of the patient… Being asked immediately afterward whether he had suffered much, he said that he had felt as if his neck had been scratched; but subsequently, when inquired of by me, his statement was, that he did not experience pain at the time….
Surgical anesthesia led directly to improved medical care. Now surgeons could focus on the complex operation at hand, taking the much-needed time to perform their work correctly.
Over the years, refinements brought surgical anesthesia to even higher levels. When I began my anesthesiology residency training in 2001, I marveled at the power of surgical anesthesia to quickly and completely shield a patient from the pain of surgery and then to bring them back to full consciousness with no apparent ill effects. The interesting thing is that we still don’t really know how anesthesia works to accomplish this, despite its universal use.
A surgeon, frustrated that few of his procedures went exactly as he had planned, turned to me in the operating room.
“Anesthesia is like magic,” he said. “It always works!”
Anesthesia forever changed society’s attitude on pain and suffering. It also gave surgeons the confidence that they could now tackle many previously inoperable conditions.
Regional, as opposed to general, anesthesia makes one part of the body numb while the patient is still awake. It gives expectant mothers the option of experiencing little to no pain during childbirth. During my residency, I spent some time on the obstetrics ward. It was immensely gratifying to find a woman in agony from painful contractions and, with the insertion of an epidural, offer her immediate and almost complete relief from that pain. It was like a switch was flipped. Thanks to the invention of regional anesthesia techniques, childbirth pain can be seen as something that may simply be avoided as opposed to something intrinsic to the experience of motherhood.
Both general and regional anesthesia represent tremendous medical advances. Pain management has been a key function of all physicians but, in retrospect, it seems only natural that anesthesiologists would gravitate toward it. After all, the anesthesiologist’s expertise lies in managing pain before, during, and after surgery. Why not adapt these powerful techniques for patients suffering with pain outside of the operating room?
That said, when I actually worked at a chronic pain clinic, I became acutely aware of how unsuccessful we were as a specialty field at helping so many sufferers.
If you’re reading this book, you probably know that chronic pain is an enormous problem, but you may not realize quite how enormous. Once you account for indirect costs like lost workdays, we spend $635 billion a year on chronic pain in the United States alone. Health care represents about 18 percent of our GDP, or about $3 trillion a year. Hard as it is to believe, chronic pain represents the equivalent of one out of every five dollars spent on the entire U.S. health care system per year.
I knew we had long ago found effective ways to manage surgical pain. I also knew chronic pain was a colossal source of suffering and a tremendous economic burden. So why, I wondered, hadn’t we figured out how to translate all of our scientific understanding of surgical pain into advancing the treatment of chronic, and sometimes even acute, pain?
Teeming with enthusiasm to seek better therapies for pain, I pursued pain management as a subspecialty. I wanted to make an impact where one was so desperately needed. After all, what greater contribution could a healer make than to conquer pain and suffering? All doctors manage their patients’ pain in some way, whether after surgical procedure or an ankle sprain, but this was a chance to really fix pain for good. How could I resist?
So I packed my bags and set off to do a fellowship at Brigham and Women’s Hospital in Boston. I didn’t need to pack much, as it was just across town from where I finished my residency, Massachusetts General Hospital, but the institutional cultures couldn’t have been more different.
As I began my career in pain management, I wanted nothing more than to ease the suffering of my patients, and I became more and more frustrated as I realized that I could not do this in every instance. As an anesthesiologist, I could elegantly render patients unconscious so that surgeons could carefully remove a tumor or repair a torn ligament. I could rest assured that as long as I did my job properly, my patients were comfortable.
As a practicing pain specialist, I could only seek to reduce pain to a certain extent; my patients still had to function in the world. But couldn’t we just isolate pain? Couldn’t we remove pain entirely from our sensory experience while keeping the rest of the body awake and mindful of the environment?
The Tragedy of Life without Pain
Shortly after becoming a pain specialist, I learned of a rare condition that renders a person completely unable to experience pain. Patients with congenital insensitivity to pain (CIP) are normal in every way except for their inability to feel pain, but their syndrome has a severe impact on their lives. The following case appeared in the Journal of Orthopedic Surgery:
In March 2010, a 7-month-old boy presented with a 4-day history of increasing swelling of the elbow, pseudo-paralysis of the right upper limb, and high fever. The child appeared to be toxic. The sensation of pain was less than expected. Multiple ulcers were noted over both hands and feet and tongue. Pain perception appeared to be completely absent, which the parents stated had been present since birth. The parents also stated the child frequently had self-inflicted wounds over the hands, feet, and tongue. Injections into the skin to test for a response produced no pain. The right elbow was found to be infected, and the patient was taken to the operating room where about 20 ml of infected pus was drained, and complete separation and dislocation of the joint were seen. The child was placed on antibiotics for four weeks. Unfortunately, the damage and erosion to the joint were so severe, the joint was permanently damaged and showed evidence of chronic lingering infection of the bone, called osteomyelitis.
This child suffered from CIP, a genetic disease occurring in roughly 1 out of every 25,000 people. Children afflicted with it have a short life expectancy because, without pain, they have little to no ability to avoid trauma from accidents. Without the ability to use pain as a protective reflex, they can’t reliably avoid the harmful things in their environment. In short, these individuals have no ability to adapt to their environment. Parents of children with CIP cannot trust that a child will cry to indicate that something is wrong and this makes it difficult for them to remedy injuries or illness.
As I learned more about the impact of CIP and other conditions that affect our sensitivity to pain, I began to realize that pain provides a critical survival advantage. When we’re caught in its grasp, it can be incredibly difficult to see it in this positive light, but my experience has shown me that pain is actually one of our greatest allies.
I have tried using the metaphor of gravity to help people put pain into perspective. Gravity, like pain, is simply a part of life. It’s not going anywhere. Like pain, gravity can shape, challenge, and direct you.
While most people don’t think very much about the earth’s gravitational force, it affects everything on the planet. For example, it works against a child learning to ride a bike, who must fight to stay balanced or risk scraping a knee. It can be fun to imagine all the things that might be possible if gravity weren’t as strong: effortlessly slam-dunking basketballs, gracefully floating through the air. In reality, a gravity-free world would be quite harmful. Without the constant pull of gravity on their bodies, astronauts’ muscles and bones atrophy despite the rigorous exercise routines they maintain in orbit. In fact, months in space with little to no gravity result in bones becoming brittle and osteoporotic.
Like gravity, pain helps us. Even though pain is certainly an unpleasant feeling that we have to experience, it would
