over time and how ones sense of self gets enmeshed or trapped by pain. It is I think the big question. At the moment all we have are cross-sectional descriptive studies and a few lab studies.

Hi Stephen

Some really interesting points and I really like your idea of looking at how the self changes as a result of Pain. I am also interested in how we currently measure the various dimensions of pain and its effects on the individual. It also questions whether our current measures looking at various aspects of catastrophizing, internal control, sel-efficacy and fear avoidance beliefs around pain capture this affect of pain on the ego and the patient's motivational views of pain (the context of the pain experience).

An important consideration: the body schema, the pariarietal lobe sensory homunculus, is modified in chronic pain, so that the painful body parts are expanded and intensified. But the body schema, is at the core of the body image, which is, in turn, at the core of the self-representation. Thus , the self is modified in a fundamental way. But, since pain is aversive, this is a conflicted way. The self becomes aversive; but of course can never be fully aversive. This is an additional llevel of conflict, in addition to the more basic one around the frustrated aversion of pain itself.

Thanks, Paul and Mathew for your comments on topics that I've been mulling over for some time. I'll give it a bit more thought and come back to you if I've anything useful to add.

research into ENDOGENOUS morphine in mammals and other animals might be a relevant topic.

Chemical characterization and regulation of endogenous morphine and codeine in the rat.

J Donnerer, G Cardinale, J Coffey, C A Lisek, I Jardine and S Spector

Abstract

--------

Endogenous codeine and morphine in poor and extensive metabolisers of the CYP2D6 (debrisoquine/sparteine) polymorphism.

G Mikus, F Bochner, M Eichelbaum, P Horak, A A Somogyi and S Spector

+ Author Affiliations

Dr. Margarete Fischer-Bosch-Institut für Klinische Pharmakologie, Stuttgart, Germany.

Abstract

Codeine and morphine are endogenous substances. Following administration of exogenous codeine the biotransformation to morphine is catalyzed by CYP2D6, which exhibits a genetic so-called debrisoquine/sparteine polymorphism which is expressed in two phenotypes, the extensive and poor metaboliser phenotypes. Poor metabolisers form only trace amounts of morphine. If endogenous morphine is biosynthesised in humans via similar routes as in the poppy plant, two of the steps involved are mediated by CYP2D6, namely thebaine O-demethylation to oripavine and codeine O-demethylation to morphine. Poor metabolisers should therefore have a much lower endogenous morphine formation than extensive metabolisers. The urinary excretion of endogenous codeine and morphine were investigated in 20 extensive and 20 poor metabolisers of CYP2D6. Substantial interindividual variation in codeine (7-6851 pmol/24 hr) and morphine (32-35471 pmol/24 hr) excretion was observed. However, there were no phenotype-related differences in endogenous codeine and morphine excretion. Administration of the competitive CYP2D6 inhibitor quinidine had no significant effect on endogenous codeine and morphine excretion in extensive metabolisers. In conclusion, in contrast to exogenous codeine O-demethylation to morphine CYP2D6 appears not to be involved in the biosynthesis of morphine in humans.

Potassium-Induced Release of Endogenous Morphine from Rat Brain Slices

M. Guarna1, C. Neri3, F. Petrioli1, E. Bianchi2,*

Article first published online: 14 NOV 2002

"These results suggest that endogenous morphine might act as a neurotransmitter or neuromodulator in the rat CNS."

Increased urinary morphine, codeine and tetrahydropapaveroline in parkinsonian patient undergoing L-3,4-dihydroxyphenylalanine therapy: a possible biosynthetic pathway of morphine from L-3,4-dihydroxyphenylalanine in humans.

K Matsubara, S Fukushima, A Akane, S Kobayashi and H Shiono

+ Author Affiliations

Department of Legal Medicine, Shimane Medical University, Izumo, Japan.

Abstract

We have identified morphine and codeine in human urine by means of gas chromatography/mass spectrometry. Gas chromatography/mass spectrometry was also used to quantitate the two alkaloids and tetrahydropapaveroline (THP) in urine of both normal subjects and parkinsonian subjects receiving L-dopa therapy. The morphine, codeine and THP levels in healthy nondrinker controls were 2.93 +/- 0.23, 2.01 +/- 0.53 and 6.70 +/- 1.13 pmol/ml (mean +/- S.E.M.), respectively. In contrast, the urinary levels of codeine and THP in L-dopa-treated parkinsonian patients were significantly elevated to 62.20 +/- 17.54 and 31.04 +/- 15.69 pmol/ml, respectively. Some of the parkinsonian patients showed high urinary morphine levels. Morphine excretion was also enhanced in patients complaining of severe pain due to herpes zoster (24.60 +/- 9.51 pmol/ml) but not in patients with severe pain due to cerebral embolus. These alkaloid levels in the urine of abstinent alcoholics were very low. There were significant correlations among these three alkaloid levels in the urine. The results indicate that morphine and codeine are synthesized in the body from L-dopa and/or dopamine, via the THP-related pathway.

Jonathan Ott's book Pharmacotheon, outlined research into endogenous morphine being found in various animals and humans and bovine/human milk

and cites ( Cardinale et al. 1987) as his source for research...

from these sources, and other research published, I have been following the possibility, that some people might possibly have poor enzyme activity that results in low ENDOGENOUS morphine content....

in addition to beta endorphin, enkephalin, and other opiate peptides, morphine levels might have some role to play in people that are more resistant/less resistant to pain control.

Cliff, I suppose the issues I've been looking at is in those individuals who report relatively HIGH pain intensity, but despite this, continue functioning and with low levels of disability. Alongside my grounded theory interviews I've also used the Profile of Chronic Pain (short form), by Ruehlman, L. S., Karoly, P., & Newton, C., & Aiken, L. S. (2005). and these people would fit with high pain severity, low interference, low emotional burden.

So, I don't think this group have a different intensity (ie they probably don't have a different endogenous opioid level, although they may have a different way of processing this. I prefer to think of this in terms of the way they evaluate their pain in the context of the important activities they wish to undertake.

They have also mentioned that they don't view themselves as "disabled" but as people who have pain - I'm wondering if this reflects the concepts of body image and self image. They appear to have integrated their view of their body as still belonging to them, "finding ways of doing normal things but doing them differently".

Ruehlman, L. S., Karoly, P., & Newton, C., & Aiken, L. S. (2005). The development and preliminary validation of a brief measure of chronic pain

impact for use in the general population. Pain, 113, 1-10.

I would attribute this to adaptive- vs. maladaptive coping measures that are adopted by the patients; either due to learned pain management techniques or by virtue of the necessity of decision. ec

The curious thing is that the people I've been studying use exactly the same strategies as people who seek treatment - they don't "pace" their activities, they boom and bust, they use pain relief prn, and they take to their beds when they feel really bad. So I'm not convinced it's the coping strategies per se - instead it seems to be associated with their ability to view their pain as nonthreatening, the level of acceptance of their current pain intensity and diagnosis, and the value they place on doing "normal things" that are important to them.

How much might be attributable to psychiatric comorbidity? The prevalence of anxiety and mood disorders is very high, and for many clinicians, difficult to recognize. And failure to recognize and treat means continuation, and longterm worsening, of pain and disabiity.

Yes, the people I'm studying don't have psychiatric comorbidity (particularly anxiety), at least, not that they have disclosed to me. At the same time, I wonder if this is one of the aspects that enables these people to remain well. The links between mood disorders and chronic pain in the neurobiology of pain is fascinating.

Very interesting topic. Thank you everyone for your clarifying ideas.

Bronnie, in your first post you wrote that your patients "function well" and latter that "boom and bust and (...) take to bed when they feel really bad". I wonder if you considered that that behaviour might reflect an overactivity pattern characterized by an endurance response to pain. If it was the case, a redefinition of the activity pattern and a progressive recovery (not pacing, but fixed increases) of an acceptable level of activity might help.

Sluka KA, Rasmussen LA. Fatiguing exercise enhances hyperalgesia to

muscle inflammation. Pain 2010;148(2):188-97.

Vlaeyen JW, Morley S. Active despite pain: the putative role of stop-rules

and current mood. Pain 2004;110(3):512-6.

Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice. Clin J Pain. 2010;26(9):747-53.

Yes, I'm familiar with those papers, the only thing is, these people are not actively seeking help, and they're undistressed. Overall, they've maintained engagement in paid employment, their relationships remain positive, they're not depressed or distressed, and they're not looking for treatment per se. They seem to use the boom and bust, and the periods of rest quite intermittently, and only during exacerbations (though it would be great to fit them with accelerometers to find out exactly what their activity profiles are over the course of a day). Interestingly, in the group of people I'm studying, exercise is a key part of their management, so at least one thing we teach in self management programmes is common!