Startling new science reveals the truth about chronic pain

By Jessica DuLong, CNN

“Medicine is nothing more than a misguided miseducation in mortal misery.”

That’s not something you’d expect to hear from a doctor, especially one with the bona fides of Haider Warraich, a Brigham and Women’s Hospital physician and assistant professor at Harvard Medical School.

The “misguided miseducation” of Western medicine, he argues, stems from “turning persons into patients and healers into providers, and by separating the body from the mind, physical sensations from emotional states and pain from suffering.”

The misery that Warraich investigates in his new book, “The Song of Our Scars: The Untold Story of Pain,” is chronic pain, which affects an estimated 1 in 5 people worldwide, including Warraich. That’s about 1.5 billion people.

Longtime battles with debilitating back pain nearly thwarted his medical career. Today, he brings his experiences as both physician and patient to his examination of the nature and history of pain. Condemning modern medicine’s failures, he calls for a more holistic, interdisciplinary approach.

This conversation has been edited and condensed for clarity.

CNN: What is the biggest misconception people have about pain?

Dr. Haider Warraich: Almost everything we know about pain and how we treat it is wrong. Both patients and physicians have been taught that chronic pain is essentially acute pain prolonged. But while acute pain rises up the spinal cord to the brain, chronic pain can often descend down from the brain, often without any trigger from below.

The fallacy that treatments for acute pain will work for chronic pain has, in part, led to the opioid epidemic and prevented people from treatments that might have given more relief.

Western medicine has tried to constrain pain to strictly physical sensations, based on the tools it has to address those. But pain is not purely physical.

CNN: What is pain, if not physical sensation?

Warraich: The science suggests what many patients know to be true: Pain is a combination of physical sensation, emotional trauma and memory. Brain imaging has revealed that the emotional brain is far more involved in the experience of chronic pain than acute pain. To the nervous system, chronic pain is most often akin to an emotion we feel in a part of our body.

By considering pain as a purely physical phenomenon, we limit treatments to pills and procedures, preventing people from getting the mental health interventions that are probably as, if not more, effective. The ideal approach to pain management is interdisciplinary.

CNN: What does that entail?

Warraich: The chief function of pain is to direct all your energies and attention to it by inducing fear that your body is under threat. For example, when I had terrible back pain, I worried that exercise might leave me paralyzed or that my spine might snap in half. Alternative modalities help us reframe how we think about pain.

An interdisciplinary approach provides patients with access to different options, including cognitive therapy, acceptance and commitment therapy, exercise, physical rehab and even hypnosis. Particularly effective is pain reprocessing therapy. Developed specifically for people in chronic pain, it helps to defang pain’s fear component.

The evidence supporting the effectiveness of alternative treatments like these is often more compelling than for many of the common procedures and prescriptions that we typically provide our patients.

CNN: With such strong science supporting alternative approaches, why have standard pain protocols remained so crude?

Warraich: One limiting factor is that doctors and nurses are highly unlikely to have lived with serious illness. They’re like chefs who have never tasted their own food. Based on our training as physicians, our thinking can wind up rigid.

Because some providers don’t take patients’ pain seriously, patients worry that the moment that they bring up their emotional state, their pain will instantly be dismissed.

Until physicians’ approaches shift, patients are going to struggle with accepting how closely linked things like mental health, depression, anxiety or history of previous trauma are to how much our bodies hurt.

Recognizing that pain is, in fact, worsened by psychological factors makes it no less real.

CNN: You write that there is “no dedicated pain center in the brain” yet also explain that chronic pain can reorganize the nervous system. How?

Warraich: One of the processes that allows pain to move from acute to chronic is the development of central sensitization. As we hurt, our bodies actually become even more sensitive to more pain. Because we become vigilant in attending to pain, the process can actually lead to distress and discomfort in areas, and with activities, that didn’t hurt before.

Pain management differentiation is vital because, over time, the therapies that work might change.

CNN: What impacts do our histories have on our experiences of pain?

Warraich: Context, in addition to biology, dictates variations in pain, meaning that our circumstances play a significant role. For example, pain from a fractured rib, which can heal, will feel different from pain due to metastatic lung cancer after a lifetime of smoking.

Pain is an event in our biographies impacted by social and cultural forces. Unfortunately, suffering begets suffering. We know from extensive research that adverse childhood experiences or other acute stressors increase risk for greater pain. Growing up in a violent neighborhood or household, or even being bullied in school can sensitize us to trauma.

Other research has shown that people who’ve faced racial discrimination are more sensitive to pain. Despite that reality, studies reveal that doctors are actually less likely to prescribe pain medicines for Black people, for example, based on false ideas started hundreds of years ago that they have thicker skin or less sensitive nerve endings.

Because pain is so subjective, we are much more likely to tap into our prejudices and biases, which can often be unconscious, to make medical decisions.

CNN: What long-term impacts does chronic pain have on people?

Warraich: It disrupts a person’s identity and how they move through life. People can feel like their own body is the enemy. Chronic pain mirrors incarceration; it essentially puts you in its cage, keeping you locked up in the penitentiary of the present. It becomes difficult to plan for the future and can, very quickly shrink your life.

CNN: What advice do you have for people dealing with chronic pain?

Warraich: First, there is no silver bullet. There is never going to be one pill, procedure, therapy or exercise that will eliminate your pain.

I urge patients with pain, their caregivers and their physicians to keep an open mind to all possible options. Remember that what works for one person might not work for another.

The other advice I give — that I wish someone had given me when my pain was at its worst — is: Don’t skip out on activities that bring you joy. Trying to minimize pain can quickly shrink your world.

The more you attend to, or try to eliminate, pain, the more powerful it becomes. Allowing pain to take the driver’s seat will only exacerbate your suffering. While it might be uncomfortable at the start, focus on living your life. This approach works to uncouple fear from the hurt.

CNN: How does the siloed nature of medicine impact pain management?

Warraich: The fractured nature of medical science impacts pain more than any other condition I’ve studied so far. Unlike cancer or heart disease, where we’ve made tremendous progress, the problem of chronic pain is actually growing. More people are suffering today than ever before. Worse, for many people, our treatments have caused more harm than good.

CNN: That’s a big statement. How?

Warraich: I wish it were hyperbole. Whether you talk to patients or you look at the research, we’re seeing that the health system is failing people with chronic pain in many different ways.

Take opioids. Without any data supporting their effectiveness, often at the behest of pharmaceutical companies, we started giving opioids to people with chronic pain.

We allowed lies to infiltrate our medical education that were essentially crafted in these companies, igniting a crisis where the United States was prescribing 30% or more of the world’s opioids, even though we don’t experience more pain than other people.

Meanwhile, a randomized trials study of people with moderate to severe back and joint pain showed that people given opioids for chronic pain actually had more pain over time than those who were given less potent painkillers such as ibuprofen.

CNN: Does the US health insurance system have any role in this?

Warraich: It’s at the root of why pain management is in such bad shape. Insurance companies restrict access to exercise, therapy and interdisciplinary care, even as they are quick to approve someone’s 10th procedure or surgery, for which both the supportive evidence and the cost effectiveness might be much lesser.

Insurance companies’ asymmetric access and restrictions have kept the pain crisis burning.

Chronic pain patients require more empathy, kindness and time from their physicians than almost any other condition. Yet we have created a system built only for profit and efficiency. Hospitals make more money off procedures, and providing prescriptions is far quicker than attentive care. We’ve seen an explosion of both these types of interventions instead of alternative therapies — including those supported by better evidence — because they are neither efficient nor highly profitable.

CNN: Do you see any hope on the horizon for people with chronic pain?

Warraich: I started writing this book in a hopeless place. But now I feel confident that we have many more interventions to offer. Given the opportunity, physicians and nurses can offer empathy and kindness. The science is quite clear that, for many patients, this attentiveness constitutes essential therapy for helping them overcome their pain.

We know that the placebo effect accounts for three-quarters of the efficacy of essentially all painkillers. A placebo’s effectiveness occurs because of the medical ritual, ie., empathy.

If medical providers can shift from being technicians back to healers, real transformation in effective pain management becomes possible.

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Jessica DuLong is a Brooklyn, New York-based journalist, book collaborator, writing coach and the author of “Saved at the Seawall: Stories From the September 11 Boat Lift” and “My River Chronicles: Rediscovering the Work That Built America.”