Pain is more than a physical sensation; it has cultural, relational, and spiritual dimensions as well. Dr. Haider Warraich, a cardiologist and the author of The Song of Our Scars, talks with Amy Julia Becker about these dimensions, the opioid epidemic, and ways we can be a part of the story of healing, for ourselves and others.
“Haider Warraich is a doctor at Brigham and Women’s Hospital, Harvard Medical School, and the VA Boston Healthcare System. He is the author of Modern Death and State of the Heart, and regularly writes for the New York Times and Washington Post, among others. He lives in Wellesley, Massachusetts.”
- Twitter: @haiderwarraich
On the Podcast:
Edited for clarity and length
“We had come to accept the fact that pain was a completely physical thing…and ignored the fact that it has these vast dimensions that are connected to our emotions, to our histories as human beings, to our histories of having lived through trauma…”
“We talk about all the things that don’t work or don’t help the person in pain, but what does help the person in pain is the expression of empathy, not just from their physicians, but also from their loved ones.”
“When I ask them about their pain…I have to choose to believe what they have to say…And so in some ways, because it is so subjective, it taps into some of our deepest prejudices. So any type of prejudice that we carry as members of this society, whether that’s sexism or racism, that is going to seep into especially how we consider the person in pain, whether we choose to believe them or not, whether they look the part of someone that we’ve been trained to think about as the right person in pain. So any vulnerability that you have in society will be exaggerated when you are in pain. If you’re a woman, if you’re a Black person, if you’re poor, if you’re disabled or different in any way, if you don’t speak English, if you’re not affluent…all those factors are going to become exaggerated when you seek help for pain.”
Season 6 of the Love Is Stronger Than Fear podcast connects to themes in my latest book, To Be Made Well, which you can order here! Learn more about my writing and speaking at amyjuliabecker.com.
*A transcript of this episode will be available within one business day on my website, and a video with closed captions will be available on my YouTube Channel.
Note: This transcript is autogenerated using speech recognition software and does contain errors. Please check the corresponding audio before quoting in print.
And, and because we had, we had come to accept the fact that, well, pain was just like, was a completely physical thing. And, and it was like your heart rate or your blood pressure that you could just essentially treat it as, as long as you just gave enough medication and, and ignored the fact that there’s more to pain than just that. That, that there, it has these fast dimensions of that are connected to our emotions, to our, to our histories as human beings, to our histories of having lived with with trauma.
Amy Julia (36s):
Hi Friends. I’m Amy Julia Becker and This is, Love is Stronger than Fear A podcast about pursuing hope and healing in the midst of personal pain and social division. Today I get to talk with Dr. Haider Warraich. Dr. Warraich is a cardiologist and he is also the author of The Song of Our Scars The Untold Story of Pain. I am really grateful for his insights into how pain operates in our bodies and how acute and Chronic Pain are really different from one another and how pain relates to our emotions and relationships and social situations and spirituality and all the rest. The inverse of healing in many ways is pain.
Amy Julia (1m 18s):
So understanding the story of pain helps us consider how we can be a part of the story of healing. I hope you benefit from this conversation as much as I did Dr. Haider Warraich. We are here today and I am so excited to be with you. Welcome to this podcast.
Haider (1m 38s):
Thank you AJ, and I’m excited to do speak to you as well about this.
Amy Julia (1m 42s):
Well, I wanna start with an introduction. I’m sure there are listeners who don’t know about your work and I want to make sure that they do. So I’d love to hear just a little bit about who you are and also why you wrote this beautiful and compelling and fascinating book. The Song of Our Scars The Untold Story of Pain. So can you just give us some background on you and why you wrote the book?
Haider (2m 5s):
Sure. So, so as, as my name is Heather and I’m a physician and researcher based in Boston and I’m primarily a cardiologist, but ended up writing this book on pain in part because pain is, it’s the most common reason why people seek the help of a physician or a nurse is because a part of their body hurts. Sometimes it’s in the chest, sometimes it’s in belly, sometimes it’s the head. Most commonly it’s actually in the back. Back pain is actually the most common cause of Chronic Pain in the world. So it’s something that I deal with as a physician all the time, regardless of what your specialty is.
Haider (2m 50s):
But, but even more so, I guess I wrote book because pain has been part of my life, even before I finished my medical school education, I suffered a, a pretty horrific back injury in medical school, which for a while threatened to completely derail my life and career. And though I got lucky and my pain got better, it’s still a part of my life. But I felt like I had this inside view of not just treating pain as a physician but also as someone who lived with it without You know any obvious deformity without, at least on the outside and wanted to, wanted to see how can we put together a narrative or build a world in which we treat people in pain better, especially those who live with Chronic Pain.
Amy Julia (3m 45s):
Well, and that brings us to this topic of Chronic Pain really seamlessly. And when I first was introduced to your book, the reason I got it was cuz someone had forwarded me an interview you did for cnn.com and in that you wrote about the fact that acute pain and Chronic Pain operate really differently in the brain. And so I’d love for you just to explain that difference because I think for so many of us, we might understand that acute pain and Chronic Pain feel different. We might have an experience of it feeling different, but we put them both under the same category and at least I assume that they operated the same way. And you’re saying they almost operate up in the opposite way. So could you explain that? Sure.
Haider (4m 25s):
And I will say that this is not just regular people, but even in medicine, I mean, if you look at You know how we define Chronic Pain is essentially the definition itself is You know pain that occurs more often than not for three months or more. And so the assumption even built into the term is that, well, Chronic Pain is just acute pain that is felt over a longer period of time. And that’s what I believed. That’s what I think most of my colleagues believe as well. But when you look at the research, it paints a very different picture. And certainly if you look at treatments, what we know is that so many of the treatments that work so well for acute pain, for pain that you might have after say you fracture your arm or or you get some type of acute injury, actually don’t work well at all for when, when you have a condition that causes you to be in pain for, for a long period of time or chronically.
Haider (5m 19s):
And what the science shows is that in many ways, let’s say you have two people who get injured, let’s say the, the, let’s say when I got hurt lifting weights in the gym, there was a clone of mine or someone very similar to mine who had the same injury. Yeah. And yet You know the chances that are that You know one of us is gonna develop Chronic Pain, but the other might not. and that the initial injury or the severity of the injury actually has very little to do with predicting whether me or my clone is going to go up to develop Chronic Pain. And if you think about, well other things like maybe you say that, well, maybe there’s something on an imaging test or an MRI that might predict, well, why did one person develop Chronic Pain and the other didn’t?
Haider (6m 13s):
Well, it turns out that even findings on the MRI are actually not predictive at all of who is gonna develop Chronic Pain if in fact they don’t even tell you if someone is experiencing pain in that moment. Because so many abnormalities that we associate with Chronic Pain, especially Chronic back pain, are found in regular people who have no pain at all. So, and, and so to understand what, why there are different, one of the things that’s really fascinating, one of the sort of piece of research that’s really interesting is that over time, if you study folks who had an acute injury and then develop Chronic Pain, you see that it is begins to occupy different parts of the brain.
Haider (6m 57s):
So when, when, when you have an initial injury, the parts of the brain that seem to be more activated are those that relate to essentially just a sort of Google maps of pain. Where is the pain happening? How strong is it? You know the whys, where’s and whens of pain? And then over time, the part of the brain that becomes much more activated with pain in, in, in the Chronic setting is that are actually the parts that are more related to emotions and fears and, and, and, and, and, and other forms of trauma. And which is highlights that this idea that we have, that that pain is a purely physical sensation is actually not true at all.
Haider (7m 39s):
It’s not supported by either the research, but also by our lived experience as human beings. But that even over, over time pain becomes even more connected to how we feel emotionally and our state of mind and almost resembles any other form of trauma that one might experience that then we relive over the course of our life. I mean, that again, shouldn’t be misconstrued as to saying that well, oh, because it’s more, it, it, it pertains more to the emotional part of the brain that somehow is less important or it shouldn’t be attended to. but it does certainly suggest that this idea that somehow acute and Chronic Pain are essentially the same phenomena.
Haider (8m 26s):
And the only difference is one is more Chronic than the other isn’t is, is actually quite false and is probably an important reason why we have actually done quite poorly at treating people with Chronic Pain.
Amy Julia (8m 39s):
Well, and I think, correct me if I’m wrong, the, the way I’ve you’ve described it is that acute pain goes from the body to the brain, and Chronic Pain goes from the brain to the body. Is that an accurate way to talk
Haider (8m 52s):
About it? I think many instances that is accurate, where I think that okay, for You know, usually what happens is that our You know we have all these nerve endings in our, in our, in our body, in our fingers, in our hands, in our feet, in our chest, that are always on the lookout for things that might be deemed as uncomfortable. Once those signals are detected, there’s a, the nerves fire and they send a signal up to the brain and that’s where the brain brain actually brings that feeling to life, which is You know, which is pain. You know pain doesn’t hurt until it gets up to the brain and is transformed into that feeling because again, pain is different from You know other conditions that we usually think about because pain is actually a normal function of the human body.
Haider (9m 42s):
It’s not a disease. Experiencing pain is actually very essential for our survival and for our growth as human beings, partly because of one of pain’s most important features is, is to teach us how to exist safely in the worlds around us. And yet what we see with many Chronic Pain conditions is that they’re no longer dependent on any signal coming from the body to generate that same experience. In fact, that experience is generated almost in an automatic fashion in the brain without, without needing any signal from below coming up to stimulated.
Haider (10m 26s):
Again, this is true for many conditions and and certainly it’s not true for everyone, but, but, but that that relationship between injury and, and pain or how we hurt changes based on whether you have an acute injury or whether you have a Chronic Pain condition.
Amy Julia (10m 45s):
Yeah, I think that’s really helpful. And I’m curious about this relationship that you’ve already mentioned between the emotional and physical dimensions of pain, which in some ways, even stating it that way is misstating it. Because as you said, I mean even that emotional center right is in the brain. It is, it exists in our bodies. So it’s not some abstract or unreal part of us. And, and the way We talk about it as separate might even be part of the problem, but I don’t really have other language for it. So I’d love to hear from you just the, the role that emotion and even you also talk about pain as memory, which I thought was so interesting.
Amy Julia (11m 27s):
Like in what way do does the, what’s the role of emotion and memory when we’re talking about Chronic
Haider (11m 33s):
Pain? So you’re absolutely right that You know how we, how we kind of frame and portray You know the mind and and the body just by saying that we are actually part of the problem. Because in reality there is no real difference between, there’s no no line where You know the mind starts. So the body begins, everything is kind of generated in our brains, our our sense of who we are as human beings, both as physical beings, but also as meta metaphysical beings is all created in the brain where You know how we know where our fingers end or our toes end, or where the top of our head is, is all based on, based on how our brain creates this projection of who we are in physical space.
Haider (12m 21s):
And same is true with how we feel and, and and You know you to to see. And this idea that that what we feel or is and how that affects us in a real way is You know, perhaps You know is, is seen in every aspect of medicine or in every aspect of health and disease. You know one condition that You know You know we, we see very often is ptsd. So You know PTSD occurs not because someone or or is not necessarily because someone had a physical injury, but whatever trauma that that person experienced is actually having a very real and very often crippling effect on that human being, both mind and body sometimes years if not decades after whatever caused them to experience that trauma to begin with.
Haider (13m 16s):
And so we have countless examples of where, where, where this idea that the mind and body are separate are completely falls and, and, and they kind of fall apart. But yet when it, when it comes to pain, I think in part because we’ve been trained to think that no pain is, or especially recently that pain is a You know, is just a, is very simple mechanical disturbance in our body. And that that what we feel is essentially a response to that is, is is is doing injustice to the complexity of pain, but also limiting the things that we can do to actually help the person in pain.
Haider (13m 58s):
but it comes to how emotions are connected to pain of You know we go back to that example of You know why does one person develop Chronic Pain and the other one doesn’t You know two people get injured on the same day and one person does, and the one person doesn the other. I’ve already mentioned the things we know do not, are not associated with that transformation. We know that the extent of the initial injury is not associated with the development of Chronic Pain. We know that that You know abnormalities are imaging abnormalities are not related to that. And the question is what well You know, one of the most important risk factors for the development of Chronic Pain is the experience of having had an adverse childhood experience.
Haider (14m 46s):
For example, So If, you are someone who has grown up in a troubled household or if you’ve grown up in a neighborhood where you were, you were, you were always scared and you you saw things that maybe you shouldn’t have seen as a child or maybe you were bullied or maybe you were abused in You know in any any, in any form, that changes our brain in a way that it makes us much more likely for that transformation from acute pain to occur into Chronic Pain in part. And again, You know, I think we are still trying to figure this out, but, and, and the more trauma that you’ve experienced as a child, for example, the more likely you are to develop Chronic Pain.
Haider (15m 31s):
We know that conditions such as anxiety, depression and others are also not just products of pain that you can develop depression and anxiety after you’ve had a Chronic Pain injury, but also that they are some of the small strongest risk factors to determining if someone is going to develop Chronic Pain or not. The way I think about this is, again, it just confirms I think that what that, what we already know as human beings, we all know that the state of our mind affects how our body feels and, and how our body feels affects the state of our mind. There’s just no, i i i I I think for, because for so long our tools in medicine and our approach in medicine was so simplistic.
Haider (16m 18s):
I think just for practicality sake, we, we created these distinctions because again, we were just, we just didn’t know. We just never understood the mind. We didn’t have tools to make that could, that were there. We were much better at putting broken bones together than healing trauma or understanding depression or understanding anxiety that we created these distinctions. But now I think that those very distinctions and that way of thinking is coming back to, to haunt us and affect the way that we can actually help people You know with regards to memory. I mentioned a bit about ptsd, but actually PTSD has a lot of similarities with Chronic Pain as well.
Haider (17m 0s):
And in fact, some of what some scientists are doing is actually thinking about could we actually use a retrofit therapies that we know work for PTSD and seen if they will work for Chronic Pain? And the reason people are thinking about this is that at least in, in animal models, because again, it’s very hard to study pain in human beings. You, you won’t want to sort of hurt a human being. And and even in animals, I think people are You know do it responsibly, but that’s the closest we can get to understanding the experience. But if you look at, if you look at for example, mice that have Chronic Pain, what you see is that the same molecules that are responsible for forming memories in the hippocampus, which is where our memories live, also start to appear in or become activated in the areas that are responsible for Chronic Pain.
Haider (17m 58s):
And in those experiments when they’ve given sort of substances that prevent the formation of new memories, you actually see that the development of Chronic Pain African injuries also much lower suggesting that. And, and, and, and we’ve seen there have been some examples in real life where people who’ve had Chronic Pain have had episodes of amnesia where they lost their memory, but not only did they lose their memories, but they also forgot, or they actually actually overcame their Chronic Pain as well. So I think there’s a lot more that we are understanding about Chronic Pain because our, our, because a I think people realize what a significant problem this is in our society, Chronic Pain effects You know one in five people both in countries like the US but also around the world.
Haider (18m 54s):
We’ve, we’ve realized that our existing treatments for Chronic Pain are actually quite bad. I mean, we’ve seen that with the opioid epidemic, which initially started with people getting opioids for pain relief, but then led to this whole sort of crisis of addiction that’s really overrun this country, but also that that, that they were just not that effective either. So, so I think that we are, I, I think we are actually at a fairly exciting place with regards to changing how we think about Chronic Pain thinking about how we can apply new approaches to help people in Chronic Pain and also just, just, just, just talking about it more rather than just let it, let it, let it, let it fester.
Amy Julia (19m 47s):
Well, and I wanna ask you, I wanna get back to some questions about both the medicalization of pain and the opioid epidemic in a minute. But before we get there, just to talk about this emotional connection for one more minute, you wrote that you often see patients, this is a quote who take offense at the notion that their pain is as much physical as a psychological disorder. And I’ve often wondered whether there is a, essentially a sense of shame in our culture around Chronic Pain if there is no, if it is a matter of memory or You know emotion as opposed to No, no, I had this injury. and that’s the only problem here.
Amy Julia (20m 28s):
It also seems to me that in terms of the treatment of pain, if, if Chronic Pain does have to do with emotions and psychology and not simply bodily harm, I mean, again, not having quite the right terms for all of this and And we deny that emotional component, then it seems it’s gonna be a lot harder to treat. And I wondered if from your own experience, like was there a way in which you were able to address the emotional or psychological components of your Chronic Pain that gives you some perspective on what’s going on with, with patients in that same position? Yep.
Haider (21m 7s):
I mean I think we, we’ve seen this with, we’ve seen this with me, mental health disorders that, that we just don’t, that You know in our society, not just here, but really around the world, that we just don’t take them as seriously as we would say a condition that we can get a blood test for or that we can see on an x-ray or a CT scan. and that that same thinking seeps into other conditions and, and patients and people are smart that they, they know that if they go to a physician or they go to seek health care and, and, and are focused on finding You know a, a, an abnormality that can be sort of visualized in a very real way.
Haider (21m 49s):
And if that is found, then they know that they’re gonna be taken more seriously, that they’re, that their suffering is going to have You know a, a a a cause that can be understood and, and and provided legitimacy in our health system, which is not the case when if, if you have a condition that is either primarily or or driven by a mental health condition or is made worse by it. So we know that, we know that many, that patients are not gonna come and want to change the paradigm here because You know that, that that, that any such attempt will mean that whatever little attention or care that they receive from the health system might get denied to them because now, because we’re so much more attentive to conditions that we think are because of anatomic abnormalities, right?
Haider (22m 48s):
So, so, so I think that the, and and, and I think the, the, the downside of some something like this is that the, what, what it’s doing is that it’s limiting the sort of things that we could provide for patients beyond just sort of pills and procedures that could actually help them not just live better with the pain, but also potentially overcome it in many, many circumstances. So it is a, it is a, but, but at the same time I’m also hopeful because we have seen, for example, a lot of progress in a better understanding and realization of the importance of mental health in this country and others as well. So we’ve, we have had progress there. It’s not like we are still living in the same paradigm in which You know, we don’t think that these things matter.
Haider (23m 32s):
I I think that people do realize that, that that that that that psychological disease or disease that’s made worse by psychological factors is as serious as anything else that we experience. And my my hope is that that, that we will carry that through and, and, and into conditions such as Chronic Pain again, so that people have a more real understanding of the condition, but also have access to therapies that could help them in those circumstances.
Amy Julia (24m 8s):
Hmm. Well, and it speaks a little bit to something you also write about, which is that I think if medicine reduces the human to anatomical abnormalities, then we are going to, especially when it comes to the problem of treating Chronic Pain, we’re going to reduce the possibilities of what it might mean to treat that pain. And, and whereas if we can expand our understanding of the human, you do a great job, I think of even writing about the ways in which, like the industrial revolution, we started comparing human bodies to machines and So If, something breaks, you figure out what the component part, you replace it and then you keep going.
Amy Julia (24m 52s):
And human bodies aren’t machines, they just are not, that, that comparison breaks down. And the medicalization of pain and of the human body have all contributed to that. And I think that moves pretty seamlessly into the way in which you’re talking about the opioid epidemic. And I, I thought your chapters on that were really riveting. I mean, I felt like I was reading like a page turning novel just to find out all of these details about the epidemic and the industry, which I’ve You know, seen, but not, it’s like I’ve read articles over the course of the past 20 years as opposed to seeing it all in one place, which you’ve done in your book. So I’m wondering if you could just explain how a modern understanding of the body and of medicine contributed to what we saw happen in this, this couple decades of over prescription of opioids and then this epidemic that really harmed so many people.
Haider (25m 49s):
So I mean, if you look at the, if you look at the history of how you’ve understood pain, You know when pain was almost You know, very frequently seen to have a purpose if you felt pain, especially Chronic Pain, that there was a reason that you felt pain. Maybe it was because you felt that you had not been a good person or that you hadn’t that, that, that this was some type of test from You know, from, from God or another, or You know celestial agent said. And, and, and that overcoming that pain or living that pain actually was not a meaningless thing, but it, it had a, it had some, it had, it had that, it was, it was not just an event, but it was a journey that you were on.
Haider (26m 39s):
And oftentimes When we sought help for pain. It wasn’t just that we went to physicians, we went to You know a priest or pastor asking for, for Spiritual help or Spiritual healing as well, because I think we understood that there was more to pain than just what was, than just You know a, a body breaking down, but really that there is a, that there is there, there is an, a greater dimension to it. And then what happened was that we, as we kind of moved towards a more biomechanical view of the body, one of the things that was done was to essentially create this dichotomy between mind and body.
Haider (27m 23s):
And part of it was that we were just better at understanding the body than we were at understanding the mind. So some of this was just, just, just, that just seemed like the You know practical solution to, to a problem. So then we You know divided medicine into doctors who treated the body, which is all doctors, and then psychiatrists who treated the minor psychologists And. we saw a lot of progress in overcoming ailments of the body And, we, we didn’t see the same type of progress with regards to how good we are understanding mental health and mental disease.
Haider (28m 5s):
What happened at this point was that we had developed these, these, these, these drugs or well, we hadn’t really developed them You know we had these opioid products, which are essentially You know products from the poppy plant have been present for thousands of years. And every so often, yeah, our societies both here and around the world have gotten into this really sort of this, this fatal attraction with this plant where it You know we, that many societies have had to deal with crises of addiction to opioids for You know for thousands of years because again, these are plant, these are compounds that are, are, are some of the strongest, most potent chemicals in existence.
Haider (28m 50s):
And they have some qualities that are, that are hard to replicate. So If you. But more recently we had this crisis of people living in Chronic Pain, especially people having a lot of pain at the end of life, oftentimes when they had some type of You know cancer diagnosis or other condition that was caused a lot of discomfort. And a movement was started to to to destigmatize the use of opioid medications for people who had a lot of pain. And this was a movement that was meant to overcome a lot of suffering, a needless suffering that people are having. But then what happened was that this movement was hijacked by, by forces that felt that, well how about we just expand this to everyone, not just people who have some type of serious illness or where people who were at the end of life, but really to anyone who’s living with has a headache, who has a belly ache, who has, who has a back, who has back pain or joint pain despite there being no evidence of the safety or the effectiveness of these medications in these Chronic Pain settings.
Haider (29m 57s):
But because I think that the time was such that we were really sort of wanted to eliminate pain and that this, this promise felt real that we could live in a pain-free world just as long as we just gave enough people these medications that, that we, we, and, and because we had, we had come to accept the fact that well, pain was just like, was a completely physical thing and, and it was like your heart rate or your blood pressure that you could just essentially treat it as, as long as you just gave enough medication and, and ignored the fact that there’s more to pain than just that, that that there, it has these fast dimensions of that are connected to our emotions, to our, to our histories as human beings, to our histories of having lived with, with trauma, et cetera.
Haider (30m 50s):
And that had all these Spiritual dimensions that we’ve known and have and have attended to, but then left all of that aside and focused on it as if we would essentially an abscess or, or, or anything else that can be that, that is, that is very much a physical condition. And what that led to is essentially the opioid epidemic where out of good intentions to, to help certain people or small segment of our population that truly needs to be pain-free because they have a, a terminal illness or have a serious illness.
Haider (31m 30s):
We, we, we allowed this to spread essentially throughout our entire society to all people who had had any sort, even after people after getting a dental procedure, for example, even if they came and they stubbed a toenail in the emergency room, they were being given opioid prescriptions oftentimes for weeks or months that addicted them to these drugs. So now, especially as we think about and, and in fact that that crisis has really gone on unabated You know almost a hundred thousand people had died of overdoses last year from opioids. I think what I think now that we think about the future and think about, well, how can we best help people, especially those with Chronic Pain who’ve now are stuck in this weird place where they have an illness that causes them discomfort, but also they’ve essentially been made pariahs in a system that treats them now as addicts, despite the system being the agent of giving them those drugs to begin with.
Haider (32m 31s):
Right? I think I, I think, but, but to get there, we, we really have to really have a clear eye view of what, especially what Chronic Pain is, what it means, and, and the fact that it isn’t just a physical sensation, but really one that spans phenomenon such as emotions and memory and trauma as much as the physical realm.
Amy Julia (32m 56s):
Well, and I wanna get back to what you just were talking about in terms of how we actually address Chronic Pain from a more holistic dimension. But before we do that, I wanted to add in just the factors of race and gender because you write about these things and I think actually bringing those in not only just names, the fact that there are disparities in who experiences pain and how they experience it, but it also brings up the fact that there’s a social phenomenon right going on. There’s a story to our pain. I mean even the title of your book, The Song of Our, Scars The Untold, Story of Pain, like there’s just an emphasis there that this is not something that simply can be kind of analytically measured on a data set.
Amy Julia (33m 38s):
And I think the fact that race and gender, and I’m sure other social factors really do contribute to our experience of pain, speaks to the fact that this is more than anatomical. But could you just give a little bit of context for the ways in which race and gender factor into pain? Sure.
Haider (33m 60s):
Despite You know our best efforts and our hopes, but I think, but I think going, again, speaking to the nature of pain, there’s really no blood test for pain. You know, as a physician, when I see someone, the only way, unless they have something that is clear and obvious, let’s say that they have a condition like appendicitis, which I can see on a CT scan and looks like the their intestine, that part of that intestine may explode. They need surgery is gonna cause them acute pain unless you have something like that or they’re having a heart attack that I can see with You know blood tests and EKGs and whatnot.
Haider (34m 40s):
Even with that, when when I ask them about their pain, I’m only relying on on what they say I have to, I have to choose to believe what they have to say and, and I have to then determine whether, whether that is gonna be something that I’m gonna go with or not. And so in some ways, because it is so subjective, it taps into some of our deepest prejudices. So any type of prejudice or any type of, that we carry as members of this society, whether that is, whether that’s sexism or racism, that that is going to seep into especially how we consider the person in pain, whether we choose to believe them or not, whether they look the part of someone that we’ve been trained to think about as the, the the right person in pain.
Haider (35m 36s):
So, so, so any vulnerability that you have in society will be exaggerated when you are in pain. If you’re, if you’re, if you’re a woman, if you’re, if you’re a black person, if you’re poor, if you’re disabled in any different in any way, if you don’t speak English, if you’re not affluent, I mean all those factors are going to become exaggerated when you seek help for pain. But even, let’s take a step forward. I mean, I, I mentioned You know for many people with Chronic Pain, oftentimes there’s no blood test or imaging test. But let’s say that we have, we look at conditions in which it is well-accepted that the patient that that, that or, or, and it can or it can be easily diagnosed as someone is in pain.
Haider (36m 21s):
Let’s just go back to the example of appendicitis. So You know acute appendicitis is one of the most common causes of sur or reasons for people getting surgeries in this country. Your appendix, which is kind of part of your intestine can become suddenly inflamed and could burst if it’s not You know, but with surgery, and it is one of the most painful things that human being can experience. And yet even in people who have appendicitis, not just people, even in children who have appendicitis that is confirmed on a CT scan, there still is a wide disparity in who does and does not get their pain attended to. So there’s this one study that I often talk about in site of, of a million kids who presented to emergency rooms around this country with a acute appendicitis that was confirmed on a CT scan.
Haider (37m 9s):
And those, even in these, and again, these are children, so you would think that opioid be more trusting of, of, of children than we might be of adults, maybe think that You know adults are just seeking drugs. You see that, that black children only have about 20% of the odds of receiving an opioid painkiller than white children even at the same severity of pain. So, so, so, so all these, everything that You know as, as physicians, as members of the health system, we are still part of this society. We still carry many of the prejudices that are, despite the fact that I think no one thinks that, no one wants to think that they think this way.
Haider (37m 51s):
I mean, and no one likes to think that they’re, that their colleagues are, are affected by these, but we’re all part of this society. And, and, and, and, and especially for the person in pain who is at such a huge disadvantage because again, they may not have a blood test to, to, to, to, to back up their claim of, of, of how much they’re suffering. It affects people even more. So many of these have, many of these biases that we have in regards to how pain is treated, have these sort of long historical records that have that shape to this day how we treat people. And When we think about black Americans, for example.
Haider (38m 33s):
I mean there’s this very prevalent thought, not just in the public, but also amongst physicians that You know black people have thicker skin than white people, and that causes them to have a higher tolerance of pain. And You know in our society, oftentimes we may feel that, oh, a higher tolerance for pain is a good thing. Many people think, for example, that women have a higher tolerance of pain because they’ve had, they have have You know menstrual cramps every month they have to undergo childbirth. Yeah. But yet that same notion actually that might prevent them from treating pain effectively because they might feel incorrectly that if you’re a black person, that your threshold for pain is higher.
Haider (39m 19s):
So somehow you need less painkiller or if that, if you’re a woman, your right threshold for pain is higher, somehow you might need more, you might need less attention for your pain. So, so, so I think especially in, in, in pain, I think these biases and prejudices play a really important factor. And I, I think it is just important to make sure that we are, and again, it goes into this idea that pain is not just a physical sensation. It is part of our society is pain is political, pain is gendered, pain is racial, and all these, and, and, and to, to, to isolate it from all these greater forces is actually doing it a disservice because we don’t realize just how broad and, and far reaching this phenomenon is.
Amy Julia (40m 8s):
Well, it makes me wonder whether there is a, I think you’re right about this, but just that we, if our pain is not believed by someone else, right? If we can’t, is that part of making meaning of our pain is like there, there’s something that happens in being able to share the story of our pain, even if someone cannot give us a drug to medicate it. That sense of even, I mean literally a listening ear, a hand on your arm, a warm embrace, whatever. I mean, there’s, there’s something about being believed in the midst of our pain that actually can alleviate at least some of it. I mean, am I right about that? Is there, there’s something that we need in terms of being
Haider (40m 50s):
Believed? Absolutely. I mean if you think about one, one of the, one of the things that You know, we We talk about all the things that don’t work or don’t help the person in pain, but what does help the person in pain is the expression of empathy, not just from their physicians, but also from their loved ones. I think you mentioned, you asked earlier that You know what is You know what in my life was You know sort of, sort of speaks to some of these sort of greater dimensions of pain. Yeah. You know, part of You know now that I look back. I mean one of the, one of when when I got hurt after my injury, it wasn’t just that I was in pain all the time, but I lost all my friends, You know, no one would You know, show up all my social activities, things that I love doing, like playing sports or going out with my friends that went away as well.
Haider (41m 51s):
And I, I I, and, and so part of my, part of what sort of was surely a factor in, in, in, in the, in the transformation of my, my, my suffering was in fact that, that that loss of sense of self and, and my own sort of sense of who I was and, and being denied essentially the things, the very things that help would allow me to recover. And it wasn’t until those things started to come back and I started to find, find a, find a network of people who, who who were able to sort of love me and be there for me, despite the fact that You know I wasn’t the most fun person to hang around anymore, allowed me to sort of get better also the, the, the, the physical therapists who worked with me.
Haider (42m 43s):
It wasn’t just that they, it wasn’t just what they, the exercises that they taught me or that, but it was their, their the fact that they cared for me and that they showed that through their actions and their words. Yeah. And, we have plenty of great research to suggest that that’s, that’s, that’s, that’s true not just for me, but for others as well. So I, I, so I, I think empathy is extremely important and, and And, we know that patients of more empathetic physicians tend to have better outcomes with pain. We know that if you teach just a physical therapist to be more empathetic and to be more present, that their patients are going to actually do better and actually require less physical therapy to get better.
Haider (43m 27s):
So everything is connected. But I think, I think love and and support and emotional connection are both a huge part of recovery. And the lack of those things are a huge reason why so many people are in pain or their, their pain gets worse is because they lack those things or that those things were taken away from them sometimes because of the pain or sometimes preceding the pain that, that, that, that then You know leads to them really being You know, You know, being trapped in the grips of this condition.
Amy Julia (44m 5s):
Yeah, I’m, so, I resonate with that so much. I, I didn’t have a pain condition when I was in high school, but I did have a paralyzed stomach. I had gastroparesis, and so it was actually not painful at all because I couldn’t feel anything. And yet the way in which I finally after many years, and there certainly was a psychological dimension to what was going on, but the way in which I really found healing was through physical therapy. And I just resonate with what you were saying because it was this physical therapist who was both massaging my internal organs and talking to me with great empathy and interest in my life. And it was that mind body, spirit, emotion, relationship connection that really woke my You know organs back up when I look back on it.
Amy Julia (44m 52s):
And similarly for me, I mean, the other thing I think about, I had an experience of pretty minimal Chronic Pain in the sense that I was not You know going to the doctor and taking opioids, but I was waking up in the middle of the night for a at least a year, maybe longer, and taking a Tylenol PM or Advil every single night because my back hurts. But there was no precipitating incident. I mean, it was just a, essentially I was holding tension in my back, but I didn’t think about it that way. I thought about it as just like You know what’s wrong with my back. And it was not, again, until I began to actually look at some of the what’s going on in my life.
Amy Julia (45m 32s):
We had moved recently, so I was separated from a network of supportive people, was asking questions about identity. There were some literal stresses just in the sense of having small children and running around after them in a new place and trying to You know, figure those things out. But the bigger issues I think had to do with the emotions. But I had no narrative. The, the only way I could make sense of the fact that my back was hurting was by taking a pill, You know. And, and eventually I was like, I can’t do this for the rest of my life. What’s going on? And so that’s when I started to explore some of these other things. And I guess it leads me to a question of just, I wonder, as we think And, we come to the end of this conversation not just about pain, but about healing.
Amy Julia (46m 17s):
How do we actually make those connections? How do we move from places of Chronic Pain to healing or even just You know alleviation of that pain on some, on some level, do you have suggestions or recommendations for people who are in the midst of Chronic Pain or even just Chronic discomfort, which maybe is what I You know would say I was experiencing?
Haider (46m 42s):
Sure. I think one of the things that I’ve You know how I’ve changed my practice is I’ve You know when people have Chronic Pain, I often will offer, I’ll explain You, know much of what I’ve, what I’ve shared here about You know both sort of myself and, and also sort of the, my sort of view of Chronic Pain as well, but also how that’s backed up at the science. But, but, but I’ll try and reframe people into thinking about pain as like any Chronic disease like You know to think about diabetes, for example, You know where You know, taking, taking care of diabetes involves changing your life and then, but also then living with it and finding a good way to live with it.
Haider (47m 29s):
It despite having diabetes. And so part of I think an approach towards living with Chronic Pain is in a way of not allowing it to dictate your life, but that which might mean doing things even if it hurts. I mean, going to see your friends or attending a birthday party even if you are in pain, because You know one of the main instincts of when you hurt is you want to not do anything at all because you worried that that’s gonna make the pain worse. But in, if anything, when you When, we cave to that desire or that that urge, we actually narrow our lives even further. We actually allow pain to direct and even more powerful cage and prison around us And we, and in our attempts to control the pain, we actually allow it to control us back even more.
Haider (48m 24s):
So that’s, that’s I think, and, and this, this way of thinking is called acceptance and commitment therapy. And it can be, you can receive it formally from a psychologist, but essentially the point is to, to emphasize quality of life and living despite being in pain rather than trying to control the pain at all costs. I think if you are living in pain, I think seeing a pain psychologist, I think is something that I recommend to a lot of my patients. And the reason is, again, they can allow you better ways or coping mechanisms to live with pain. I think surrounding yourself with people who are empathetic is, is important.
Haider (49m 6s):
I think if you’re in, if you’re in a toxic relationship, it’s not just gonna affect how you feel in your minds or in your hearts, it’s also gonna affect how your body feels. Yeah. So, and then, so those are some of, and and then the, the, you, you mentioned this already, but I’m a big believer in the role of exercise as well. For me, that was really one of the main things that helped me to get better. And the reason sometimes people can be reluctant to exercise is because after you hurt yourself, exercising really hurts when you go and you stretch. And if you have a sore back, chances are initially you, you might actually feel more pain.
Haider (49m 49s):
But what we know is that exercise, especially for people with Chronic Pain, can be extremely helpful and useful in helping in, in essentially providing an additional path to to, to recovering. And then the last thing I will say, and This is also the area of really interesting and important research is that You know one of the, one of the, the one of the worst things about pain is the fear that it generates. And for often, oftentimes You know when you, when you heard, when you, when I heard in my back and it was bad, I’ve worried that You know, am I gonna be able to walk again?
Haider (50m 29s):
Or if I did something and that hurt, I would immediately stop because I was worried, am I gonna make things worse? But, but once you have Chronic Pain, or once you’ve had You know that that that, that, that fear is essentially doing You know good. And, and there are new forms of sort of cognitive therapy. There’s one called pain reprocessing therapy. And all it does really is to separate that fear that people have of pain. And what the You know trials of that type of therapy have shown is that You know people who receive that therapy are much, much, much more likely to be pain-free and to be, to have their pain go away than those people who get sort of our usual care for Chronic Pain and This is studied in back pain, but it is being studied for other reasons, other indications as well.
Haider (51m 22s):
So what I, what I, I think what is clear is that there’s no silver bullet for pain. If someone’s selling you a magic potion or a way out, chances are that they’re not being completely honest. But I think that if, but it takes a lot, but I think that if you surround yourself with good people, if you have a mindset that in which you are not going to sacrifice your life in the service of being pain free, if you seek out physicians who are empathetic and if you keep an open mind about new forms of therapy, whether that’s mental health therapies or non-opioid forms of therapy, I think that that, that, that there is hope for recovery for, for most people.
Amy Julia (52m 6s):
Yeah. I love that. And I, it makes a lot of sense of what you’ve said. I do wonder is just kind of a final question on the Spiritual dimension of things, which obviously is not something that any doctor is going to prescribe, but at the same time, a lot of what you’re talking about, I think does speak to the human spirit. And I’m thinking about practices of prayer or meditation or, I mean, even the, even the prayer practice of literally like laying on of hands, which You know can certainly be used as kind of a sham You know huckster thing. But also it seems like even that experience of physical touch and empathy that’s expressed through that, and not to mention whatever might be happening on a Spiritual level with prayer, but I’m, I’m curious just to hear whether you think they’re, for people who are open to it, is spirituality another dimension of potential care when you’re in pain?
Haider (52m 57s):
100%. I mean, You know, the way I ask patients is that You know, I i i, an open-ended way to ask this is if You know faith or spirituality hold importance in someone’s life. And if they are, the answer is yes, then I think that that opens up in a whole different avenue for, for helping to again, find meaning, find resonance, find for, for, for why we are here, why we exist, why we feel the way we we feel. Yeah. And then potentially using that as a way to, to, to chart a course towards, towards healing. You know, like I said, it takes a, it takes, it takes a lot.
Haider (53m 37s):
I mean, and, and, but it takes a lot of You know sometimes just good luck. But also just having an environment in which you can look beyond the pain, you can look, you can get out of your body. You know one of the things that pain does is that it directs all your energies inwards. So you’re only thinking about what’s going on in your body right now because pain just grabs your tension and just holds it in a way that a few other things do. And again, there is a reason for that. The reason is that that’s pain is meant to be protective. You know if you step on a rusty nail, pain wants you to immediately dislodge it from your foot before it gets infected. Yeah. But after a certain time that, that, that, that power, that force becomes a negative force.
Haider (54m 19s):
And it, it serves no purpose other than to just multiply or perpetuate suffering. So anything that can help us get out of our bodies and, and live our lives and, and, and, and be, be open to, to joy and happiness and experiences in other people, I think is gonna be essential to allow people to get better.
Amy Julia (54m 42s):
Hmm. I love that. Well, thank you so much for being here with us today and just for your great work. I’m gonna mention the name of your book again for listeners, The Song of Our Scars The Untold Story of Pain. It’s a beautiful book and was really thought provoking and helpful to me. So thank you for writing it and thank you for being with us.
Haider (54m 60s):
Thank you, aj. It was a pleasure talking to you.
Amy Julia (55m 4s):
Thanks as always for listening to This episode of Love is Stronger Than Fear. Thanks to Jake Hanson for editing the Podcast to Amber Beery, my social media coordinator. And finally, as you go into your day, Today I hope you’ll carry with you the peace that comes from believing that love is stronger than fear.
Learn more with Amy Julia:
- To Be Made Well: An Invitation to Wholeness, Healing, and Hope
- S4 E2 | Where Is God When the Pain Won’t Stop? with Liuan Huska
- S5 E17 | The Role and the Limits of Medicine with Dr. Matthew Loftus
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