Dr. Sanjay Gupta: All pain lies in the brain, and here’s what you can do about it
By Dr. Sanjay Gupta, CNN
(CNN) — One day a few years ago, as I stared at all the sophisticated machinery in my operating room — high-tech microscopes, image navigation tools and exquisitely designed instruments — I was struck by the realization that the patient in front of me had pointed to an archaic frowny face to help make the diagnosis that landed him in the OR in the first place. I have been practicing neurosurgery for more than a quarter-century. Whether it’s a brain tumor, a herniated disc or a pinched nerve in the wrist or arm, pain is often what first brings most of my patients to the hospital. Pain can be difficult to treat, in part because it is subjective and has no objective measure. It is one of the mysterious sensations that we collectively experience as humans, and throughout our history, we have had a hard time describing our truly unique pain.
Over the past few years, I have been working on a book about pain. I’ll be honest, when I first started thinking about this topic, I thought there wasn’t that much left to say. After all, there have been plenty of books, movies and documentaries about the opioid epidemic over the past 25 years. But I realized that because opioids had commanded so much attention, there has been very little written about all the remarkable ways we can treat pain without the need for opioids. Because we had become such a “monotherapy” culture, there was hardly ever any mention of effective alternative, complementary or combination pain therapies – even by many of my medical colleagues.
Arrogance and greed had fueled the opioid epidemic, and for pain doctors, it left very little room for conversation about other approaches to treating pain. To be clear: For some people, opioids can be a lifesaver. And although you may not realize it, our body is constantly making its own opioid-like substances, known as endorphins, which are part of the endogenous opioid system, or EOS. This system is good at not only suppressing pain but at improving mood and making you less likely to remember painful events. Without the EOS, women would probably never have more than one baby! Taking opioid pills, however, will suppress your body’s own natural opioid production. That is why they are hardly ever a good solution for chronic pain. Over time, the opioid pills typically work less and less, and as a result, you hurt more and more.
That, however, is not what this new book is about. Instead, I wanted to lean into the idea that pain is an unpleasant physical and emotional sensation that has as many forms as there are people on the planet.
Unlike a specific cholesterol level or the size of a tumor, pain is much more difficult to quantify and convey. There were so many times I wished I could feel what my patients felt to better understand their experience. I have often felt the same way when my little girls came to me with an ache or a bruise – wondering whether there was some way to truly feel what they were feeling.
But that is the nature of pain; it is far more enigmatic than just about anything else in medicine. Not only does it differ from patient to patient, it may vary wildly within the same patient. You could accidentally hit your finger with a hammer on a Tuesday, and you might have a totally different pain experience than if you did the same thing on a Wednesday – and it might be dependent on seemingly arbitrary factors such as what you had for lunch, whether it was a nice day or whether you just had a challenging phone call with one of your parents. Add in a history of childhood trauma, depression or anxiety, and your pain experience will undoubtedly be adversely affected by all those things, even as they remain invisible.
As someone said to me, “Chronic pain never occurs in isolation. It almost always comes with baggage attached.” Accounting for that baggage is as important as treating the pain itself.
For many patients, this sort of paradigm has too often felt minimizing of their pain. “You think it is all in my head,” they would often reply in frustration. And, yet it is all in their head, which can be said of anyone in pain.
After all, if your brain decides you don’t have pain, then you don’t have pain. The brain can make your pain go away, and it can also create it out of nowhere, as is the case of phantom limb pain. All pain ultimately lies in the brain.
On top of that, your expectations and experiences are inextricably linked. If you expect something to hurt, even the most innocuous injury will be painful. And if you don’t expect it to hurt, you can do almost anything to the human body – within reason – without inducing a pain experience.
Now, most of what I am writing about has to do with chronic pain, which should be almost completely separated from acute pain. As a general rule, chronic pain is the type that lasts at least three months, but for many people, the pain can last decades or even become life-long. Acute and chronic pain are so different that they are even located in different areas of the brain, with hardly any overlap.
While writing the book, I at times wished they had entirely different names, given how distinct they are. Acute pain, the sort of pain you feel in the moment, serves a purpose to teach and protect. Don’t touch that hot pan or step on that Lego piece. Chronic pain — that is more perplexing, with its biological purpose, if there even is one, proving elusive.
Some of the experts I interviewed described chronic pain as a sort of glitch in the body’s central nervous system, with the pain message being stuck on some sort of endless loop. An Armenian physician-poet described chronic pain as a “memory that cannot be extinguished.”
Although as my friend Bessel Van der Kolk writes in his brilliant book, “The Body Keeps the Score,” chronic pain should also perhaps encourage us to dig deeper. Even as the conscious brain has forgotten a previous psychological trauma, he argues, your aching hip or back may still be a flicker of a memory, because the body is pretty adept at keeping score. This is some of the baggage that accompanies the most shadowy of sensations – a truly biological, psychological, social, cultural, environmental phenomenon, all mashed together.
An ER with fewer opioids
It’s fair to say no one likes pain. In the United States, however, we seem to have a particular disdain for it. Even though we are just 4% of the world’s population, we take 80% of the world’s pain medications, perform more operations for pain per capita than other countries and routinely use high-powered sedatives for routine procedures.
For example, in Japan, colonoscopies are commonly performed without sedation, and the same is true in China. In Finland, only about 6% of patients are sedated for the procedure. In the United States, it is close to 100%.
To be fair, I had propofol when I had my colonoscopy and have a hard time imagining going through that procedure without it. I now realize, however, that is greatly influenced by cultural expectation rather than some shared human experience.
No doubt, however, things are starting to change. This summer, I visited Maimonides Medical Center in Brooklyn, New York. It is a remarkable place that serves as a Level 1 trauma center for an incredibly diverse population. One of the ER attendings told me that 120 different languages are spoken there.
This is also one of the first places in the country to practice opioid optimization. In the Maimonides ER, opioids are used sparingly, if at all. And they are never used as a first-line therapy, only as a last resort.
Instead, I watched the ER doctors use nerve blocks, ketamine and intravenous Tylenol. Sometimes, they used both ibuprofen and Tylenol together, instead of always choosing one or the other.
On the day I was there, a 76-year-old man was being treated for a fractured hip after a fall. While an opioid would’ve been an easy choice, a doctor performed a nerve block instead, numbing the peripheral areas of pain rather than sedating the brain. It took about 10 minutes, and it worked. Another patient, a 67-year-old woman, came in with terrible knee pain. I watched the medical team send her on a trip to a beautiful Indonesian beach through virtual reality goggles. Within 10 minutes, her self-reported pain score dropped from an 8 to a 3.
More than a fifth of US adults live with chronic pain
I thought about that woman a lot when watching my own mom deal with pain. My mother is one of the toughest people I know. I had never heard her complain about pain in her 80 years of life. She wore adversity like a badge of honor, proudly showing off the scars and injuries she has accumulated. Years ago, she treated a cancer diagnosis and the invasive procedures to treat it like a faint blip on her radar. She didn’t have an epidural during any of her deliveries and is genuinely surprised that anyone else would be surprised by that.
But then she had a fall, resulting in a broken vertebra in her lower back. When I flew down to see her, she was lying back in a chair, grimacing with every tiny movement. I hardly ever saw my mom sit still, let alone lie down in the middle of the day. I asked her how she would rate her pain on a scale of 1 to 10.
It’s an 80 out of 10.
“If I can’t get rid of the pain, I don’t want to live like this anymore,” she added.
Even writing that sentence is still very upsetting to me. Within a few days, pain had hijacked my mom’s entire identity. Luckily, a procedure known as a kyphoplasty, a spine procedure that uses cement to stabilize the broken bone, eventually brought her some relief, along with the meditation we practiced together.
As she quietly sat with her eyes closed in her Florida condominium, visualizing her broken bone – leaning into it, rather than away from it for those 15 to 20 minutes – her pain score dropped to zero. No pain whatsoever. Although the pain came back later, it was yet another example of how powerful the brain could be when it came to deciding whether you should have pain.
In the United States alone, nearly 21% of adults lives with chronic pain – that’s more than 51 million people. For 17 million of them, their lives are fundamentally restricted because of the pain. Chronic pain is one of the fastest-growing conditions in the country, and so many people have resigned themselves to the idea that their body has betrayed them and they will never feel pain-free again. And yet, after years of researching and traveling the globe, I am convinced that is not the case.
There are things you can do to treat, reduce and even prevent pain. It is not a pre-ordained part of life, even as you get older. With simple strategies and an open mind, you too will become convinced that “It Doesn’t Have to Hurt.”
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