The urgency of pain demands attention. It’s a truism everyone can relate to sooner or later. There are no exemptions. It’s a condition even biblical writers grappled with in detail. In the Old Testament/Torah, God and Satan tag-team Job, inflicting soul-crushing physical and emotional pain. Even under extreme duress, Job famously refuses to denounce God even after his riches are stripped from him, his children smote by God’s will, and his body riddled with disease (thanks to Satan whom God tells “All right, he is in your power, but you are not to kill him.”) When his wife asks Job why he remains loyal, he replies, “You are talking nonsense! When God sends us something good, we welcome it. How can we complain when he sends us trouble?”
Yet beneath Jobs’ valiant display, he is plagued with doubt. He asks God-
Why let people go on living in misery?
Why give light to those in grief?
They wait for death, but it never comes;
They prefer a grave to any treasure.
they are not happy till they are dead and buried;
God keep their future hidden
and hems them in on every side.
Instead of eating, I mourn,
and I can never stop groaning.
Those aren’t the musings of a happy man. But that’s what pain does to you.
An Anatomy of Pain: How the Body and the Mind Experience and Endure Physical Suffering (Scribner) by Dr. Abdul-Ghaaliq Lalkhen is an exploration of pain, its causes, and treatments. It approaches its subject from an alternative viewpoint while making a case against current conventional wisdom (and practices). The fact that the book comes as an opioid epidemic rips through communities makes it all the more relevant.
The most common understanding of pain focuses on the wound. Makes sense. Lalkhen explains that what seems like a no-brainer — I hurt my leg so that is the source of my pain — the perception of pain throughout history hasn’t always focused on the injury. While the Egyptians did show signs of realizing a physiological aspect, they focused more on the influences of gods or spirits in the production of pain.
Other ancient cultures like the Babylonians and Hebrews shared similar beliefs. In ancient China, pain resulted from internal imbalances in the life forces, yin and yang. A similar concept of imbalances was also at the heart of Ayurvedic medicine.
In a shift from divine origins, the Greeks viewed pain as having physical and emotional origins. Importantly for the theory of pain, some Greeks proposed, for the first time, that the brain was the center for sensation and reason. Unfortunately, the idea didn’t gain widespread acceptance and they also preferred a theory based on imbalances, in this case the four humors – blood, phlegm, yellow bile, and black bile.
The theory of pain inched closer toward physiological explanations during the Roman era when Galen divided the body into a network of sensations connected by nerves.
It wasn’t until the 19th century that purely physiological explanations were established, first with the specificity theory (which said that pain had its own sensing organ) and later with the summation theory (which theorized that pain was the result of excessive stimulation of nerves. The latter was the basis of later theories that focused on overstimulation of nerve receptors).
For Lalkhen, the most notable feature of these historic theories of pain is that they all ignored the emotional aspect of pain. The same holds true today.
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 content.
In not so many words, Lalkhen blames that flawed approach to pain management for the current opioid crisis. Specifically, he argues against the purely physical interpretation of pain because it fails to take into consideration the brain’s role in sensing pain. In its place, Lalkhen makes the case for a biopsychosocial model that incorporates the how people perceive their relationship with an injury and subsequent discomfort.
The meat of An Anatomy of Pain deals with the approach to treating chronic pain employed in his clinic. It’s notable for its avoidance of prescription drugs, when possible. In its place, Lalkhen puts into practice the principles he discusses earlier in his book, namely adjusting the patient’s mental approach to pain. On top of that, he often implements another alternative approach in the form of spinal cord stimulation which entails implanting a small lead into the epidural space in a patient’s spine. This allows the nerves to be stimulated with electrical charges that elicit tingling in parts of the body experiencing pain.
One of the strengths of An Anatomy of Pain lies in the fact that Lalkhen doesn’t just offer abstract, jargon-filled arguments and cite equally confusing studies. Instead, he argues by example. Specifically, he describes the work being done in his clinic that incorporates the therapeutic approaches he discusses in the book (granted that it’s anecdotal and not a rigorous study). He demonstrates at exactly what point he transitions his patients from medical treatment to a medical-psychological hybrid. What’s more, Lalkhen does not hide how confident he feels about the effectiveness of SCS treatments.
I insert spinal cord stimulator trial leads on Monday morning. It is the best part of my week. I know that there is at least an 85 percent chance that I will provide the person lying on the operating table with more than 50 percent pain relief, on average. Some patients get close to achieving 100 percent pain relief.
An Anatomy of Pain is as timely as it is important. The opioid crisis has prompted doctors to seek alternatives to medicating the slightest discomfort into drug-induced numbness. Pharmaceutical companies are scrambling for new classes of painkillers that are less harmful and addictive compared with the ones currently on offer. What makes the book so prescient is the fact that Lalkhen understands exactly what is at stake. A life free from pain is a blessing while a life plagued by pain is a curse. As Job said when faced with the prospect of constant pain, “I have no peace, nor rest and my troubles never end.”
WORDS: Marc Landas