Daniel M. Doleys - Pain: Dynamics and Complexities

Daniel M. Doleys, PhD

Director, The Doleys Clinic and Pain and Rehabilitation Institute
Birmingham, Alabama

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Library of Congress Cataloging-in-Publication Data
Doleys, Daniel M., author.
Pain: dynamics and complexities / by Daniel M. Doleys.

p.; cm.

Includes bibliographical references and index.
ISBN 9780199331536 (alk. paper)
I. Title.
[DNLM: 1. Chronic Pain. WL 704]
RB127
616.0472dc23
2013034353

This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

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To my parents, Julia and John, to my father-in-law,
Rev. H. T. Henderson, and to my children, Thomas,
Dannette, Nicholas, and Brad.

To the thousands of patients with chronic pain who entrusted
our clinic with their story and care.

And most especially to my wife, Sue, for her patience endurance
and support during the long days and weeks in the office and all
those working vacations. She cannot imagine the influence her
love, intellect, and insight have had on this project.

This book is a mixture of neuroscience, psychology, and philosophy of science. It is designed to present the evolving concept and complex nature of pain, especially chronic pain. It does so by reviewing the history of pain and outlining the current concepts and theories regarding the mechanisms involved in the experience of pain. The experimental and clinical research in a broad number of areas, including infant pain, empathy and pain, psychogenic pain (medically unexplained symptoms), and genetics and pain is summarized. The notion of pain as a disease process rather than a symptom is also highlighted.

Although there is continued interest in activation of the peripheral nociceptive system as a determining factor in the experience of pain, there is a growing appreciation for the brain as the ultimate pain-generator, this is noted here. The definition of consciousness and conscious awareness and a theory as to how it relates to nociceptive processing is also outlined. In addition to putting the study of pain in an historical perspective and summarizing current research and theories, the manner in which concepts from systems theory to quantum theory can be applied is illustrated. A rationale for considering pain as an emergent phenomenon and hypothetical construct is also outlined. In part, the intent of Pain: Dynamics and Complexities is to encourage and promote a broadening of the existing paradigm within which pain is viewed and understood.

The book is designed primarily for health care professionals, paraprofessionals, academicians, and students interested in pain. This book is not a clinician or patient manual. There are, however, illustrations of how experimental and clinical research can be being translated into treatment options and provide implications of a broader view of pain for future therapies. Although many of the chapters contain a summary of the relevant research, no attempt was made to conduct an exhaustive review of the literature. Commentary, clinical anecdote, and observation are used to provide real-life illustrations, when appropriate.

Daniel M. Doleys

I owe a debt of gratitude to Andrea Miller, Carolyn Holmes, and Erin Thrift for their invaluable assistance in obtaining the many references needed for this book. I appreciate Doctor Roger Fillingims thoughtful review and comments on Genetics and Pain (

For all the happiness mankind can gain is not in pleasure, but in rest from pain.
John Dryden, 17th century English poet and playwright

Pain is perhaps the most fundamental, complex, and common of all human experiences. Chronic pain results in limitations in daily function and physical activities, compromised emotional health, impaired quality of life, and a significant increase in health care utilization. Pain knows no gender, age, ethnic, or socioeconomic boundaries. People with chronic pain represent the largest group of individuals with a long-term disability. About 90% of the U.S. population will experience pain, and 3050% (some 100 million adults) will go on to have chronic pain. The estimated health care cost (in 2010 dollars) ranges from $261 to $300 billion, and the loss of work productivity from $299 to $335 billion. In 1996 the total cost of chronic non-cancer pain was $150 billion and the average cost of treatment per patient approximately $35,000.00 per year. The health care costs for patients in moderate pain are some $4,200.00 more per year than a person in no pain and about $7,700 more for those in severe pain (Gaskin and Richard, 2012). The overall emotional impact of chronic pain is reflected in the lifetime prevalence among patients expressing their wish to die: it is 1.47 times higher than that for non-patients. Patients in pain report an active suicidal ideation or plan up to six times more than non-pain controls, and suicidal attempts occur 14% more often (Fishbain, 1999; Fishbain et al, 2008).