Millions of Americans live with chronic pain. But we have yet to fully contend with the impact pain has on people–and our ability to treat pain remains limited. In fact, our failure to engage with the complexity of pain is, in part, what led to the opioid crisis, which took over 100,000 lives last year. One of those people living with chronic pain is Dr. Haidar Warraich, a physician who’s written a book exploring pain as a biological and sociocultural phenomenon. He joins Abdul to talk about pain–what it is, how it shapes our society, and how people and their providers need to have a better conversation about it.

Transcript

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Dr. Abdul El-Sayed: Before we get started today, I just want to make sure that you all are plugged in to Vote Save America. In 2022, let’s face it, there’s a bit of a gap in enthusiasm. That means we have to work twice as hard to inform and mobilize voters to make sure their voices are heard despite of the efforts of anti-democratic forces across the country. That’s why Vote Save America is launching its biggest volunteer effort yet and asking you to be part of your region’s midterm madness team: East, South, West or, of course, Midwest. Sign up and learn more at Votesaveamerica.com/midterms to receive actions you can take every week to get involved in the most important elections in 2022.

Dr. Abdul El-Sayed: COVID cases are climbing fast, again. Two new BA-2 sub-variants have been discovered in the Northeast in the United States. President Biden signed an executive order to regulate ghost guns just as a gunman on a Brooklyn subway reminds us how desperately we need sensible gun reform. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. Pain is both the beginning and the end of illness. Let me explain what I mean by that. Most people only go to the doctor when they’re feeling some sort of pain. A pain is telling them something’s just not right. It’s, in provider parlance, the quote unquote “chief complaint.” And no matter what a doctor does to address any underlying pathology, addressing pain is foremost. They can fix everything, people don’t really feel like you fixed anything at all. Biologically, pain is the firing of a set of neurons from part of the body experiencing that pain to your central nervous system, which then registers the experience of pain in your brain. We’re hardwired to avoid pain, which is, by definition, a noxious stimulus. It turns out that pain, however, well, painful it is, is an extremely effective system for self-preservation. There’s this extremely rare genetic disease that knocks out the body’s ability to feel physical pain. This congenital insensitivity to pain occurs because of a mutation in a protein that’s critical to the function of your pain neurons, rendering them incapable of firing the pain stimulus to your brain. You might think that it’d be great never to have to feel pain, but people with congenital insensitivity to pain don’t usually live past 25. They simply don’t know about the bumps and bruises and burns and cuts that you and I learned to avoid and care for because, well, they’re painful. The irony is that pain is a lifesaver. But pain isn’t simply a biological phenomenon. It’s a social one too. Consider the millions of Americans who suffer unexplained chronic pain. They can’t see a beginning or an end to their pain, only constant gnawing pain. There may also be the trauma of the moment that caused that pain. The constant remembering and remembering, a sort of haunting by that moment. And then there’s the anxiety that there may never be an answer to why this pain even exists, or it’s never going to go away. And that’s just physical pain. Consider emotional pain, the grief of a lost loved one or the betrayal of a close friend. And while emotional pain doesn’t flow through our neurons, increasing evidence has shown that our brain processes it in a very similar way. That pain lights up the same parts of our brains that would light up if we cut ourselves or banged our knee. All of this makes treating pain extremely hard to do. And when we get it wrong, people suffer. It’s not just the pain that goes untreated, it’s also the overtreatment of pain. I went to medical school in the late aughts, and that was in an era where I was taught that pain is the quote unquote “fifth vital sign.” You know, alongside things like temperature and heart rate and blood pressure and respiratory rate. That was back when doctors were unabashedly pushing aggressive treatments with opioids, which they thought could be formulated in a way that avoided their notorious addictiveness. We were wrong, and it kicked off a massive opioid crisis that claimed hundreds of thousands of lives, over 100,000 this year alone. Today I want to explore pain in all its complexity. And I came across a really thoughtful new book called “The Song of Our Scars” that did just that. What made it unique, at least to me, was the author’s vantage point, both as someone who treats pain for a living as a cardiologist, and someone who suffered chronic pain as well. I wanted to understand how these two perspectives sit in tension and what they reveal about how we’re conversations about pain ought to evolve. My conversation with the author Dr. Haidar Warraich after this break.

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Dr. Abdul El-Sayed: Ready to go.

Dr. Haidar Warraich: Yep.

Dr. Abdul El-Sayed: All right, can you introduce yourself for the tape?

Dr. Haidar Warraich: My name is Haider Warraich and I’m a physician, researcher, and writer based in Boston. And I wrote the new book, “The Song of Our Scars: The Untold Story of Pain.”

Dr. Abdul El-Sayed, narrating: One of the hardest parts of the conversation we often have about pain is that most people only hold one perspective on it. They’ve either dealt with terrible pain or they’ve tried to treat it. It’s rare to find somebody with both perspectives and the humanity to appreciate what both of them have to offer. I wanted to speak with Dr. Warraich because he’s one of the rare people who brings all of those.

Dr. Abdul El-Sayed: So I got to ask, I mean, pain is, well, painful. What what prompted you to write a book about pain?

Dr. Haidar Warraich: So I’ve written a couple of books in the past, but I would say that this was probably my most personal book, in part because I suffered a really terrible back injury when I was a medical student back in Pakistan. This was almost 10 years ago. And like, you know, most painful events and this is, there’s an evolutionary reason for this, I remember that day and that injury very, very well. And initially I thought, Oh, this is awful, this hurts, I can’t, you know, do anything, but it’s going to go away because that’s how we think pain usually is that it was the worst at the start, right after say, we bang our head in that glass door, but then it gets better. But this one really didn’t and really lasted for more than a year. In fact, several years to the point where I forgot, I lost hope that I would ever be pain-free, that I would ever, ever know not being in pain, that I would ever be a physician, that I would really be able to do anything that I had hoped to do in my life. And then over time, I, and it took a village, an army, if anything, to get me to get me better, but then when I came to the United States as a medical resident, one of the biggest shocks for me was not how to treat a heart attack—because how you treat a heart attack is the same everywhere or how you treat an infection—but it was really how we were treating people with chronic pain. I had almost never given a prescription for opioids and yet, as a resident in Boston, that’s pretty much my main job was to prescribe opioids, you know, every time. And this is before we identified the opioid epidemic as a real, major public health crisis. And so I, you know, I felt that, you know, pain feels so personal for people that I did feel that if anyone’s ever going to write something on pain, they have to have experienced it themselves, to feel like, for folks to feel like that he or she is one of us, that they’ve experienced what we’ve experienced. But also to look beyond the opioid epidemic and think about, well, what really is pain and how are we going to do a good job of actually helping people in chronic pain, which affects one in five Americans and one in five people around the world? So that was my journey to this book, was this its own experience of having lived with pain for most of my adult life, but then placing that in context and really thinking about what the science tells us about the nature of pain and how are we going to help people who are suffering.

Dr. Abdul El-Sayed: Yeah, I really appreciate that, those two views on pain. You know, you suffered chronic pain. You understand what it’s like to to go through that and to experience that and you know, the anxiety about whether or not it’s ever going to go away. But you’re also a physician who has learned to think about pain in a very scientific way and to treat it that way. And you know, those perspectives often differ substantially. I mean, it is a almost canonical aspect of the interaction between doctors and people with chronic pain, that the doctors just don’t understand. Where do you find that those two perspectives unite? Where did it unite for you? Maybe, maybe in the book?

Dr. Haidar Warraich: I think they unite in the fact that, you know, the core training of a physician, their initiation, as if you may, in how do you actually speak to a patient, how to approach them, how to touch their body, is in the context of pain. You know, almost always the first simulated case that we are taught about in medical school is someone with abdominal pain, and we’re taught all these ways to ask questions of a patient in pain. And yet still that big gap remains, as you said, right, between the people who feel pain and the people who are, who have access to the therapies and interventions that could help them. And I think where it unites is that I think physicians find nothing more gratifying than helping people, especially people in pain. I think that that’s one of the most, I mean, you know, any type of pain, whether it’s pain from a dislocated shoulder and just being able to put it back in place and person feels better, there’s free things like it. Or if you’re a heart doctor, someone comes in with crushing chest pain and, you know, performing a procedure that relieves them of their pain, it seems—and that is one of the reasons why I think in some ways, medicine went overboard a bit with the opioid prescription as well was because it did seem to work so well for patients in the acute setting. That, you know, there’s nothing, no intervention that we can do for someone who is suffering more effective than an opioid prescription that can put them at ease in that moment. And I think that that’s really, and that’s what the patients want too. Patients want to feel better. Pain, because of its nature is unacceptable to our body. You know, of all the science that can go off in your body pain is the loudest. It’s meant for you to to do whatever it takes as the person who occupies that body to get rid of it. Because it could, it could signal something that is fatal, that threatens your very existence. So I think both physicians and patients are driven to find ways to overcome pain, and yet their perspective is different because medicines tools are still, in many ways, too primitive for many patients with pain. You know, we’ve become so oriented towards doing blood tests and imaging tests, etc. that when we have someone who has an illness that cannot be captured on an X-ray or cannot be documented in a blood test, then we feel a bit constrained about how we can help them. And I think it’s that subjective nature of pain that has made it so, in some ways, contentious because it forces us to rely entirely on trusting the other person. And as you say, and as we’ve seen in so many ways, that that relationship between patients and physicians is really under stress right now.

Dr. Abdul El-Sayed: One of the important truths that I think you dig out and that you were just speaking to is that pain is both a biological and also a socio-cultural phenomenon. When you say that, what do you mean by that, and how does that complicate the way that we treat pain?

Dr. Haidar Warraich: So for most of history, and every culture, pain has been something that has resided under the purview of a spiritual force or a metaphysical force, oftentimes a way for the divine or for God to communicate something to the human. Whether it was a form of punishment, whether that was a form of helping someone grow, or whether helping someone become more resilient or helping someone pass a challenge, it always held some type of meaning. So, you know, as an example, if you look at at the Christian tradition, pain that women got during childbirth was essentially a punishment for Eve’s transgressions in the Garden of Eden. So early attempts at trying to relieve the pain that women felt during childbirth was actually something that people were burned at the stake for. In fact, the first witch burned in Scotland, her main crime was that she tried to provide a woman pain relief during childbirth. And yet there are other cultures in which the experience of pain is somehow, can absolve someone of a prior misdeed and can be a way for them to be even, get even closer to the Divine. I mean, you know, this is the holy month of Ramadan, and many Muslims believe that the pangs of a fasting that you feel is a test of your character and connects you not just to the divine, but to people who don’t have as many means as you do, so—and yet there are other sort of cultural ramifications as well. During the era of slavery physicians in the South created this phantom conditions that essentially posited that black slaves don’t feel pain, that their bodies are not as sensitive to pain. And that the way to overcome that was actually being more aggressive, doing more torture, and that was their way of justifying all of their evilness that they did. And yet many of those myths actually still persist to this day. There is a study that was published a few years ago in which a third of medical students believed that Black people had thicker skin than white peoples. And people who had this belief also taught that Black people needed less pain relief than white people did. And so pain is not just something like how we see or how we hear or how we smell, it is a sensation that is shaped by racism, by sexism, by colonialism, by all sorts of situations in which there was a power imbalance present throughout history.

Dr. Abdul El-Sayed: I want to I want to ask about that because you write, and I quote here from the book, “Pain in how it’s recognized, treated, and inflicted has always been and remains a tool of power, often used against the weak.” What do you mean by that?

Dr. Haidar Warraich: So in its most obvious interpretation, I mean, if you think about the long and rich history of torture in which pain has been used as an instrument to punish people, and in fact, it used to be thought in Greek times that confessions that came after torture were actually more accurate than confessions that were obtained without torture, in some ways that the expression of pain and torture would in fact somehow purify someone’s words, when in fact, we now know that it isn’t. And in fact, one of the shameful aspects of our profession has been that throughout history, whenever there have been torture, physicians have always been involved, not so much to help the person, but to make sure that they don’t die before the torture ends. And to some extent that that presence remains. But really, any time a patient comes to a physician and the patient is in pain, there is an immediate power imbalance where the physician becomes the person who holds unto them, the ability to make a diagnosis, the ability to legitimize someone’s suffering or experience, and the ability to provide them access to resources that might help them. Resources like maybe surgery, resources like medicines. And yet so many of these greater social and cultural norms and inequities that affect society in general come in effect that very interaction. So I’ll give you a small example. You know, I think there are a lot of times in medicine, as you know, where there can be ambiguity about what is the best step or what is the best diagnosis. And yet, I think one conditions where I think most people can sort of agree on is acute appendicitis. So for listeners, acute appendicitis is a condition that can happen very quickly. A part of your intestine gets inflamed. It can be diagnosed on a CT scan. So there’s usually no, you know, there’s a quote unquote objective way of knowing if the condition exists and the treatment for that is surgery, but until you get surgery, it is recommended that your pain be controlled aggressively, including with opioids. And yet there is this one study that I think was one of the most eye-opening studies for me, was a study of a million kids who came to emergency rooms who had appendicitis that was confirmed with the CT scan, and this is children. And what it found was that if you’re a Black child, your chance of getting an opioid is one fifth of a white child’s chance of getting an opioid. And this was after they controlled and adjusted for all sorts of factors. And there is no reason why that should happen. There is no biological reason, right? And there is no, even if you think about risk for addiction, this was at a time when addiction rates for opioids were much higher among white individuals then they were for Black individuals. And yet what it really tells you is that so many of the issues that affect our society at large, systemic racism being one of them, come into play when it comes to the patient in pain. And that’s why I think if we just view pain as a singular biological thing that is somehow divorced from everything else that’s going on in the world, the most vulnerable are going to suffer the most.

Dr. Abdul El-Sayed: One of the important themes that emerges again and again in the book is its trauma, and the thing about trauma is that it can leave emotional pain that lasts long after the physical pain has left us. How should we be thinking about trauma, and how does it shape the way that we interact with different kinds of pain?

Dr. Haidar Warraich: I think one of the big ideas that I hope that this book can really dismantle is this artificial distinction that we have created between the body and the mind. And how does that relate to trauma? So we know, for example, that, so I work at the VA, so I have the pleasure of serving our country’s veterans. but one of the one of the big aspects of what I do is as a V.A. physician is I take care of patients with PTSD. Many of these patients will have had a trauma during their time in service. That is a purely emotional trauma. And yet it leaves an imprint on them that is, that can be horrifying, that can be so deep that, you know, really that they’re, it’s hard to describe how, how real and how deep that trauma can be. And the same thing can happen with pain, where you can have an injury, and regardless of the intensity of the injury—that’s another thing that I think I learned in my research, was that the intensity of your initial injury does not predict if your pain is going to turn from an acute pain into a chronic pain. It is really all the other factors involved in your life, how whether you’ve had—I mean, as an example, one of the biggest risk factors for people developing chronic pain is if they’ve had a history of childhood abuse or trauma. And what I’ve found and what the research suggests is that the physical, the nature of trauma and how it affects, whether it’s an emotional trauma or a physical trauma, honestly, it really doesn’t matter. What matters is that either form can affect us deeply and yet we as a society and as a specialty, we just often gravitate towards physical sensations and physical injuries and things that we can understand, things that we can visualize—and things that we don’t understand and think that we don’t, that our tools can’t measure, we somehow dismiss them. And I feel like this is what has traditionally happened with folks who have had, you know, predominantly mental or psychogenic or psychiatric illnesses, is that they have been stigmatized and have not been taken as seriously as people who have had maybe a demonstrable injury. And yet when I got my back injury, I didn’t have, you know, I had some abnormalities on my MRI, but I didn’t have a scar, I didn’t have a bone sticking out of my body. I looked fine. I was, you know, otherwise healthy. And so I think many people presumed whether I was play acting, whether what I felt was in my head or whether it was real or whether it was imagined or etc. etc. And yet I think that’s really what we have to move beyond as a field, is I think trauma can come in any form and it can have any manifestation. Emotional trauma can have physical manifestation, and physical trauma can have emotional manifestation. And I think that is really one of the main messages of the book, is that neither is more important or more legitimate than the other. That trauma, no matter what form it takes, what matters is how deeply it affects the person, and that’s what we need to respond to.

Dr. Abdul El-Sayed: And, you know, one of the important tensions that you are surfacing here in this conversation is the potential consequence of having such a focus on diagnosable, provable, treatable pathology and, you know, going all the way back to the sort of early moments of evidence-driven, science-based medicine was that we wanted to be able to prove out the underlying physical manifestation of a disease so that we could treat that physical manifestation. And what has happened often is that we have created, almost, as you say, two classes of illness. There’s the kind that you can see, whether you can see it with your own eyes, most obviously, or you can see it based on some sort of outcome of a diagnostic test, and the kind that you can’t. And you know, as regular listeners know, my partner, Sarah is a psychiatrist and one of the hard parts about psychiatry is that it’s pattern based. There aren’t provable diagnostic pathologies that you are looking for or that you can find, but you see a set of patterns that fit a particular disease type that you can then treat empirically. And when I say treat empirically, I mean that we have done study after study that shown that this medicine helps to alleviate the noxious symptoms of this disease. And the hard part of that, though, is that it leaves patients in a position where they become second-class patients because their diseases become second-class diseases, and that includes almost all of mental health. And so that that link between body and mind has to continuously be reignited. And I’m grateful that you took that on because, you know, we all know what happens to a body when you decapitate it, right? And this is in some respects what our health care system has done, we’ve figuratively decapitated the body from the mind and we ignore the parts that are often so painful, in terms of the kind of disease that our minds can either have or that they can manifest.

Dr. Haidar Warraich: I mean, our health system is as much at fault for what we’re seeing with regards to the chronic pain crisis and the opioid crisis as anyone at Purdue Pharma or the Sacklers were. And I worry that we haven’t learned the lessons. And one of the chief lessons for me was that, you know, one of the reasons why we ended up where we are with regards to chronic pain is that giving an opioid is just one of the fastest things we could do as physicians, because as a physician, you might be booked to see X number of patients and your revenue, your incentives are all tied to how many patients you see. And over time, the amount of time a physician has to spend with their patients is gone less and less. And writing a prescription almost became the quickest way to help someone in the acute term. And yet none of that was evidence-based. None of that was—we made the mistake of conflating acute pain with chronic pain, thinking that, oh, something works for an acute condition, it’ll obviously automatically work for it and in the long term as well. And it has not been the case. And you know, I think one of the things that as a patient, as someone who suffers, one of the things you worry about, one of the things I worried about the most was being told that what I felt was all in my head because I think that was, that’s a very sort of quick way for someone to just tell you that your experience doesn’t matter or that everything you’re doing is essentially artificial or fake. And yet, if you look at the science, our mind has so much to do with how we experience pain: our context, our autobiographies, our history, our memory—I mean, all those things come together—our relationship with who is in front of us, who is inflicting our pain or relieving it. And yet what we know is that if there’s any sort of suggestion that pain is not just a physical sensation, that people fear that automatically, that means that their pain is going to be not met with the same type of respect or that it would if it were if we purely just package it as a physical sensation. And I think that we need to really sort of move beyond that. And it’s not just people with chronic pain who are going to suffer this. This is going to, this might happen with people who have, say, long COVID symptoms where, you know, you may not have a blood test for long COVID, you may not have a scan for COVID, and yet those people are having clear and obvious symptoms. How do we recalibrate our approach as physicians? How do we recalibrate our approach as a health system that moves away from simply making more bank, and thinking about how we can help people feel better and how can we achieve good outcomes, rather than just maximize profit? And so this is, so which is why I really think that if we recalibrate our approach to the person in pain, the person who comes with no X-ray finding or lab test, and that we forgo our biases and we forgo all the stereotypes that affect us as human beings who live in a flawed society, I think that’s really the key point that’s a starting point for what I hope is going to be an equitable society as well.

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Dr. Haidar Warraich.

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Dr. Abdul El-Sayed, narrating: And we’re back with more of my conversation with Dr. Haidar Warraich.

Dr. Abdul El-Sayed: If we could go back to the mid ’90s and you had an opportunity to cut the opioid epidemic off at its tracks, what would that have looked like? What were the cardinal mistakes that were made at that time, and, you know, what can we do about it from here?

Dr. Haidar Warraich: I think one of the cardinal mistakes that were made at that point was that we didn’t follow our usual approach, our usual evidence-based approach. Well, what does that mean? So opioids have come and gone through American society. At the end of the Civil War—at the start of the 20th century, 1 in 200 Americans were addicted to opioids. The first, there is an opioid, people were addicted to morphine. And then there is a company, I think is Baer, that developed a new drug and they actually marketed as it as being less addictive than morphine and was actually used to treat morphine addiction—that drug was heroin, by the way. And so then we went through this cycle where we decided that all opioids are bad, we were just going to completely stop every one, we’re going to never give an opioid prescription. And that led to a crisis in which people are having these incredibly horrendous deaths, often with cancer, in unremitting pain. And that’s really where the hospice movement grew and the palliative care movement grew out of. And so what happened in the 1980s was that several drug manufacturers had, you know, had developed drugs that were helping people who were in pain at the end of life, often with cancer. But that group of patients, there’s just not that many of them. There is not enough money to be made out of those patients. And they wanted to expand the use of opioids for chronic use—not for acute use, because for acute use I think there’s plenty of evidence that they’re very effective, but there is no real evidence about how effective opioids could be for chronic pain. And yet there, and many physicians rightfully feared about potential risk for addiction. And there was this one research letter. It was five sentences long. Five sentences. That’s it. That was published in the New England Journal that reported, supposedly that only, that less than 1% of patients given opioids ever got addicted to them. Now that letter was then cited. It was not a trial. It was not even designed to be able to answer the question of addiction. And in fact, since then, the authors have now written about how deeply they regret writing that letter, but that regret came almost three decades later. During those three decades, that one letter was used as essentially a, green-lit everything, every patient, essentially with any type of pain—chronic back pain, neck pain, migraines, what have you—to be given opioids, and being told that there’s little risk for addiction, less than 1%. This number is quoted again and again, not just in presentations by drug marketers, but also in medical schools and in other places. And then I think one of the other things that then, the fuel to the fire was OxyContin. And OxyContin was this drug that was made by Purdue Pharma and there’s been so much focus on the relationship between the FDA and drug manufacturers, but really, if you look at the test case for that, that was OxyContin. Because many of the many of the same folks who approved OxyContin and said, without evidence, in the label that this is a less addictive opioid than others—even though there is no evidence for it—then went on to become executives at Purdue not long after. And I think when Purdue Pharma had this greenlight by the FDA, of all institutions, that this was a drug that wasn’t addictive, then it allayed physicians fears, because physicians trusted that the FDA knew what they were doing, that they would never add something to a drug label that would be false or incorrect or not based on evidence. And then we were off to the races. And that led to, and even though now the epidemic has shifted, it was a spark that was needed for an epidemic that now, that killed 100,000 people last year. That is killing more people today, 30 years after, than it ever did, even in any prior year. That is now affecting our urban communities as much as it was rural communities, that now affects Black people as much as it did white people. And that’s gotten so much worse with the pandemic. And there’s his one study that was published just a few months ago in January that that shows a type of conundrum that physicians are in. And it looked at people who had been on chronic opioids. So let’s say you have a patient with chronic opioid and you’re a physician, and so you have two decisions. You could either cut back on opioids because you want to minimize the risk of having an overdose, or you could continue the dose or potentially increase it to potentially help the patient with their chronic pain. And both options are bad because what the study showed is that if a patient had an acute, so let’s say someone is on opioids and was acutely withdrawn, their risk of suicide actually was much higher afterwards. And you can imagine if someone’s body has developed a tolerance to this drug, they lose the ability to feel normal. They lose the ability to fight off aches and pains that you wouldn’t even think twice about, because your body has not been reset by these opioids. And yet the other group in which either the dose was increased or the dose remained the same, their overdose rate was higher. So I think what I think what we need to think about now is really think, medicine needs to take responsibility for what it did and how it got so many people on opioids and treat these patients with respect, not treat them like criminals, and really have the sort of conversations needed to think through the risks of continuing opioids, and not cut them off without providing them all the resources they need. But I think the decision to start someone on opioids is probably something that needs to be taken very, very seriously because really, there’s no good off ramp once you’re on these therapies long term. If I could go back, what I would do is I would really push for better evidence that we have now, and the evidence is actually quite surprising. There is one trial is called the SPACE trial, this is actually run by the VA, this was published in JAMA. It looked at folks who had moderate to severe either joint pain or back pain and they randomized patients to getting either opioids or or non-opioid painkillers, which are much safer, like ibuprofen or Tylenol. And actually, the folks who got opioids had more pain when they were assessed at 12 months, showing just how just taking the opioids resets your body, resets your pain tolerance. And even though it was such a great therapy in the acute setting, so for example, when you come in with acute appendicitis, you should absolutely get opioids—but something that can have such a disastrous effect in the long term.

Dr. Abdul El-Sayed: I want to ask because, you know, I was in medical school in the mid aughts and I was taught that pain is the fifth vital sign and that on a pain scale, your patient’s pain should be zero. And I didn’t appreciate a lot of the fact that that had been coming from the same system that would ultimately teach me to treat my patients with chronic opioids. And I want to ask you, is there an appropriate amount of pain? Because, you know, all of us sort of understand that if you’re sick, you’re going to be in pain, that your body’s symbol to signal to you that something is wrong. And at the same time, like you talked about, being able to treat someone’s pain is one of the most fulfilling parts of being a provider. Is there an appropriate amount of pain that patients and providers ought to tolerate, and how do we know what that is? Because pain is subjective, one one person’s excruciating pain is another person’s, you know, dull ache that they’ve learned to manage, and vice versa. And part of that is biological. There are a lot of reasons to that. But how should we be thinking about pain in the context of subjective pain tolerance? What is an appropriate amount of pain? Is there one?

Dr. Haidar Warraich: So first of all, you know, I think medicine has had so many successes. Even recently, I mean, look at mRNA vaccines, for example. And yet there have been other spaces in which I think that we have over promised and we have under-delivered, and one of those promises was that we’ll make everyone pain free and that pain is going to be, you know, figment of our imaginations and that just isn’t possible. And the reason it’s not possible and it shouldn’t be possible is because pain is actually, pain is not a disease. Pain is a normal function of the human body, it is essential for our survival as individuals and as a species. And yet zero, so zero pain is not something that I think is a goal that is realistic, because even, studies have shown that, you know, when hospitals used the ‘pain as the fifth vital sign’ system, they actually had much more higher overdose rates and people are more likely to die using that. I think it really depends on how much it affects the person, and I think that in the end, it ends up, you know, in the end, those decisions are going to be made at the bedside. I think what when I’ve looked at a lot of the research that shows, that looks at folks who are in chronic opioids, many patients report that they were just told, the risks of chronic opioids were never explained to them when they were started. Many patients felt that that, you know, they were just in pain and that they were just prescribed opioids without being told that you might have a potentially life-threatening constipation, you could have high prevalence of mood disorders, you might get addicted and then there is no good off ramp. And so I think what we need to do is spending a lot of time with patients at the upfront. And the most important thing is finding out why they’re in pain, because I think that’s what people fear the most when they’re in pain. Pain is the loudest alarm signal that can go off in your body, and it immediately needs to have a meaning. Pain needs to find its meaning. Is it because you’ve fractured, is it because you turn your rotator cuff, or is it because you’ve ruptured a muscle, is it because you have an appendix that is about to blow up in your body, are you having a heart attack? And so I think that every patient in pain we need to first of all, the first, foremost thing that we need to do is make sure that why are they having in pain? Is there a life threatening illness that is affecting them? And if that is the case, then you go ahead and treat it, and oftentimes that”ll take care of the pain. But if we don’t find it, but if you’re able to tell the patient for certainty that pain is not going to lead to any type of bodily consequence, then our focus should really be on trying to separate the fear that pain causes by the effect that it’s having on their body. I mean, I, you know, as a cardiologist, for example, you know, we get lots of patients who come in with chest pain. Chest pain is the second most common reason people come to the emergency room. And yet a very small amount of those patients will have a heart attack or a true, life-threatening emergency. And for the most part, for the other patients, when you tell them that you’re not having a heart attack, when you’re not having, your aorta isn’t rupturing or you don’t have a clot in your lungs, that can be incredibly reassuring. And that’s really what we need to do better at as physicians. I mean, one of the things that I’ve learned writing the book is that, you know, without even giving a pill, without even performing a procedure, physicians can have such a powerful impact on how someone feels, actually feels in their body. And oftentimes that effect is called the placebo effect, and yet, what people focus on with the placebo effect is often they focus on the pill that someone takes or the procedure that was performed that wasn’t real procedure, but it is really the person giving that pill. It is the person providing that procedure, performing that procedure that gives people the reassurance that empowers your body, that they are cared for, that they are attended to, and that their pain is being taken seriously. Which is why, and that effect is actually more potent among Americans than any other people, because research suggests that Americans have a more powerful placebo response to pills for pain than any other country in the world. And not only that, but that effect is actually increasing over time. And you’ll be surprised to know that even when in studies—and there’s been plenty of randomized trials for this, especially for pain—even when patients are told that ‘You are getting a placebo’ but if it is done in an environment that is caring, if it is done in an environment where people feel heard and seen, they often will have a very, very powerful response to even when they are told they are getting a placebo. And I think that’s really what we need to focus on, is thinking about how can we be more empathetic? How can we be more, how can we be kinder? How can we enhance our innate placebo-genic qualities as physicians, to put people at ease, to separate the fear that they feel from the pain that they’re experiencing? And I think that instead of using phrases like, you know, ‘all in your head’ as a way to de-legitimize people, I think it should be used to empower people for them to know that our bodies have these really, really potent systems to overcome pain and that many interventions, such as, for example, cognitive therapy, can be extremely effective in helping people live in pain. They may not eliminate pain, but they can help people live a more productive life and have higher quality of life despite them being in pain. And I think that’s really why having a more expansive view, having a more realistic view, about the complexities of pain, rather than trying to simplify it to something that’s very crude and one dimensional, is really necessary if we are ever to kind of go beyond the opioid epidemic and really start helping people living with pain.

Dr. Abdul El-Sayed: You know, and that brings us back to the beginning, which is the understanding that pain is both biological and socio-cultural, and the ethos of treatment ought to include both in the way that we think about people who are suffering pain. And, you know, one should not be ever left in their own pain, but that engaging with the complexity of their pain allows you to think about multiple avenues, most of, you know, first of which begins with empathy, understanding, and caring and consideration. I really appreciate you joining the show to talk about your new book. The author is Dr. Haidar Warraich. He’s the author of the book “The Song of Our Scars.” I hope that you’ll check it out. And again, thank you again for joining us today.

Dr. Haidar Warraich: Thanks for having me on the show, Abdul. It’s a pleasure.

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. When it comes to COVID, this was the news all this week:

[news clip] Tonight, pockets of the Northeast are again seeing the most significant spike in new infections.

[voice clip] The CDC estimates that sub-variant BA-2 now accounts for 90% of new COVID cases in the Northeast and more than 85% of cases nationwide.

Dr. Abdul El-Sayed: Cases are rising nationwide, climbing the fastest in the Northeast, but rising quickly elsewhere, too. In the Midwest, cases are up 40% over the past two weeks. Let me start with the good news. Cases are going up, but they’re going up rather slowly, and this increase is well off the trajectory of the BA-2 surge that hit Europe over the past couple of months. The bad news is that we’ve been slow to respond. Testing centers have been largely deactivated and mask recommendations have been slow to come back, but there has been some movement in some communities.

[news clip] Philadelphia is bringing back its indoor mask mandate. The city making that announcement just hours ago as COVID-19 cases rise in our area.

Dr. Abdul El-Sayed: Look, here’s my worry, and I’ll say it again: the best time to intervene is when cases are limited, but spreading rapidly. That’s when we have the best opportunity to slow down the spread and limit the overall peak of the surge. But mask guidelines won’t kick in until there have been substantial hospitalizations, which is when it’s too late. I’m not advocating that we should all go back to our houses and lock the doors, but I am advocating that we be prudent. Putting a well-fitting N95 mask back on in crowded indoor settings would be a good idea. For their part, the Biden administration has extended the mask requirement in airports and on airplanes to May 3rd. Meanwhile, public health officials have discovered two new BA-2 sub variants, BA-2.12 and BA-2.12.1. Which reminds us that we’ve really got to come up with better naming mechanisms. These are sub variants of BA-2, which appear to be up to 25% more transmissible than it, which was up to 50% more transmissible than the original Omicron. We’re talking about an extremely transmissible variant. There’s still not much known about their severity right now, though, given their connection to Omicron, it’s suspected that they have a similar profile. Viruses evolve in two main ways, which scientists refer to as “shift” and “drift.” Shift is when a virus makes a massive leap by trading genetic material in a shared host. This is how we believe Omicron emerged. Drift, though, is when a virus slowly evolves incremental changes that improve its transmissibility. That’s what seems to be going on here. All of this reminds me to remind you that as much as we all wish, COVID is not over yet, and we ought to be smart about what we need to do to protect ourselves and our families. That said, we are in a fundamentally different moment in this pandemic. Alongside extremely effective vaccines and a knowledge of the public health measures we can take to protect ourselves, we have treatments that are up to 90% effective against hospitalization. The key thing, though, is that Congress needs to make sure we have enough of them! And that takes funding, which Congress has yet to authorize, which is simply bonkers.

Finally, President Biden took an important step on addressing America’s gun violence epidemic last week. And yes, it is an epidemic. Gun violence is one of the leading causes of death among young men, and given our lax gun policies, homicide by gun in America far outstrips other high-income countries. Just last week, a gunman on the New York subway opened fire, shooting 10 people in Brooklyn. For his part, President Biden’s actions focused on ghost guns. Ghost guns are untraceable guns that are built out of kits or 3D-printed, and last year alone, there were 20,000 found, up tenfold since 2016, largely because of the ease of 3D printing. This new rule requires kits to be made more traceable and that folks purchasing them undergo the same background check as those buying regular guns. It also requires retailers to add serial numbers to second-hand ghost guns. That said, the rule doesn’t really address the newly 3D-printed guns, which is an important next step. But the real onus here is with Congress again. So Congress, while you’re passing that COVID funding, can we get on sensible gun reform too?

That’s it for today. I know I ask you this every week, but if you do me the honor and the favor of rating and reviewing the show, I would very deeply appreciate it. So would all the new people who get access to the show, because it really helps us out. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store. We’ve got our logo mugs and t-shirts, our Science Always Wins t-shirts, sweatshirts and dad caps, and our Safe and Effective tees, which are on sale for $10 off while supplies last. And lastly, if you haven’t subscribed to my newsletter The Incision, I hope that you will: Abdulelsayed.substack.com. I just had the opportunity to interview Casey Michel, author of the new book “American Kleptocracy.” I got to talk to Casey about all of the ways that our porous system for laundering ill-begotten wealth from abroad has hurt Americans here at home. I hope you’ll check it out.

Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivia Martinez. Veronica Simonetti mixes and masters of show. Production support from Tara Terpstra and Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez, and me, Dr. Abdul El-Sayed, your host. Thanks for listening.