Chapter 4
The Pharmacological Pursuit of Relief
Pain medicine sits uncomfortably among anesthesiology subspecialties. Most anesthesiologists don't understand our choice to work with distressed patients in clinic settings rather than operating rooms. Unlike our operating room colleagues, we run outpatient practices, requiring different skills-active listening, managing emotional distress, empathy, conflict management, and collaboration with other healthcare professionals.
Many doctors mistakenly see pain merely as a symptom rather than an experience worthy of focus itself. Pain involves unpleasant sensations interpreted by multiple brain areas responsible for both sensation and emotion. This is why the pain of a broken heart can be as distressing as a broken leg. How we think about pain influences our approach to alleviating it.
As medical science advances, we perform increasingly complex surgeries that require patients to cooperate psychologically with physical trauma. Since most people can't hypnotize themselves through surgical procedures, we use medications to enable these interventions. Anesthetics make patients unaware of what's happening, local anesthetics block sensations from reaching the brain, and opiates affect how sensations are interpreted-they make you care less about pain signals, earning the nickname "perfect whatever" medications.
When treating pain, we target different processes: where tissue is damaged (transduction), the network sending signals (transmission), the brain itself (perception), and pathways that inhibit pain nerves (modulation). Beyond drugs, psychological techniques can help manage pain. "Knee schools" prepare patients for knee replacement surgery by teaching that post-surgical pain is normal and doesn't indicate failure. This "normalization" of abnormal sensations facilitates rehabilitation through changed perception and managed expectations rather than pharmacological intervention.
No current medication completely abolishes pain except temporary local anesthetics, which block all electrical signal transmission. These aren't suitable for long-term use due to infection risks with prolonged infusion devices. Other pain medications don't stop all signals to the brain, and whatever information gets through is interpreted according to the individual's unique expectations, beliefs, mood, and previous experiences. Managing patients' expectations about pain relief is therefore crucial in both perioperative settings and chronic pain management.
Drugs for complex persistent pain aim to modify the dysfunctional alarm system without overwhelming patients. Antidepressants like amitriptyline work by enhancing descending inhibitory pathways that require serotonin and noradrenaline. However, these medications only help about one in seven patients and cause harm in one in fourteen, providing just 30-50% pain relief.
Antiepileptic medications like gabapentin and pregabalin target calcium channels to inhibit excitatory neurotransmitter release, taming hyperexcitable nerves. Despite poor efficacy (helping only one in seven patients), these drugs are now prescribed ubiquitously for all forms of chronic pain, causing side effects like confusion, sleepiness, and falls.
The medical-industrial complex promotes pharmacological solutions despite our limited understanding of pain mechanisms. Doctors often prescribe medications out of desperation-to manage their own distress rather than because evidence supports effectiveness. Many patients don't realize these medications take six weeks to reach maximum efficacy and complete pain relief is rarely the outcome.
Chapter 5
The Opioid Dilemma: When Treatment Becomes the Problem
The explosion in opioid formulations (lollipops, sprays, patches) has created new addiction pathways through rapid absorption methods. For chronic abdominal pain patients, the temporary escape opioids provide makes them resistant to reduction efforts, leading to difficult confrontations between pain specialists and patients.
Our poor understanding of nerve dysfunction in pain without injury leaves drug companies without precise targets. The opioid crisis emerged from our desire to alleviate suffering combined with medical hubris-believing we could manage pain pharmacologically while ignoring its biopsychosocial nature.
We're repeating this mistake with cannabis, rushing ahead without adequate clinical trials. Most of the twelve randomized controlled trials in the past five years indicate cannabinoids are ineffective for neuropathic pain, yet we risk replacing one mind-altering substance with another because we can't accept that health requires more than packaged pharmaceuticals.
Historically, opium has been used more for its tranquilizing and behavior-modifying effects than for pain relief. Opioid deaths, termed "deaths of despair," reflect deeper societal issues and our complex relationship with pain. These substances narrow our perception, reducing anxiety and despair when life overwhelms us.
The opioid saga is a cautionary tale of how therapies with little supporting evidence and centuries of documented harm can be promoted. History repeats itself from the 1914 Harrison Narcotics Tax Act to today's epidemic. As US opium commissioner Dr. Hamilton Wright noted in 1911, America has long consumed more habit-forming drugs per capita than other nations with fewer safeguards.
Pain treatment swings between extremes while prescribers rarely take the drugs they recommend, and patients receive insufficient information about risks. We prefer prescribing pills to investing in psychological therapies or physiotherapy.
Pain clinics now focus on helping patients reduce opioid use, facing difficult conversations about medications that lack evidence bases. The proper role for opioids in chronic pain remains unstudied, though we know they work for acute postoperative pain with careful monitoring.
Modern medicine's hubris-believing our technological advancement means we have all the answers-blinds us to healthcare's complexities. Poor lifestyles cannot be medicated, and wellness cannot be prescribed. Without patients challenging doctors and engaging in treatment decisions, we may eventually swing back to ubiquitous opioid prescribing-or perhaps cannabis will become "the new morphine."
Chapter 6
When Pain Persists Without Injury
Pain typically fades gradually after healing, becoming "an itch at the edge of your perception" before disappearing entirely. However, sometimes pain persists despite tissue healing, challenging the common perception of pain as merely a symptom of injury.
Helen, a 48-year-old operating-room nurse, presented with widespread pain throughout her body-a deep ache worsening throughout the day, affecting her legs and arms. She experienced constant fatigue, memory problems, unrefreshing sleep, and unexplained low mood episodes. As an OR nurse, she stood for hours during operations, managed heavy equipment, and balanced responsibilities as mother, grandmother, wife, and healthcare worker.
Helen suffered from fibromyalgia syndrome, a poorly understood condition involving widespread nervous system dysfunction. Patients experience diffuse, achy tenderness throughout all body quadrants. Environmental triggers include soft tissue injuries, prolonged psychological stress, certain infections, and war deployment. Genetic susceptibility combined with environmental factors leads to neurological and hormonal dysfunction, causing pain system excitability and disrupting sleep and mood regulation.
Complex Regional Pain Syndrome (CRPS) is another primary chronic pain condition that can develop spontaneously or following trauma like fractures or surgery. Dating back to Civil War physician Silas Weir Mitchell's observations, CRPS has been known by various names reflecting different theories about its cause.
The name itself reveals our limited understanding-"complex" acknowledges mystery, "regional" indicates its tendency to affect a limb, "pain" describes the disproportionate symptom despite healing, and "syndrome" admits we don't fully understand its origins.
CRPS manifests as an exaggerated, unregulated continuation of normal injury responses. Affected limbs may change temperature or color, develop tremors or movement inhibition, experience hair loss, skin changes, and nail growth abnormalities. Symptoms often begin dramatically and gradually reduce, though pain persists in 15% of sufferers.
Chronic pain is real, not imagined, resulting from malfunctioning nerves. Unlike acute pain where disability correlates with injury, chronic pain disability depends on personal resilience and management approach-similar to how diabetes outcomes vary based on self-management rather than access to treatment.
Three approaches exist for chronic pain management: obsessing over the "alarm," trying to ignore it (which consumes energy), or learning to live with the unpleasant situation. Unlike managing diabetes or hypertension, pain constantly demands attention "like a small dog yapping at your heels," affecting identity and preventing the accomplishment of memory-forming tasks.
The persistence of pain likely has biological foundations: enzyme differences affecting neurotransmitters like noradrenaline and serotonin; psychological factors causing physiological changes; genetic variations in pain receptors; and spinal cord changes increasing pain signals. The brain itself physically changes with chronic pain, reducing gray matter and forming new connections that heighten pain sensitivity-a bitter irony where pain creates more sensitivity to pain.
Catastrophizing thoughts activate brain areas that amplify pain pathways-like water carving wider channels in a riverbed. Behavioral changes contribute too: someone with Achilles tendon pain might stop walking, causing the tendon to thicken and become immobile. When they eventually try moving, they experience pain, reinforcing beliefs that something is wrong. Modern approaches encourage rehabilitation despite pain, assuring patients it's "safe pain," though not all doctors embrace this paradigm.
Chapter 7
Interventions: From Needles to Electricity
Modern interventional pain techniques fall into three categories: nerve destruction procedures, therapeutic injections of local anesthetics and steroids around joints or nerves, and electrical stimulation of the nervous system. These techniques naturally align with anesthesiologists' skills in nerve blocking.
Despite their widespread use, many interventional techniques are being decommissioned worldwide due to lack of evidence. Steroid injections, discovered in the 1920s and successfully used for rheumatoid arthritis after WWII, were applied to supposedly inflamed spinal areas without proper randomized trials. Between 1953-1993, most studies were retrospective and biased, with the first prospective studies showing mixed results-some showing benefits, others showing epidural steroid injections no more effective than placebo for lumbar disc herniation. Despite this weak evidence, the practice continues today.
Nerve destruction procedures like cordotomies (first performed in 1912) destroy pain pathways in the cervical spinal cord, offering relief for patients with pain on one side of their body. Similar techniques use alcohol, phenol, or glycerol to destroy nerve supplies, but these methods disrupt not just pain nerves but also those controlling gut function, potentially causing diarrhea, incontinence, and leg paralysis.
The disconnect between interventional pain medicine and the biopsychosocial understanding of chronic pain has created a troubling divide in pain treatment. This division is exemplified by cases like Diane's, where increasingly invasive procedures provided only temporary relief before leaving her disabled.
The fundamental problem with interventional pain medicine is its failure to understand the conditions it treats. MRI scans of pain-free individuals show the same changes as those with back pain, undermining the pathological connection between imaging and pain. Despite this, the industry continues performing procedures and collecting fees-sometimes unethically, as when doctors split procedures across multiple visits to triple their earnings.
Though interventional techniques may help some individuals temporarily reduce pain, they don't improve function or reduce distress long-term. For younger patients, repeated interventions create a harmful collusion between physician and patient that validates disability. Pain medicine has never properly understood the condition it treats, instead borrowing therapies from other specialties to justify its existence.
Chapter 8
The Pain Clinic Journey
Patients arriving at pain clinics have typically endured a long journey through multiple specialties, arriving confused, wary, and desperate like "survivors of an apocalypse." Many have been subjected to numerous treatments and investigations, often leaving with increased distress and dire predictions about their future disability.
The pain clinic represents a frontier town with two types of practitioners: the "mavericks" promising magical single interventions, and the "reformed gunslingers" who work collaboratively with psychologists and physiotherapists to address pain's complexity. Patients' desperation makes them vulnerable to promises of quick fixes, often expressing the heart-sinking phrase "I will try anything"-revealing their passive expectation that doctors will simply repair their broken bodies.
Pain clinic patients fall into three main categories based on biological mechanisms:
First are those with neuropathic pain from nerve damage or injury. The most common are patients with intervertebral disc prolapse causing nerve compression (sciatica), experienced as sharp shooting pain down limbs. Many have had surgery but pain persists due to irreversible nerve damage and genetic predisposition. Other neuropathic conditions include trigeminal neuralgia and nerve damage from diabetes or multiple sclerosis.
The second group has nociplastic pain from repeated inflammation due to trauma or rheumatological diseases. These autoimmune conditions cause the body to "digest itself," resulting in constant background pain with inflammatory flare-ups.
The third and largest group includes those with nonspecific chronic lower-back pain and chronic widespread pain conditions like fibromyalgia. These patients benefit most from pain management rehabilitation, either through individual sessions with physiotherapists and psychologists or group cognitive behavioral therapy programs.
The author's pain management center uses comprehensive questionnaires and psychometric tests to measure patients' pain experience across multiple dimensions. These include body diagrams where patients mark pain locations, the Brief Pain Inventory (rating pain severity and interference with daily activities on a 0-10 scale), quality of life assessments, depression screening (including suicide risk monitoring), anxiety evaluation, and specific tests for pain-related fear and kinesiophobia.
The doctor-only consultations are described as emotionally demanding, particularly when patients arrive with unrealistic expectations or misconceptions about their pain. The author acknowledges their approach has evolved over time, tempering initial enthusiasm about "saving" everyone with pain management with a more realistic understanding of the challenges in changing patients' beliefs and behaviors.
Chapter 9
Electrical Innovations in Pain Management
The therapeutic use of electricity dates back to ancient times, beginning with Egyptian depictions of electric fish shocks around 2500 BCE. Two millennia later, Aristotle noted torpedo fish (electric rays) effects, and in the first century CE, Roman physician Scribonius Largus documented using these fish to cure gout. Understanding of electricity advanced in the eighteenth century when Henry Cavendish constructed an artificial torpedo fish, leading to numerous electrical medical devices.
Spinal cord stimulation (SCS) evolved from Norman Shealy's 1967 innovation to stimulate nerve fibers directly in the spinal cord's posterior columns. Early devices required external power supplies, but modern versions are fully implantable in the epidural space. Technical advances included multi-contact electrodes in the 1980s and rechargeable batteries by 2005. Despite costing over 15,000, studies show SCS is cost-effective compared to ongoing surgeries, investigations, and medications.
SCS therapy initially relied on paresthesia-based systems that produced tingling sensations in painful areas. This approach faced significant challenges-leads could migrate, spinal cord movement altered stimulation patterns, and patients often disliked the tingling sensation. The stimulation changed with body position, preventing use while driving or sleeping.
Around 2008, a revolutionary 10 kHz high-frequency system emerged that didn't rely on producing tingling. Initially met with skepticism, this paradigm shift was validated by landmark randomized controlled trials published in 2015 showing superior pain relief compared to traditional methods. This paresthesia-free approach allows patients to use stimulation while sleeping or driving, removing barriers to rehabilitation.
The SCS field has become fiercely competitive since paresthesia-free therapies emerged. Companies battle over patents, with some attempting to undermine competitors through hastily assembled trials and public criticism. Pain medicine faces a crisis as interventional therapies are increasingly rationed due to poor evidence bases. Despite SCS having the strongest evidence among interventional therapies, it suffers from limited availability while we lose specialists and fail to attract new ones.
Chapter 10
The Twilight Years: Pain and Aging
Aging brings inevitable physical changes that many accept as normal, gradually contracting their world as function diminishes. Some elderly people remain engaged through work and exercise, while others seem to give up, becoming "folded in on themselves." The elderly patients I see fall into two groups: those aggressively pursuing health through exercise and mental stimulation, and those seemingly waiting at death's door-one group seeking functional improvement, the other palliation and comfort.
Aging brings physiological changes to the nervous system-reduced fatty layers in spinal cord nerves, fewer brain connections in pain processing areas, and decreased natural opioids. Older patients often report less pain or different pain distributions compared to younger patients with identical conditions. Pain assessment becomes particularly challenging in those with cognitive decline or dementia, requiring specialized pain scales that observe behaviors like grimacing or restlessness rather than relying on self-reporting.
The average age of patients receiving steroid injections for lower-back pain is seventy-seven. While back pain rarely correlates with MRI findings, nerve pain radiating down limbs often does. Aging spines remodel, depositing bone where it shouldn't be, narrowing nerve canals. Even after surgical decompression, nerves may remain damaged-like a peach that appears intact but is bruised inside.
Spinal stenosis in the lumbar region acts like a dam restricting water flow. Patients can walk only a certain "claudication distance" before compression causes pain and weakness, requiring rest before continuing. Active individuals struggle most with these limitations. Though evidence for steroid injections is poor and no longer recommended by NICE, they remain the only option for some patients unsuitable for surgery.
We don't fully understand why joints become painful with age. Facet joint pain in the spine occurs despite cartilage having no nerve supply-possibly because the brain perceives joint deformation as dangerous. While knee replacements work well, equivalent spine surgeries like fusion have been abandoned as ineffective.
In anesthetics and critical care, we face difficult ethical choices about prolonging life versus allowing natural death. Western medicine often operates at the blurry margins between quality of life and suffering. Cultural attitudes toward medical intervention vary dramatically-in South Africa, families accept taking terminal patients home to die, while in the UK, many expect every available therapy before death.
Chapter 11
The Business of Pain and Our Cultural Contradictions
Our gleaming hospitals with technological marvels and armies of specialists perpetuate the myth of medical omnipotence. Yet the undisclosed reality is that basic sanitation, proper nutrition, safe driving, avoiding alcohol, limiting sugar, regular exercise, and mindful living prevent 90% of conditions requiring medical intervention. Only genetic conditions and certain cancers remain beyond our control.
We live in contradictory times-warning against sugar while supermarkets dedicate aisles to chips and chocolate, making healthy food prohibitively expensive while selling cheap, nutritionally poor alternatives. We confuse people with conflicting dietary advice about meat, dairy, and veganism. Meanwhile, chronic pain rises alongside sugary inactivity and nihilism.
Society rarely addresses chronic pain as the epidemic it is, nor acknowledges how biopsychosocial approaches could improve population health. We know the science behind avoiding refined sugar but continue selling it; we understand exercise benefits yet invented binge-watching. Perhaps we don't consider ourselves worthy of saving, or our awareness of mortality drives a "you only live once" mentality. When we inevitably break down, we demand "Fix me, Doctor" from physicians who aren't incentivized to promote lifestyle changes that would reduce their income.
As a public sector doctor funded by taxpayers, I provide evidence-based therapies restricted by organizations like NICE based on scientific evidence. This wasn't always the case-forty years ago, doctors could offer treatments they personally considered successful.
Private healthcare operates differently. Paying patients can find doctors willing to perform desired procedures, though this system has flaws. An orthopedic surgeon admitted the threshold for knee arthroscopy varies dramatically between NHS and private patients-impatience for recovery combined with surgeon fees lowers intervention thresholds.
The financial incentives in private practice often lead to unnecessary procedures. A conversation about managing chronic pain through movement despite continued discomfort generates no revenue, whereas offering injections every three months does. Private pain medicine often attracts the most desperate patients willing to pay for quick solutions. These psychologically distressed individuals benefit least from interventional techniques but are most likely to demand them.
Pain medicine in the UK faces extinction as revenue-generating services are stripped away, revealing the uncomfortable truth that medicine, whether public or private, remains a business where the patient is the product.
Chapter 12
A Journey Without End
I now understand that patients don't just bring their pain to the clinic-they bring psychological difficulties, social circumstances, poor diets, and substance dependencies. My approach has evolved from narrowly treating pain to addressing overall well-being. I explain to patients that while pain isn't "all in their head," they can influence their abnormal sensations, and every aspect of their lives affects their pain.
My clinic has become more of a "well-being clinic" where I discuss dietary recommendations and psychological wellness alongside pain management. All doctors should adopt this holistic approach rather than repeatedly treating symptoms without addressing underlying causes. Our paradoxical attitudes toward health-warning that smoking kills while continuing to produce cigarettes, lamenting soft drinks' health impact while manufacturing them-mirror our contradictory nature as the only species aware of our mortality.
I've grown increasingly despondent about my role, feeling caught in a system with an understanding of pain no better than a century ago. Pain medicine has built an industry on weak evidence, wasting resources on poorly studied injection therapies. My most therapeutic tool is simply explaining pain to patients-acknowledging when conditions are permanent initiates healing, though most continue seeking treatments.
Medicine requires fundamental rethinking. We need independent bodies to evaluate treatments without industry collusion. We understand disease prevention but invest little in it, profiting instead from managing self-inflicted conditions. As doctors, we've lost our way, treating lifestyle diseases rather than preventing them.
Working in a unit offering pain management physiotherapy and psychology seems the best option for me now. Spinal cord stimulation for peripheral neuropathic pain and exploring pain dysfunction to design specific therapies are worthy pursuits. I resist empiric cannabis use until clear evidence emerges, knowing that treating existential crises with substances won't improve quality of life.
Most importantly, I explain pain based on current understanding, highlighting aspects of positive living found in societies where people live well: whole foods, regular physical activity, community living, and finding your ikigai-your reason for being.
I hope this book helps you take responsibility for your health, understand pain as a biological alarm while recognizing your response as a choice, appreciate that pain cannot be completely extinguished with medicines, work better with healthcare providers, and feel acknowledged if you suffer from chronic pain. As Edward Trudeau said, "Sometimes to cure, often to relieve, always to comfort."
