Unlock the mysteries of pain

If you visited in a doctor’s office anytime in the past five decades, after having your blood pressure taken and your weight measured, you’ve probably been asked this seemingly innocuous question: “Do you have any pain?”

BOOK REVIEW“The Song of Our Scars: The Untold Story of Pain”, by Haider Warraich (Basic Books, 320 pages).

“Are you in pain” and the 1-10 pain scale have become an integral part of American health care. But does it make sense to reduce pain to a binary yes or no, or a number on a scale? Haider Warraich, a physician and professor at Harvard Medical School, says absolutely not. In his new book “The Song of Our Scars: An Untold Story of Pain,” Warraich argues that modern medicine has “asked people to have the most complex experience they could have, an experience that fundamentally challenges the artificial distinction between body and mind, between the physical and the metaphysical, experience emotional, spiritual, genetic, epigenetic, evolutionary, racial, and psychological dimensions, and reduce it to a single number on a 10-point scale.

Our modern misconceptions about pain have had dire consequences, Warraich says, ranging from the chronic pain epidemic to the ravages of the opioid crisis.

Warraich approaches this subject from a personal point of view. While a medical school student in Pakistan, Warraich was lifting weights one night in the gym when his back clicked and he dropped a barbell on his chest. Warraich first found himself immersed in acute pain and then, over the years, in the dark world of chronic pain. Like many people with this disease, his narrative about himself fell apart. His relationships grew distant. “Everything in my past life seemed so distant, I felt like another person had experienced it,” he writes.

Thus Warraich, now a cardiologist at Brigham and Women’s Hospital in Boston, set out to deconstruct the scientific, historical, psychological and social dimensions of the nebulous experience of pain. In pre-modern times, he writes, pain was seen as a transcendent experience, inseparable from spiritual ecstasy. But with the Enlightenment came new ideas. René Descartes celebrates the demarcation between mind and body, postulating that pain resided in the body while suffering lived in the heart and soul. With this false binary established, modern medicine began its quest to banish pain from the body.

But this understanding of pain is totally wrong, says Warraich. This approach confuses pain with nociception, the process by which the body encounters sensation and then transmits it to the mind. Pain is so much more complex than the physical process of nociception, argues Warraich. He cites examples of soldiers with horrific injuries who reported no pain, perhaps because they were so relieved to escape the battlefield, an example of how nociception doesn’t always lead to pain. On the other hand, phantom limb syndrome – when a person feels a sensation in an arm or leg that has been amputated – is an example of how excruciating pain can torment a patient in the absence of nociception. . So pain is never just a mechanical physical process; it is intimately linked to emotion, to experience, to context.

Our modern misconceptions about pain have had dire consequences, Warraich says, ranging from the chronic pain epidemic to the ravages of the opioid crisis.

And then there’s the confusion of sharp pain with its more sinister cousin. “When we talk about an epidemic of pain, we are not referring to more people being injured by falling from trees,” Warraich writes, “we are concerned about the emergence of a different form of pain.” Chronic pain has traditionally been understood as a form of long-lasting acute pain, but Warraich argues that chronic pain is a whole different experience. Chronic pain, he says, is “modern-day leprosy” and our clumsy attempts to treat it resemble the days when doctors ripped out the lungs of tuberculosis patients.

And these clumsy attempts had disastrous consequences. Much of the second half of Warraich’s book is devoted to excoriating a health care system that purported to treat the chronic pain epidemic, but instead burdened millions of Americans with opioid addiction. Warraich traces the history of opium, heroin and morphine, from the Opium Wars of the 19th century to the rise of consumerism and pill culture after World War II.

The story of the Sackler family’s development of OxyContin as a pain club is well known, but Warraich blames the entire pharmaceutical and medical systems, and the researchers and government officials who went with it, for prioritizing profit over people. “[M]Modern health care has figured out how to monetize the poorest and most suffering people in the United States,” says Warraich, and we have paid the price.

Warraich is a cardiologist, but he draws on his own experience in medical school and his own experience with opioid dependent patients to further the concepts he explores in his book. He shares harrowing stories of patients whose only contact with the medical system is to get new opioid prescriptions, and other medical students who have fallen prey to opioid addiction and destroyed their lives. Worst of all, says Warraich, opioids don’t even help chronic pain; on the contrary, he cites studies that suggest that the use of these drugs can destroy a patient’s ability to generate their own pain response and can, in the long term, make the problem worse.

The greed and bad ethics that fueled the opioid crisis are part of the longstanding relationship between pain treatment and the power structure. As doctors threw opioids at masses of white Americans, their black counterparts were less likely to receive such prescriptions for their pain. (Public health experts report that it helped perpetuate a myth that black people were spared the opioid crisis.) Black patients’ lesser access to opioid prescriptions, according to Warraich, stems from black pain – such as pain during childbirth – often ignored or disbelieved by the medical system. Pain has therefore never been objective: it is always linked to the context.

So if chronic pain isn’t a number on a scale, or an extension of acute pain, then what is? It’s likely that our experiences shape this kind of pain: Warraich brings up the theory of neuroplasty, which postulates that instead of remaining static, our nervous system evolves throughout our lives. Perhaps chronic pain, says Warraich, is the sum of our disappointments and our experiences of prejudice, our fears, our regrets and our past hurts. “What if chronic pain was neither a physical sensation nor an emotional state?” he thinks. “What if chronic pain was something else: a memory?

Chronic pain has traditionally been understood as a form of long-lasting acute pain, but Warraich argues that chronic pain is a whole different experience.

In a way, “The Song of Our Scars” is the story of a doctor’s crisis of faith. Faced with the opioid crisis and the medical system’s twisted, money-driven approach to pain management, young Warraich lost his idealism. But this book is an attempt to regain his faith. Warraich believes that to combat our current “paindemic,” doctors need to ignore the bottom line and instead take a holistic approach. They have to sit and listen to the patients; they must practice empathy; they should encourage patients to learn to live with their pain rather than fight it.

These ideas may seem controversial, even harmful, and indeed there were times, reading Warraich’s impassioned anti-pharmaceutical passages, when I worried that he was downplaying the benefits of “taking pills” for many people with anxiety, depression and other mental health issues. . I feared he would fall into the trap of stigmatizing interventions that help certain patients.

And yet, the fact remains that we haven’t found a good way to deal with the pain, and Warraich’s riveting, informative, and deeply personal account remains an invaluable and empowering call to arms for rethinking our relationship with this nebulous human experience. As Warraich writes: “The truth, however, is that the pain is really in our heads. And it is there, within ourselves, that we will find a way to overcome its overwhelming influence. A provocative statement – but one worth considering.

Emily Cataneo is a New England writer and journalist whose work has appeared in Slate, NPR, the Baffler, and Atlas Obscura, among other publications.

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