Exploring the Nature of Chronic Pain with Haider Warraich

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are delighted to welcome back to the GeriPal Podcast, Haider Warraich, who is the author of The Song of our Scars: The Untold Story of Pain. Haider is a physician at the Brigham and Women’s Hospital, and the VA in Boston. Welcome back to the GeriPal podcast, Haider.

Haider: Thank you guys so much for having me back. It’s just such a pleasure to be back. Despite your background, Alex. I know that was a nice dunk, but we’re in the middle of an NBA finals and I think your Warriors are going down today.

Alex: We were recording this the day of game four of the NBA finals. The Warriors are down 2-1. By the time this comes out, the finals will probably be decided and hopefully in the correct… Oh, Haider’s holding up a Boston Celtics shirt. This is hurting me. It’s also probably hurting your Room Rater score, which was a 10 out of 10. And I’m delighted to see that your background has improved so much. But when you hold up that Celtic shirt, it just plummets.

Eric: It drops to one out of 10 right there suddenly.

Alex: One out of 10.

Eric: Room Raters just…

Eric: Well, we’re not here to talk with the Celtics. We’re also not here to talk about… Haider you’ve been on with us twice already, right on the GeriPal podcast?

Haider: Yeah, threepeat.

Eric: I don’t think we’re going to mention the cardiovascular system during this podcast. We’re going to be talking about pain and your book. But before we go into that, you got a song request for Alex.

Haider: Yeah, this is a special song. It was actually in the first draft of the book. But my editor cut it, to my dismay. I think most people who listen to rock music know this song. It’s Comfortably Numb by Pink Floyd. And I thought it was just perfect for today.

Alex: Great choice. I wish I could do the guitar solo because that’s the best part of the song. But I’m going sing the first verse.

Alex: (singing)

Eric: That’s one of those songs that Alex will play for like a half an hour if I allowed him to.

Alex: Yes, I would’ve kept going. Oh, I love that song.

Haider: Good to know your English is better than your Urdu.

Alex: Good point, yeah. That’s the first time. I think the last two times we’ve had you on you’ve requested Urdu. And I didn’t have time to learn an Urdu song this week because it’s super busy. So thank you for that Pink Floyd softball. Appreciate it.

Haider: Of course.

Eric: All right. I got to start off with a question. You’re a cardiologist. You have written books about other things like mortality, but you wrote a book about pain. And it’s not chest pain. What prompted you to write a book about pain?

Haider: Well, that’s a great question and I think a great way to just get into it. But I think most of us hurt on a daily or almost occasional basis, usually transiently. And that had been my experience as someone who was growing up, who’s playing sports, getting daily aches and knocks. And then one day when I was in my third year of medical school, I was in the gym and I hurt my back in a really horrific way. I heard this loud click. I couldn’t move any of my body. I was helped into a wheelchair kind of rushed to the emergency room, which was not far away because I was on the medical school campus. Got some Toradol and was told that I would get better tomorrow. And I believed it because that had been my only experience with pain before that, that pain was a transient visitor in my life, but that over time it would go away.

Haider: But that just never happened. And pain really became a part of my life for first it was days and weeks and months. And every day I would wake up hoping that pain would not be the first thing I would experience. And every day I would be wrong. And this went on for a long time. I thought I couldn’t finish medical school. So even before I became a physician, pain was something that really sort of shaped me as a human being, as a person and then as a physician. And then once I came to the United States, I saw this whole different dimension of pain, because I started residency in 2011, this was really at the peak of the opioid prescription epidemic, if you may. And I was an internal medicine resident. And this, to my surprise, was one of the one of the most time consuming and frequent things that I had had to do as a resident. Something that I’d very little experience of having been a medical student in Pakistan.

Haider: So now a couple of years removed, and even though my pain has gotten better, I just felt like there was just so much here in this topic, both with regards to how we understand pain, how we’ve treated pain to date and how we might treat it in the future, shaped in part by my own experience that I felt that there was enough here that you could write a book about it that really shaped the conversation about how we hurt.

Eric: Yeah and also about how we think and how we define pain and its problems. When I was in medical school and residency really being taught, so there’s nociceptive pain, there’s neuropathic pain, you treat them differently. We use rating scales to assess how bad their pain is. I loved your book because it takes a deep dive into stories about pain, like your own. It talks about the pain process, nociceptive pain, acute pain, chronic pain. I’d love to get into all of that. I guess one question just to start us off, how do you think about defining or thinking about things like nociceptive pain, nociception and how that’s different than the perception of pain, and where the heck does suffering fit into this? Because you talk about all three of those in your book.

Haider: I thought that framework was helpful for me to both understand and set the framework for what we are going to be talking about. Like yourself, when I was a resident, and pain has been shaped in our mind as being a purely physical sensation, especially on the clinical side, where this idea that pain is complex and that pain is as much an emotion as much as physical sensation is not really something we are trained to do. We are really trained to treat it as a purely physical sensation that you can rate on a scale of zero to 10 with specific tools. But if you read the scientific literature, if you go and if you look at how, for example, the ISP which is the large organization that brings together all these pain experts, the way that they define pain is something that’s very different from how I’ve been trained in both medical school and residency to think about it.

Haider: Pain is as much a physical sensation as much as it is an emotion that is shaped by context, by memory, by attention, by all sorts of factors. Nociception is, for people who did not have to struggle through medical school like any of us did, is essentially the generation of these nerve signals in the skin and in the periphery of our body in response to an uncomfortable sensation. Let’s say it’s a sharp pin or needle in your shoulder that will send nociceptive signals up your nerves, up your spine to your brain. But nociception itself is subconscious unconscious experience. It’s when it comes to consciousness that it transforms into pain, and that transformation happens in the brain. And it is as much an emotion that one feels as it is a physical sensation. And in fact, if you think about what are other brain processes that are very, very similar to the experience of pain, the one that’s actually very close to it is actually memory. And there’s a lot of overlap between memories, especially traumatic memories and the experience of pain.

Haider: And then suffering is what I would call the interpretation of pain. It is our interpretation of what we think that pain means. Obviously, that interpretation does not have to be proceeded by a physical injury, but often it is. One of the definitions I liked a lot was the late Eric Cassell’s definition-

Eric: And you actually interviewed Eric, right?

Haider: That was a great story. So Eric Cassell, for folks who don’t know, was a primary care physician. But really was a seminal pioneering figure in the field of bioethics, palliative care, et cetera. And he had had written this definition of suffering, which I was really drawn to. It was essentially anything that threatens the intactness of the person. And it could be a physical thing, or it could be something that is different. And I was Googling Eric and I found this almost like a yellow page ad that has this landline number. I was in the middle of work and I just called. I picked up the phone, called him basically to introduce myself. And to my great surprise, he picks up the phone, starts talking at million miles a second, classic New Yorker. And before I knew it, I was typing away and he just shared his entire story. So generous.

Haider: And then by the time that I was finishing up the book, wrapping the up the book, I wanted to follow up with the folks that I’d interviewed. And that’s when I actually learned that Eric had actually passed away only a few weeks after we spoke. And so that put even more responsibility on me because now I had the words of this great mind and all the things that he had learned. And in some ways I have this special responsibility in part, along with others, to pass those teachings along to a new generation who may never get to talk to him in the middle of a day on a landline. But I certainly did. And so that’s how-

Eric: Encourage all of our readers too. We’ll have a link to it. But Eric Cassell’s The Nature of Suffering, New England Journal is an amazing piece to read as well. And also seems like, even part of that is that you can have nociception without pain. You can have pain without suffering.

Haider: There’s a Venn diagram that’s on the internet and that help me think about these things. But think about nociception without pain. A good example, for example, is when you were under anesthesia, you still have all those nociceptive signals coming in, but you never have that conscious transformation because of anesthesia. Another example-

Eric: Or your five year old trips and falls, they start bleeding, they’re doing fine until like, “Oh my God, like there’s blood there.” And then they start crying and howling in pain.

Haider: Exactly, exactly. Or even more fascinating was there was a study done in Second World War in which they found that about 50% of soldiers who came in with these horrific injuries actually had no pain at all. Presumably, because their brains were so occupied with the fact that they were in the midst of this battle that they couldn’t even-

Alex: Trauma.

Haider: Yeah. That they couldn’t even enact this transformation. And certainly, if you look at pain without nociception, another example for that is perhaps phantom limb pain in which after a long time, you don’t need signals from downstairs to generate that experience of pain, all you need is in fact that memory, which is why people who’ve had any type of traumatic amputation are much more likely to have phantom limb pain than people who, for example, did not have a traumatic amputation or were born without legs or arms to begin with. And then suffering, as we know, oftentimes can be followed by a pain, but can exist on its own quite effectively.

Alex: And you I love that you delve deep into suffering. And I wonder, you note here that in your native language, in Urdu, the word for journey is a hominem of the word for suffer.

Haider: Yeah, so I grew up hearing the word suffer all the time and it meant that we were going from one place to another. And surely it’s a coincidence that they mean the same. But I think for a lot of people, especially for me, suffering is not a destination that you are moving away from or towards. It is really in that journey. And I found that to be quite… It’s always been how I’ve thought about suffering in part is because to see it as moving from one place to another, rather than somewhere we are reaching.

Alex: I also appreciate the multifaceted view you have on pain in the way it teaches us, in the way it teaches our children not to touch a hot stove, in the way pain has been used for good or for ill by religion as way of interpreting a spiritual experience, and the richness within which we have experienced and viewed pain over time. And the way that’s shifted dramatically over time.

Haider: To me, if I can achieve that with this book, it will be the ultimate goal is to actually accept that pain is very complex. That pain is not just something that’s extremely simple that we can easily fix with specific tools. Sometimes it is that simple. But often oftentimes than not, it is something that is very, very complex. Every time you experience pain, it is informed by so many different things. One example is if you have that sharp feeling in your shoulder, maybe it’s you are getting a flu shot, but it could be something else. Maybe you’re in a dark alley and then you feel something sharp, your reaction is going to be very different. Let’s say you’ve had a prior history of trauma or abuse and how you react to pain is going to be very different. Or if you’ve had a history or have lived with racial discrimination or gender or sex based discrimination, how you’re going to perceive that pain, how you’re going to ask for help, how you’re going to get folks to pay attention to that pain is going to be different than someone who hasn’t had those experiences.

Haider: So I think in some ways medicine wanted to simplify pain because our tools were very simple. And I think that that simplification, certainly it can help, sometimes in the acute setting for sure it can help. But I think that especially when it comes to chronic pain, one of the coolest studies that I read about and I interviewed the person who did it as well, was this idea that we’ve talked about how pain is as much a physical sensation as an emotion. And that is not to undermine it or de-legitimize it. But that is really the nature of this experience. And that over time, if you look at people who have this transformation of acute into chronic pain, the transformation is not linked to the severity of your initial illness or your severe initial injury. It is not linked to any imaging abnormality. So for me, my origin story was I had this MRI, and that was a reason why I could tell people I have pain because I didn’t have any scars, I didn’t have any surgical incisions, or I didn’t have a bone sticking out of my back. So that to me was what I could give someone if they doubted why this otherwise healthy looking young person is in so much pain.

Haider: And yet, when I was researching for the book, MRI abnormalities, spinal abnormalities, like prolapses, degenerative genes, etcetera, I have no correlation with who has pain. In fact, a large number of people who are completely asymptomatic, young people even, have these changes on their spine on their MRIs and they’re walking around perfectly fine without pain. And so there’s so much that I think I appreciated more about pain. I felt like going into this, I knew about this topic quite well having lived with it and having researched it. But it really blew my mind just how much really eyeopening research is out there that just needs to be connected together.

Eric: Another thing you said in your book is that pain is a social emotion, one that needs to be performed to be recognized. Can you tell me a little bit more about that? I think you were alluding to that a little bit already.

Haider: I go back to the story you just shared about the child who falls but then waits until they’re seen and then they express it because it’s a cry for help. I think we’ve had this idea that pain is somehow something that cannot be communicated in language, that it’s something that is so personal, so essential that, there’s just no way that anyone of us can feel anyone else’s pain. But whatever I’ve seen and whatever I’ve research actually suggests something that might be quite the opposite. In fact, one of the chief functions of pain is communication. One of the chief reasons why we have these pain behaviors, like let’s say you get hurt, you might limp. Let’s say you get stuck in a trap and you might scream, is to inform other people that there might be a threat or to inform other people that you may not be able to do a certain task because you are hurt. At the same time, those pain behaviors can become detrimental. They can be a sign of vulnerability, which is why some people may not want to show their pain in certain scenarios.

Haider: And because it is so subjective and because we have these arbitrary rules around what the right patient with pain looks like, I think we really trap patients in a really difficult situation. One of the patients I spoke to really said this quite well. She was a college dean and had had this really horrific injury when she was a young girl, had had multiple surgeries. So really essentially lived with chronic pain. But she was also a very proud person and didn’t want to walk with a cane. And so sometimes when she would park in like a handicap spot, she said that people would make fun of her saying, “She looks totally fine. Why are they disabled?” Because again, that person was not acting the part of what we would expect someone to be in pain. If you have someone and they tell you that they’re in extreme pain, you would want them to be grimacing, you’d want them to be withdrawing or having some of these behaviors that are intuitive to us as behaviors of pain.

Haider: On the other hand, if you have someone who’s sitting very, very comfortably eating a meal and you ask them they’re in pain and they say that they’re in 10 out 10 pain, well, now you might feel the other, “Well, is this person exaggerating their pain?” So patients have to, and those were her words, have to really perform in a way that fits essentially the rules that we lay down in medicine about what the patient in pain does and should look like. And I think that that’s one of the reasons why I think pain is so susceptible to our biases. Because unless you have a condition, we talked at the top of the hour, I’m a cardiologist, one of the beauties of being a cardiologist is that we have these blood tests called troponins. So if you do have someone coming in with chest pain and the troponin is normal, for the most part, we can assure them that even though this pain is awful and you feel bad, but we have ruled out anything that’s threatening your very existence.

Haider: But for most people in pain, they don’t have that luxury. Most physicians don’t have that luxury. Which is why so many times when we are seeing the patient, we may revert to some of our deepest biases that we see around us in society, but obviously we’re all parts of that society as well. Which is why I think issues around inequity, justice are so linked to the appreciation of pain as well.

Eric: I guess another question too is… Because we talked about attention to pain, and I thought it was fabulous. Because in your book you talked about as you started writing your book and you got into it, you started paying attention to your own body’s pain. And attention to pain builds pain. And I wonder as you think about that and as you think about pain being a vital sign, every shift in the hospital people are asking if they’re having pain, we’re going in there asking people, “Are you hurting? Do you have pain anywhere?” How much is that also part of the problem that our system is in right now?

Haider: The fuel for pain is attention. Without attention, pain cannot exist. And but pain is evolutionary designed to take up all your attention. Because pain was designed to sort of alert us to when we fell from a branch or our legs are in the mouth of a saber-toothed tiger and we need to run for our life. It was meant to just halt every mental process going on and completely and entirely focus our attentions on that.

Eric: Acute process. “Hello, we got to do something about this.” And then it goes away.

Haider: And you have or you’re going to die.

Eric: Or you’re eaten by the saber-tooth.

Haider: Exactly. But then what happens when you have… And that is exactly what you’d want to do, if I have someone who has chest… We have so many people who have chest pain who don’t show up to the hospital. What becomes a problem is when the pain becomes chronic, when the pain becomes chronic and the pain is not signaling any type of bodily threat in that moment. So when I had that initial injury, I couldn’t do anything. I couldn’t stand, I couldn’t sit, I couldn’t lie down. I really couldn’t do anything. And I didn’t even know my back did all these things until I was in all this distress.

Haider: And when I first went to the physical therapist, it was one of the most awful 30 minutes of my life because this person was making me do all these exercises. And I thought I would snap my spine in half. Would I be able to walk? Is this making it worse? I had all these visual imagery in my head, which was just being fueled by everything that I was experiencing. And if you look at many of the most effective therapies for pain essentially what they do is they take your attention away from the pain and focus on other things. But that is, I think, the real struggle with pain, especially in chronic pain is that our brain responds to pain the same way. Our brain doesn’t change its behavior unless we work on it, unless we are trained to do it. And there are therapies that are working on changing that reaction that we have to pain as a way of blunting the edge of pain, especially in the chronic setting, especially when you know that there’s no new acute process that has occurred.

Eric: And how important is it? In medicine, we love to categorize things, right? So you have nociceptive, neuropathic, visceral pain, you have acute versus chronic. Some people say you have cancer pain, and non-cancer pain. You have physical pain or the pain’s all in your head. How important are those categorizations?

Haider: I think they’re extremely important. I think defining pain as in identifying what exactly is the nature of the pain, not only may you may change what type of therapy that you get benefit from, but it might alert you to a diagnosis that may have been missed in the past. Having said that, because our treatment options are still so blunt, sometimes it just doesn’t matter. How many people do you see every day who are on Gabapentin or pregabalin and for all sorts of just random aches and pains that have really no indication, it’s never been tested. And that’s just one example of how, especially when you’re on the clinical side, talking about it as a science and talking about it to scientist pain is very, very clean. You can have all these sort ideas about nociception pain suffering, but when you see patients in the hospital, it’s never one thing. It’s always a combination of all of those things, and everyone is different in slight ways.

Haider: So I do think that phenotyping pain in different ways is really, really important. And then tailoring your therapy accordingly is also important and something that we’re just not doing. And if you just think about how are we assessing pain, it’s still on that zero to 10 scale or that sad face, happy face, which is my favorite, scale. We have better tools to better phenotype pain. We have better tools to understand how everyone might experience pain differently. And yet, if you look at our clinical approach to pain, it still remains quite basic.

Eric: I also threw that all in your head statement in there. Is pain all in your head, Haider?

Haider: Well, technically pain is in fact all in your head because unless the pain reaches your head, it actually is something that you never experience. You can have all the nociceptive signals you want, and yet it is not until it reaches your brain, specifically until it crosses the thalamus and it reaches your limbic system and your cortex that it actually transforms into pain. So pain is a experience that’s generated entirely in your head. And yet this phrase has been weaponized. This phrase has been weaponized to tell people that their pain doesn’t matter, that their pain is imaginary, that their pain is something that is their fault because they have somehow contributed to it as well. And part of what I think I would like to do is to actually reclaim that phrase. I think it’s okay to say that pain is all in your head because it really is. But that doesn’t mean in any way that we are de-legitimizing pain or that we are saying that this pain is not to be taken seriously.

Haider: In fact, I think one of the things that allows us to do, and one of the things that I’m a big proponent for, is that many patients with pain, especially patients with chronic pain can really, really benefit from specific cognitive mental health therapies that have been designed to help those people in pain. And yet very, very few patients are actually using those services. Very, very few centers are providing those services. Again, because of the stigma attached to this phrase. Because I think patients rightfully believe that if they say that, “Can I see a therapist to help me deal better with this pain?” That the physician might feel like, “Oh, this is just a psychiatric issue. This is something that I don’t need to deal with because it is all in their head.” Which is why I think this phrase has become so problematic.

Eric: And I’ve seen plenty of patients who don’t want to see a psychologist because, “Wait, are you trying to tell me my pain isn’t real?”

Haider: We have created this. And those patients, they’re doing something that’s smart because they know that as long as they have a physical sensation that their pain is going to be attended to with more resources and with more attention and with more care than if they say that there might be an emotional component to this pain that is either contributing to it or making it worse or not allowing them to live their life with this pain. We’ve seen the stigma associated with mental health. That’s getting better now, but it is still there. But we all know that our health system, the way that it treats symptoms that it can see, that it can diagnose, that it can get a lab test for, an imaging test for the services that we can provide that person is just so much different than the services we provide someone who doesn’t check any of those boxes.

Haider: And so the patient is never going to say that. They’re going to be rightfully reticent to feel that way. A, because of this general cultural idea that we’ve created that somehow if something is psychosomatic, that it represents some type of failure of character or that someone is contributing to their own suffering or that it is in their control and they can eliminate it just by not thinking about it. But I think that approach, A, it doesn’t represent the sensation that people experience, but also it restricts access and it restricts acceptance for therapies that might work, which are even more important given where we are with regards to how bad we treat pain.

Eric: And when we think about chronic pain, what do you think, if you had to come up in your research, where we are far as the best evidence for managing chronic pain, what are those therapies?

Haider: Yeah. To me, I think to start, the first thing that I’ve learned about pain as far as treatment of pain is concerned is that there’s no magic bullet for pain. There might be something for some specific patient, but in general, there’s no one thing that-

Eric: It’s not Gabapentin?

Haider: It’s not. It’s actually pregabalin. No. Talk to my sales representative. But if you look at how the specialty of pain medicine started, it started with this guy who is really truly one of the heroes of medicine. His name is John Bonica. He was born in Sicily, moved here as a young boy. Trained as an anesthesiologist, and then really was exposed to these horrific injuries that people are suffering while he was up on the West Coast, in the Northwest. And then really wrote the first textbook of pain and started what’s the first pain center in the world. And that really, to me, still remains the gold standard of pain. And that center was essentially based on interdisciplinary pain management, which meant that if you are a person in pain and you go to the center, that you are evaluated by multiple different specialists who have different expertise, and who think about what might be the best approach to you. It’s a tailored approach rather than a cookie cutter approach that we’ve adopted. And someone might say, “Well, that’s not feasible.” And the argument is actually, that’s not true at all.

Haider: In fact, one of the organizations that has really become, in some ways, a gold standard for pain treatment in the United States is actually the VA health system, which I’m proud to be a part of. And the VA has become really the center of excellence for interdisciplinary pain management. The VA offers its veterans more options and services for pain than really any private health system does. And it includes prescription opiates, it includes surgeries and interventional procedures. But it is so much more than that. So just to think about some of the other things that I think that we are under using and are making it very hard for patients to get, one of the ways… And in fact, I would say that the real reason why my pain got better was because of physical therapy. I was in the physical therapy suite for hours and hours.

Haider: But the reason I was able to do that was because I was a medical student and I knew all the therapists and they would just say, “Okay, you can just show up. If you see an empty room, just do your thing. Here’s the equipment you need.” And they would all work with me. And it was not just the exercises, but also this caring environment that they created for me. That I think because of that, and because of just a lot of hard work and because so many of my attendings said, “Okay, you don’t have to stand in the OR for five hours. You can leave early.” That over time, I did in fact get better. But getting physical therapy can be very, very hard. Oftentimes it can be associated with additional copays. And somehow we’ve created a system in which it’s easier to get your third or fourth back surgery than it is to get the physical therapy that you might need to get better. The other thing that is, I think, extremely effective and the evidence is really strong, is essentially cognitive therapies of different sort that focus on folks with chronic pain and helps them really cope with pain better, but also changes the goal that they have.

Haider: So as you mentioned, pain is so attention grabbing and it wants you to eliminate it at all costs. If you are in pain, you want to do everything you can to get rid of the pain as soon as you can, no matter what. And the more severe the pain, the more strong that urge. And one of the forms of therapy that is very, very effective for people in chronic pain is something called acceptance and commitment therapy. And this doesn’t mean that you should just accept the pain. It doesn’t mean that you should just be resigned to the fact you’re in pain. But the goal of acceptance therapy is to change your focus away from controlling the pain at all times, to living your life as well as you can despite the pain. Not to limit your life and the things you do because you hurt as bad as it feels.

Haider: Because one of the things that pain does is that as soon as you hurt, pain creates this cage and the cage gets smaller and smaller. The things you can do gets fewer and fewer. Your social contacts and acquaintances and friends start to dwindle because you’re not able to go to that dinner. You’re not able to go to that party. You’re not that fun anymore because you’re in pain. And what acceptance does is that it tells you that, “No, you should go to the party even if it hurts. You should go to that dinner even if you’re in pain, even if you’re not having the best time. Because you need to focus on your life.” Because the more we try to control pain, the more attention we give it, the more stronger it grows.

Haider: And then one form of therapy that is very, very exciting to me is something called pain reprocessing therapy, which was the subject of a randomized trial in JAMA Psychiatry just a few months ago. And this form of therapy, this was tested in people with chronic back pain, changes how we think about that pain, especially in the chronic setting when we’ve ruled out any type of bodily threatening process, as something that is not threatening your body, but is something that is essentially a false alarm in some way. And what this trial found was that they could get more than 50% of their patients pain free at one year. But if you looked at the usual care arm, that number was only about 16%. So I think those are the sort of things that we need to think about. Again, this doesn’t mean that some people may not benefit from procedures, some people may not benefit from opioids. I think there are those people. But I think increasingly we need to embrace the complexity of pain and make sure that we can get patients all the options that have been tested.

Eric: Where do or does the opioids fit into all of this? Because this is the hard thing, right? You give opioids to somebody in chronic pain who’s never been on opioids before, they’ll often feel relief. They’ll be, “Oh my God. My pain is so much better.” You give it to somebody with acute pain, “Oh my God, my pain is so much better.” Where does it fit?

Haider: I mean, this is really the challenge of this generation is what do we do with opioids? One of the things that we know about opioids is yes, they’re very effective for acute pain. They’re probably some of the best things we have for people in acute pain. And yet, it’s in really in the chronic setting that they become quite problematic. And one of the things that they do is, and the best evidence for that is again from the VA, this is the space trial that was published in JAMA, which showed that in people with moderate to severe back or joint pain, people who were given opioids versus people who were given other painkillers such as NSAIDs or ibuprofen, the people who had got opioids had greater pain intensity at a year than those who are getting these other things. So even though opioids can be great in the acute setting, and yes, is there anything more gratifying than giving an opioid to a patient who’s in pain right now? As a physician, there’s very few things that we have of that nature.

Haider: And yet, not only do they carry well known risks that we all know about, but the fact that they actually might not be effective in the long run is really, to me, the most problematic aspect of opioids as well. The other thing that opioids do is that they essentially flatten this inner universe of endogenous opioids that we all have. So everyday emotions, our everyday lives are dependent and our everyday sense of normalcy is dependent on this rich network or rich system of endogenous opioids that our body produces itself. These are the things that give you joy when you have a great meal or you hug your daughter after you come back from work or make sure that the everyday knocks that you get, maybe from sitting in a chair for too long, or maybe staying up on your feet too long, that they all go away because your body’s always supporting these endogenous opioids to not just keep you pain free to a fairly great extent, but also to keep you happy, to give you the sense of social connectedness, which they’re really essential to.

Haider: But when your body sees an exogenous opioid, so an opioid pill or an opioid injection, the dose of that is just so much greater than anything that your body can ever produce, that the only way you get to feel even normal is to go back to it. And again, I think that’s really why there’s so much comorbid anxiety, depression with these as well is because, again, it’s hard to tease out, but there’s very clear evidence that these do increase the rates of comorbid disorders as well. Primarily because they take away your ability to feel those things. Do I think that no one should get opioids? No, that’s not what I think as well. But we really, really need to take a hard look at how often we’re prescribing opioids. If you think about this one study that showed that American dentists are about 36 times more likely to prescribe opioids to their patients than British dentists. And yet, the patients who were prescribed opioids also had worse patient satisfaction. So they’re less satisfied with their treatment as well.

Haider: To me, what I go back to is that the initial decision to start an opioid on a patient is probably one of the most important decisions any physician will make. And the reason is that once you’re on an opioid and you become dependent on an opioid, the patients and their clinicians are really stuck. And there’s this recent study, this is a study of Medicaid patients in Oregon, which basically showed that if you have patients were on long term opioids and you acutely or abruptly withdraw the dose, then the risk of suicide in those patients goes up. And certainly we have seen that during the pandemic, and even before where people who were abruptly taken off of opioids for one reason or another went and got illicit fentanyl from the streets or got some other opioid thinking it’s going to be something else, but was laced with fentanyl. And then that’s one of the reasons why the death rate from opioids has skyrocketed in last few years.

Haider: But in that same study, what they found was that if you kept the dose the same or increased the dose, then the rate of overdoses increases as well. Which to me means that once you are on that ramp, you don’t have a lot of great options. What I do think is that if we do reduce the dose of opioids, which I still think that it should be the goal if it’s possible, it has to be done in a shared way. It can’t just be a dictate coming from the physician saying that, “Oh, you’ve broken the rule. Or you’ve done this, or you’ve done that. Or you’re not acting the way I think you should be acting.” And abruptly cut off patients, because I think that can be, and can demonstratively be, quite difficult. I think the key is that we have to get patients and ourselves on the same page. This is a tough situation. It puts patients at risk. And I’ve seen that once you have that relationship, once you have that trusting relationship, many patients might be open to it. But if it just feels like something that your patients are being forced to do, I think that is dangerous.

Alex: Yeah. All right, last question from me. I love that you get into Ivan Ilyich, the Leo Tolstoy story about Ivan Ilyich.

Eric: Alex, you wrote a paper about Ivan Ilyich.

Alex: Wrote a paper about that in The Lancet with Guy Micco and Patrice Villars about what would happen to this story of Ivan Ilyich today if he were in hospice. Ivan Ilyich’s character was a jerk. He was an asshole. He was mean. And then he had this horrible, painful condition that resulted in his death. And as he was dying, he refused pain medication. And he had this epiphany, this redemptive moment, he realized he’d been a jerk. He apologized to his man servant, and then he died. And what might happen to him today? Maybe he would be snowed on opioids and never-

Haider: Well, first he would never die without a diagnosis. Because you’re not allowed to have that. He would get pan scanned from the tip of his head to his toes. They’re find something, right?

Alex: Yes, they’d find something.

Alex: The second Ivan Illich, who wrote this polemic Medical Nemesis, Bob Arnold recommended I read that years ago. It is a polemic, but boy does it take to task the industrialization and profiteering by so many aspects of our culture, particularly medicine, particularly pain. And you right here, your prose is outstanding, “Modern medicine has crafted a philosophy supplanting millennia of cultural norms and position pain as a purely physical sensation that only medical interventions can alleviate.” And we don’t have a lot of time, we’re running out of time, we’re in our last couple minutes here. But thoughts on that bigger picture of forces that are outside of the physicians’ control one on one in the office or at the bedside with the patient that are just sort of dictating the direction of an interpretation of pain in our culture?

Haider: I mean ever since I’ve written this book, my inbox, especially on LinkedIn, is inundated by people who have these products that they assure me is the next cure for pain, but they have to do all these pesky clinical trials and is there any way to get them approved without doing the clinical trials and whatnot? And especially with opioids, I think that now that people are realizing that opioids are not very, very safe and they have risks and they might not be very effective, that’s opened the door even more because now people can pitch that, oh, this is going to be-

Eric: Ketamine for everyone.

Haider: Ketamine for everyone. Exactly. And I’m getting ads on my Facebook for ketamine. So I think in medicine, we have to make sure that we don’t repeat the same mistakes we made again. We all want to treat people in pain. It’s one of the best parts of being a physician is being able to relieve pain. But at the same time, we cannot do this again. We’ve already been through this way too many times and exposed patients to therapies that are just not effective or harmful. And that’s going to be tough.

Eric: Or also just finding that balance. There’s no magic bullet here. And it does require a team. It requires a thoughtful approach. Thinking about when you should use certain agents. We made fun of ketamine, but there’s a place for that. There’s a place for opioids. There’s a place for hypnosis, which we didn’t even go into. There’s a place for all of these things. And that’s why I really loved reading your book. And I want to thank you for coming on. But maybe before we end, we can hear a little bit more of Comfortably Numb. See how many minutes Alex takes us through the guitar solo.

Alex: (singing)

Eric: I’m trying to think back to college. I remember I think that song’s like seven minutes long on the album. So, Alex, thank you.

Alex: The guitar solo is five minutes of that.

Haider: Eric, it’s only three minutes, but the ketamine makes it feel like it was seven minutes. [laughter]

Alex: That’s right.

Eric: As you disassociate, Haider, I want to really thank you for being on this podcast. It was really lovely to have you on. And I really appreciate your book. The book is called Song of our Scars. And I will have a link to it on our show notes for this podcast. Thank you, Haider.

Haider: Thank you, everyone.

Eric: And as always, thank you, Archstone Foundation for your continued support and to all of our listeners.