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  To my wife, Nichola, whose patience and kindness has no equal, and to my parents and siblings, who have always been both the anchors of my life and the wind in my sails.

  But pain is perfect misery, the worst of evils, and, excessive, overturns all patience.

  —John Milton, Paradise Lost

  INTRODUCTION An Unexpected Journey

  There is a special quality to the sound of the telephone when it rings at two in the morning. When you are working as the anesthesiologist on a labor and delivery ward, that call causes your heart to race and your stomach to do a little flip, adding another layer of fatty damage to your overstressed coronary arteries. You have usually just fallen into an uneasy sleep on a lumpy bed in a damp but overheated on-call room, where many doctors have tossed and turned before you. The voice on the other end of the line is typically that of a harassed and overworked midwife. “Epidural—room 4” might be all you hear before the deafening click of the slammed handset. There is the urban legend of an anesthesiologist who, on receiving such a message, walked up to the room he had been sent to and stuck an epidural needle directly into the door before turning around and going back to his bed.

  On entering a birthing room at 2:00 a.m., when the human spirit is at its lowest ebb, the scene is often predictable. There is a partner who looks scared out of his wits, a midwife who is fretting and trying her best to reassure everyone, and a pregnant woman who is screaming in pain. You are greeted by an individual who would normally present a reasonable and calm image to the world but who is now reduced to a feral and illogical specter as she is consumed with pain. The pain experienced during labor does not spare social class, color, or creed. Pain reduces us all to our basest elements; it is a great equalizer and unifier and one thing we all experience.

  As an anesthesiologist I am confronted by a woman who is demanding pain relief and is now screaming at me and everybody who comes into her line of vision. Administering an epidural in these circumstances is challenging, to say the least. When I return later, however, after the epidural has taken effect, I am greeted by somebody completely different: a calm, personable individual. The ability to transform someone’s demeanor completely by abolishing a barrage of unpleasant sensations that are coming from distended and damaged tissues has made a lasting impression on me, and I continue to be amazed at the transformation that takes place when pain is removed.

  While we now accept pain relief in labor as being an absolute right—and in first-world countries epidurals are provided on demand—this was not always the case. We have vacillated over the centuries between advocating that pain should be aggressively treated and believing that pain is necessary and important to the curing of the condition or an integral part of the treatment being given. Inflicting suffering was thought to sometimes be inevitable, for example in the case of amputations before the invention of anesthesia or when “releasing evil humors” by bloodletting with leeches. Pain was sometimes thought to be intrinsic to the success of the therapy, a sign of the patient’s vigor and helpful to their personal growth. “Pain is weakness leaving the body” was a phrase often shouted by my rugby coach. “Pain is good for you. It tells you that you are still alive” was a lesson sometimes uttered by stressed doctors in the emergency department where I worked, when the umpteenth stab victim of the evening complained about the chest drain inserted to inflate a collapsed lung.

  At one time priests believed that the pain of childbirth strengthened the bond between mother and child, reinforcing the idea that self-sacrifice is inherent in motherhood, and that interfering with the pain would disrupt this maternal bond. Even in the early days of medical procedures, pain was not always seen as something that needed to be treated, largely because it was a sign of whether the patient was well and whether the treatment was working. It was only after 1800 that doctors became increasingly preoccupied with managing pain from injury or surgery, treating patients who had painful cancer as well as those with arthritis and migraines. When surgical anesthesia was first introduced in the mid-nineteenth century, however, there was uncertainty about the ethics of operating on an unconscious person and a concern that pain relief might retard the healing process. Priests, and some physicians, feared that anesthesia would corrupt the individual’s soul, bringing into play a moral calculator to assess whether or not pain should be relieved. The development of medicine and surgery as endeavors that can be accomplished only by relieving pain, and a philosophical shift toward the value of the individual, changed the narrative from one claiming pain was necessary and a part of human life to viewing pain as an experience that needed to be actively managed.

  Religious writers initially deemed anesthesia in the context of childbirth a violation of God’s law. This was obviously an idea proposed by men, and it was not until Queen Victoria had chloroform to facilitate the birth of one of her children that the practice of providing women with analgesia during labor achieved acceptance. Even today the application of pain relief in labor varies across the globe; the mechanical stretching and contraction of tissues during labor is interpreted, perceived, and responded to through each woman’s unique social and cultural lens. In Chinese and Korean cultures, for example, birth must appear to be pain-free and is endured in silence in order to not bring shame to the woman’s family, whereas in some other cultures a more vocal response is believed to ensure a more solicitous and attentive husband.

  What is it about pain that makes some people require medical intervention and others not? The storm of information created and transmitted by nerves when we are burned, stabbed, bumped, bruised, shot, frozen, disappointed in love and life, jarred, shaken, and irradiated is perceived, interpreted, and modulated by our individual brains, which are as unique as snowflakes famously are. Pain, too, is therefore unique and individual and often confounds us and those we love and who love us.

  * * *

  I work at the Manchester and Salford Pain Centre at Salford Royal National Health Service Foundation Trust in the United Kingdom. The hospital is a major trauma and neurosciences center located about three miles from the Manchester United soccer stadium. I split my time between anesthetizing patients in the operating room, inserting electrical devices to relieve chronic pain, and assessing individuals with chronic pain in an outpatient setting. But the reason I chose a career in anesthetics was to become an intensive care doctor.

  I was born and raised in South Africa, attending school and university under the shadow of Table Mountain. As a junior doctor I worked in a major trauma center and was exposed to some of the most horrific human-inflicted trauma imaginable. During the nine months I spent in an inner-city trauma unit I developed a deep and pervasive antipathy toward people in general and felt that I would survive in medicine only if my patients were asleep and my interaction with them was brief. I found myself more comfortable with patients who were uncommunicative and the stabilization of the injured person less emotionally taxing than a biopsychosocial assessment of the journey that had brought them to the hospital. It didn’t help that at the time I was unhappily in love. This was also when some influential government leaders denied that HIV causes AIDS. When this statement was repeated to me by a patient who was HIV-positive and refusing to disclose this information to her partner, I coped by runnin g away from home.

  I went on to become an anesthesiologist, completing my training in the UK, where I have remained. Over time I specialized in pain medicine, an area often assigned to departments of anesthesiology, for reasons we will come to later. I now work in a clinic with patients who suffer acute pain—that is to say, pain with an easily identifiable cause (traumatic injury or surgery) that will eventually go away when the physical damage heals—or with chronic pain, which may not have a clear cause and may not go away.

  The primary emotion a doctor feels when faced with somebody who is in pain is extreme helplessness. In many ways pain is designed to elicit this response from others; we are social animals, and one of the purposes of a visible pain experience, manifest as pain behaviors, is to encourage help from others—pain behaviors have survival value. Seeking assistance after an injury is as biologically imperative today as it was a thousand years ago; what has changed, however, is the place of healing and the people we seek healing from. A thousand years ago a sick person might have gone to a temple to meet with a priest; health and spiritual well-being were inextricably linked, and so the priest served as both healer and spiritual guide. At an even earlier time in human history, the person consulted might have been the local medicine man, who would have communicated with the ancestors to find answers to various afflictions. Today we have huge biomedical temples called hospitals and networks of shamans called general practitioners, organized into a hierarchical system and monitored by professional bodies.

  The nature of the interaction between doctor and patient has changed over the centuries based on our accumulated knowledge of physiology and anatomy, as well as our understanding of disease and treatments. Today most individuals can understand traumatic pain without any knowledge of the complex neurophysiology involved. We understand to a degree that if we injure ourselves, then we experience pain, in the same way that a car or house that is broken into results in activation of an alarm. Pain is an alarm bell that something is wrong and a call to seek medical help. In the modern world, however, our understanding of pain as an alarm system has a limited benefit in a society where we voluntarily subject ourselves to the trauma of surgery, for example—and yet pain continues its primitive wail despite our enhanced ability to understand and manage trauma and disease. It is this disconnect between the biological and the psychological that often makes modern pain management ineffective. Even when pain is due to an injury, seeking help is still governed by the individual’s perception of the severity of the injury and their health-seeking behavior, which in turn is governed by a host of psychosocial and cultural factors. Most people, including doctors, do not appreciate that the organ that produces pain is the brain. It is not the broken bone or the damaged tissue or the bleeding wound. The experience of pain is the sum total of more than just the physical injury—it is the result of this information being filtered through the individual’s psychological makeup, genetics, gender, beliefs, expectations, motivations, and emotional context.

  We have a collective delusion that the human body is a simple machine that can be repaired by the medical profession when it breaks down. However, the reality is that the human body is not a simple machine; it is an organism that progressively deteriorates over time and then, eventually, ceases to function. Pain as an experience is often seen simplistically as a manifestation of a dysfunctional machine and is often a consequence, when it becomes chronic, of a machine that has been poorly treated. Unfortunately, rather than recognizing that it is the behavior toward the machine that needs to change, we have a tendency to medicalize this pain and therefore often apply excessive amounts of lubrication in the form of opioids and surgery, which do nothing to improve the function of the machine and in fact can cause a significant deterioration of the organism.

  Simply put, we need to stop viewing our bodies as machines that medicine can fix when they go wrong. If people are educated about their body and about pain, perhaps we might put an end to the undulating fashions of medical meddling—meddling that, in some cases, has far-reaching consequences appreciated only decades later. We are currently, for example, at the tail end of an epidemic of opioid prescribing and are beginning to see the effect of that rampant scourge on individuals and on society. Once upon a time opiates were the province of recreational drug users, and abstaining from them, even in the face of severe pain, was considered not only appropriate but admirable. The changing understanding of the possible advantages of treating pain after surgery or injury swung the pendulum toward increased opioid prescribing, with the relief of pain regarded as a human right and a benefit to the patient. We now see addiction, tolerance, dependence, and withdrawal as well as the long-term physical effects of prescription opioid use on patients. As medical professionals, we have begun to realize that our overzealous management of acute postoperative pain and our mistaken treatment of chronic pain (as opposed to acute pain due to injuries) with the same medication has had unintended consequences.

  My mission in this book is to explain pain in all its forms: pain from physical trauma, cancer pain, and pain that appears to continue in the absence of any physical damage. We all suffer with pain at some point in our lives and are witness to the pain of those we love and care for. With renewed knowledge and understanding, we can become active participants in the art of caring, understanding, and coping with an experience that can become all-consuming.

  CHAPTER ONE How Does Pain Work?

  You may have purchased this book to read while on vacation somewhere, as you bask in sunshine. Perhaps you are being tortured or delighted by the excited screams of children or feeling gentle breezes blowing from the sea, while the smell of sunscreen permeates the air. Your swimsuit may be slightly damp from being in the pool. Regardless of the sounds, smells, and temperatures you are exposed to, these sensations are all quite easy to tune out so they become background noise. However, if you were to be bitten by a mosquito or an exposed part of your body started to object to the strong sunlight, this experience would demand your attention and it would take a great deal of conscious effort to ignore. This is the universal experience of pain. Physiologists refer to pain as “aversive at threshold,” which means that it cannot be ignored or subdued easily. By its very nature it demands attention, and this is as true today, as you sit languishing idly around a swimming pool, as it was when we were a primitive species fighting for survival in a harsh and untamed world.

  But while damage to our body may eventually demand our attention through the experience of pain, this experience can be ignored, sublimated, or delayed by the brain. Pain is a warning system, informing us that there is a threat to the safety of our body or even that damage has already occurred, but if experiencing pain and receiving this information is not immediately beneficial, then the message relaying this information will be de-prioritized and sometimes ignored by the brain. We all know how crippling and all-consuming the experience of pain can be, and if it might delay, for example, our flight to safety, then it is not immediately helpful and could even be dangerous. The relationship between physical damage and the experience of pain can tell us a lot about the complexity of the biological pain alarm system and the processing of the information about damage, the route this message takes, and why, how, and when it can be disrupted.

  While playing for Milan against Chievo on March 14, 2010, the soccer star David Beckham ruptured his Achilles tendon in the eighty-ninth minute of the game. Video footage shows him turning sharply and trying to control the ball; the sharp turn is probably what caused the injury. He then starts to limp because his ankle will no longer flex and extend since he has now lost the use of his calf muscles, which rely on being fixed to the ankle bones via the Achilles tendon. It appears that initially he does not realize he has injured himself. I imagine most professional athletes exist with a level of discomfort that would be abnormal to the rest of us, and so Beckham’s natural tendency would be to ignore the messages reaching his brain and carry on in the context of practicing his profession. He tries again to run up to the ball to kick it but finds that he cannot perform this action; his progress is halted not by pain, as yet, but by loss of mechanical function. The tear to his Achilles tendon occurred moments before, and while the process by which information about this damage is converted to an electrical signal began at the moment of injury, it has not yet registered in his brain as pain.

  When you sustain an injury, the traumatized tissue releases and attracts chemicals called inflammatory mediators. The aim of these substances is to heal the damaged tissue, but they also play a role in triggering the pain alarm. The release of chemicals such as hydrogen ions, potassium ions, bradykinins, and prostaglandins stimulates the harm-sensing receptors in the tissues. The first step in the body’s complex pain alarm system, which we all possess (unless we are born with congenital hypoalgesia, a condition where people do not feel pain), is the conversion of damage to the body into an electrical signal. Throughout our bodies there exist harm-sensing receptors (which are like locks on doors) on free nerve endings called nociceptors; the prefix noci means “harm” or “mischief” in Greek. Harm-sensing nerve endings are widely distributed in the skin, muscle, joints, organs, and the lining of the brain and are either covered with myelin, which is a fatty tissue, or are uncovered. Myelin-sheathed nerve endings (A delta fibers) conduct electricity faster than their thinner, uncovered counterparts (C fibers); the faster signals from the A delta fibers make you instantly remove your hand from a hot object, whereas the slower fibers produce the sensation that teaches you not to touch the hot object again.

  The human body can be injured in only three ways: by mechanical trauma (such as gunshots, stabs, bumps, and scrapes), chemical injury (a burn from an acid or an alkaline substance), and injury from extremes of temperature. All of these injuries result in the release of inflammatory mediators. (Inflammation can also occur when the body’s immune system attacks itself or joints become inflamed.) Nociceptors are of different classes and, like locks, are opened with different keys: intense pressure, temperatures greater than 104 to 113°F or less than 59°F, or chemicals released from injury and inflammation. In Beckham’s case, the damaged Achilles tendon released histamine, serotonin, bradykinin, hydrogen ions, and other substances that insert themselves into nociceptors, triggering an electrical impulse that communicates and codes for harm and damage and begins its journey to the brain, where that message can be decoded.