The Song of Our Scars

February 15, 2022
An investigation of a little-understood sensation. After suffering a back injury at his gym in 2008, physician Warraich became one of an estimated 1.5 billion people affected by chronic pain. In a wide-ranging overview, the author draws on scientific and medical studies, his work at the Pain Management Center of Brigham and Women's Hospital, and his clinical practice to examine the history, physiology, biology, and treatment of pain. Acute and chronic pain, he asserts, are "entirely distinct phenomena, and there is no justification for treating them the same way." Acute pain, incited by a physical trauma, ascends up the spinal cord to the brain, whereas chronic pain "descends down from the brain, often with no need for an incitation from below." Recurrent and invisible, chronic pain frustrates physicians. "If doctors didn't learn about it in medical school or cannot make it go away," writes Warraich, "it must not be real." Patients, forced to doubt themselves, become frustrated as well, and "their lack of conformity to the rules of medicine can turn the healthcare system into an agent of persecution rather than therapy." In the U.S., medical response to chronic pain has resulted in an opioid epidemic "carefully orchestrated [and] intentionally designed" by the Sackler family, which developed OxyContin through their company Purdue Pharma. A physician who had worked in advertising, Arthur Sackler brought his expertise to pharmaceuticals, redefining the patient as a consumer. From their use in alleviating the pain of dying patients, opioids, Sackler saw, could be sold to customers who would be alive longer and who could be convinced that they could live without pain. Coming from medical training in Pakistan, Warraich was shocked at American patients' demands for opioids and doctors' complicity in prescribing a medicine proven ineffective against chronic pain. He has been shocked, too, at the underlying racism, sexism, and ageism that affects how the medical community treats patients in pain. A clear and timely examination of the complexities of pain.

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March 7, 2022
Warraich (State of the Heart), a physician who suffers from chronic pain, explores the biology, psychology, culture, history, and treatment of pain in this fascinating meditation. Warraich distills pain into three components: nociception, “the sensory nervous system’s response to stimuli”; pain, the meaning given to the sensation; and suffering, the way one interprets that meaning. He posits that in medical contexts, these aspects are often conflated, and points out the how pill-based treatment that has resulted in “eerily similar cycles of opioid outbreaks” throughout history stems from an over-focus on the initial nociceptive response. Warraich draws on thinkers such as Descartes (who believed “only humans were capable” of feeling pain), Freud (who believed pain was closely tied to emotions), and Tolstoy (whose stories offer an example of “medicine’s new antiseptic approach to the management of pain”), and covers such emerging interventions as ketamine, cannabis, and acceptance and commitment therapy. Warraich makes a convincing case for a deeper understanding of pain and a “truly ‘person-oriented’ ” healthcare system: “Synthesizing our knowledge about the fundamentals of pain could move us closer to a future in which even if we hurt, we don’t suffer.” This solid survey makes a memorable case that those in pain need not suffer in silence.

Starred review from March 1, 2022

Physician Warraich's (State of the Heart) very well written book looks at all aspects of acute and chronic pain: its history, its biology, medical treatment and mistreatment, and disparities in pain management and care that stem from racism and other biases. Warraich, who himself has chronic pain, draws from his own experiences in addition to scientific research. His book begins with historical views of pain (how some in earlier eras connected pain to sin; how societies treated and viewed people who were in pain). Warraich also details how paternalistic white medical establishments have often ignored the pain of women and people of color (for instance, the pain of childbirth). He goes on to discuss the biology of pain, including new studies in neurobiology that aim to learn how the environment and the context of pain can change patients' perception of it; later chapters cover recent studies in alternative ways to treat pain, including hypnosis and exercise. There are also several chapters on the opioid crisis in the United States and the social, commercial, and medical factors that contributed to overprescription of opioids. VERDICT A must-read for anyone with chronic pain and those in the health professions.--Margaret Henderson

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