Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

At The Nocturnists, we are careful to ensure that all stories comply with healthcare privacy laws. Details may have been changed to ensure patient confidentiality. All views expressed are those of the person speaking and not their employer.Support for The Nocturnists comes from the California Medical Association. To learn more about the CMA visit CMAdocs.org. Support for The Nocturnists also comes from the Patrick J. McGovern Foundation. You're listening to The Nocturnists: Conversations. I'm Emily Silverman. All of us have experienced physical pain at some point in our lives. We've scraped a knee; we've gotten a headache; we've thrown out our back. Yet many of us are unaware of how essential context is to the pain experience. Failure to grasp the complex nature of pain can sometimes lead to harm, especially in medicine. And nowhere is that more evident than in the treatment of those with chronic pain. How is it that something so core to being human can remain such a mystery? Joining me to unravel some of these complexities is Dr. Abdul-Ghaalq Lalkhen, an anesthesiologist and author of An Anatomy of Pain: How the Body and the Mind Experience and Endure Physical Suffering.I am sitting here with Dr. Abdul Lalkhen. Abdul, thank you so much for coming on to The Nocturnists to talk about your book.

Abdul-Ghaaliq Lalken

Thank you very much for having me, Emily. It's a pleasure to be here this afternoon.

Emily Silverman

I loved this book. Thank you for writing it. I think it's going to be such a rich conversation. Tell us a little bit about your path to Anesthesiology and Pain Medicine.

Abdul-Ghaaliq Lalken

I grew up surrounded by doctors. And my Dad's a GP; his sister is a midwife. His older sister is a GP; her children are doctors. We have pathologists and psychiatrists in the family. So, I followed in the family tradition and I went to medical school. The most fun course I did at medical school was the first six months, where you could choose to do something in the Humanities, and I did a six-month course in Comparative Religion. And I have to say that, intellectually, that was probably the best and most challenging aspect of going to medical school. But I think what I liked the most is that you could just help people at a very basic level. And when I finished medical school, it was quite a turbulent time in South Africa, which is where I'm from originally. So we were transitioning from the apartheid government. President Mandela had just been freed, so this was the early 90s. There was a real effort to change the way that had been done from the past, where, really, if you had a particular color skin, then you were given the jobs in the hospitals in the city where you grew up, that was near the beach. And if you were of a slightly different color and a darker shade, you got into other places. So they wanted to change that system, so it became quite random. And as part of that random process, I got sent to quite a rural part of South Africa. In retrospect, clinically, it was probably the happiest year I've ever had. We used to walk to work in the mornings. And you can imagine miles and miles of unspoiled bush. And the first thing you would hear in the morning is the sound of singing, as the nurses sang their morning prayers. For the second year, I came back to Cape Town, which was the complete opposite. Really it was quite horrible. You know, gang violence, the consequences of... first of all... the illnesses: hypertension, diabetes. And I think... I think I kind of broke a little bit during that year, and I kind of decided that I couldn't see a way forward for myself clinically in South Africa. At that point, I wasn't white enough, and I wasn't Black enough. And so, I kind of felt that I'd fallen in the cracks, in terms of career progression. And so I effectively ran away from home, and I came to England, and I started in Anaesthetics. In Anesthesiology, I suppose, as most Americans would know it. And I quite liked Anesthesiology; it's very controlled. I quite enjoyed it for a while. And then I worked in Critical Care (or Intensive Care). But, I didn't like the fact that that, you know, the mortality rate was really high. And, I suppose at this point, your listeners are probably thinking, "Oh God, this guy should definitely not have become a doctor." But, I remember intubating a 34-year-old man, and he had leukemia, and the only reason we put him on a ventilator was because he was so young. I remember the consultant in charge of the unit saying listen, "We need to wait for his family, because this is probably the last time that they'll see him." And I remember, to this day, the 8-year old and the 10-year old who came to say goodbye to their father. And then, when I was putting the breathing tube into his throat, I suddenly realized that mine was the last face that he was going to see. And I just thought, I'm not entirely sure this is for me. And I was thinking about it when I sat in a Pain clinic, because Pain Medicine is a sub-specialty interest of Anesthesiologists. Because there was a time when we believed that you could treat pain with a needle and a strong arm, you know, in a sort of House of God- type style. And I watched the Pain consultant. And I saw how, just understanding the nature of chronic pain changed that person's outlook, and so, you could almost see them visibly relax within the consultation. So yeah... so that's... that's how I ended up in the job.

Emily Silverman

That story... so beautifully told, by the way... is a great example of how each moment just gives birth to the next moment. And, at the end of our careers, we can tell stories about our trajectory, as if it were all premeditated. But it requires a great amount of improvisation. There was a quote from the book that I loved where you said, "Most other anesthesiologists can't understand our choice to be pain physicians (to see distressed patients and sit in clinics). Sometimes "we are perceived as helpful. But we are also viewed with suspicion and curiosity because we choose to work with a group of patients that most anesthesiologists try to avoid." So, tell us a little bit about this patient population, and why do they scare people away so much?

Abdul-Ghaaliq Lalken

I suppose, to answer that question, it really requires a reflection on the experience that is "pain". It's where the organism feels threat. And in a medical setting, most of the time, people will come to the doctor for one of two reasons. Either something has stopped working (so you've lost vision, or you can't hear anymore, or your limb isn't moving), or you have pain. And pain is usually treated by most doctors as a symptom. So it's kind of at the door. You might appreciate the nature of the door briefly; you might note its color; you might look at the door handle. But actually, the aim isn't the door; the aim is what's through the door. And so, looking beyond the door, at the cause for the pain, is what most doctors focus on. And that's fine, because if you've broken your arm, and you say, "I've got pain in my arm," and your arm is disfigured, and you X-ray the arm and the bone is deformed... that is not a difficult conversation. Eventually that pain will go away. Once we've done what we needed to do and the arm is healed, the pain goes away. The difficulty is with pain that doesn't go away. I sometimes explain to patients that having chronic pain must be a bit like having a little child constantly tug at your hand, when you're trying to do other things. And, you're trying to focus on your job or your family life or engaging meaningfully with other people, but this child keeps pulling at you and you become frustrated and you become irritable. And, that changes you as a person. And then, nobody can quite understand why you're complaining of pain, because, structurally, your spine doesn't look particularly abnormal, and nobody can tell you why. And so, you start to think that it's all in your head. And actually, if your model of pain is that there must be something broken for you to have pain, it reinforces that belief. Because you're now depressed, quite rightly, or anxious, because you don't understand the pain and it's affecting your ability to accomplish day-to-day tasks, you go, "Well, actually I am anxious and depressed. So maybe that is why I have pain." And the reality is that individuals who develop chronic pain have had psychological insults previously... not always, but a lot of the time... which have in some way pre-programmed or damaged their nervous system. So that, on exposure to another trauma or to a stressful life event, the exposure early on in life translates into this constant feeling of discomfort. So the individuals who come to a pain clinic have often been to loads of places. In the book, I talk about them being like weary travelers who arrive at the final outpost on the railway line that terminates in the dusty western town, where not a lot's been built. And along the way, they've stopped at many stations, you know, and visited Orthopedic Surgeons, Neurosurgeons... You know, they may have turned to alternative healers; they may have tried their own remedies. But they finally arrived at your pain clinic, feeling as if this is the last stop.

Emily Silverman

There's a couple sentences in your book that I really loved. One of them was, "The primary emotion a doctor feels when faced with somebody who is in pain is extreme helplessness." And I definitely related to that. And then you said, "The prescribing of a drug is often to manage the distress of the prescriber," which I also really related to. And I wanted to get to those issues a little bit later in the conversation. But first, let's talk about how pain works. You have this analogy of the spinal cord as a bowl of soup, whose flavor can be altered by inputs from the brain (up top), or from the peripheral nerves (down from below). So tell us more about this.

Abdul-Ghaaliq Lalken

You have to start with a cognitive map, I break it down into four components: The first bit is wherever the injury occurs. (And that injury can be chemical, or it could be due to a temperature insult - hot or cold. Or it can be mechanical: a cut or a wound that produces inflammation, because the body responds by trying to heal itself. And those inflammatory chemicals attach to nociceptors, and Noci is the Greek god of Mischief. So, these are sort of mischief-sensing receptors. Those receptors, when triggered, send an electrical impulse to the spinal cord, where... The spinal cord isn't passive. It's a sort of gating mechanism. It's a kind of border check. And it makes decisions, and receives information from the brain "head office". The information initially is passed upwards to different centers within the brain that tries to make sense of the damage: Where is it? What does it mean? Have I experienced it before? And then the fourth bit is modulation, where the brain can then, based on the information it's received, decide how important it is, and it sends messages down to the spinal cord. In the book, I give the example of watching David Beckham experience an Achilles tendon rupture during a football match, and you watch how initially he doesn't really respond in a way that we would recognize his pain. But what you do see is he can't kick the ball anymore, because he can't flex and extend his foot. But that's not pain. And then what you see is him making sense of what has happened. And then - probably knowing other people who've done it - how long you'll be out of the game for... You know, what it means for his future career. Not just, you know, the next two years, but what his legacy will be because of what he'll miss out... and then you see him fall to the ground. There's no reason to fall to the ground, because previously he was stood up. But you see him fall to the ground. And you see this utter look of distress and helplessness. And then, later on... the foot hasn't healed, but you kind of see him sat down, as the modulation has occurred, as his brain is kind of making plans and seeking alternative routes. Nobody's fixed him. And then that system usually switches off. But, in a proportion of individuals, the alarm doesn't switch off and the signal keeps on ringing. The analogy with regards to the bowl of soup was very much in relation to a treatment called spinal cord stimulation where the idea is that early on, when everything is still quite plastic, you can influence the pain with an electrical modality like spinal cord stimulation. But later on, things become a bit more fixed. But what also becomes quite fixed is the disability, because the person hasn't been rehabilitated. And so all of the effects of chronic pain: the anxiety, the distress, the catastrophizing, the kinesiophobia, the loss of employment, the loss of loved ones, the loss of status, the damage done by opioids,... all of that becomes quite irreversible, and people become quite stuck.

Emily Silverman

Yeah, in the book, you say pain is not a symptom. Pain is an experience. And I think the David Beckham story really brings that into relief, and shows us how we attach meaning to pain. We attach stories to pain, and that affects the experience of pain. And you also talk about how this is a very modern idea that's supported by research and evidence. But there's these older ideas of pain. Like the philosopher Descartes talks about how a large fire causes a large pain and a small fire causes a small pain. So this idea that pain is proportional to tissue damage, which is not true, has been debunked by science. But you say, today, many healthcare workers mistakenly still believe in this idea and that it's extraordinary how a 400-year-old idea about pain can persist in the face of overwhelming evidence. So my question to you is, why can't we take up this idea? Why can't we take up this evidence? Why are we still clinging to this 400 year old idea of pain and what it is and how it works?

Abdul-Ghaaliq Lalken

There is evidence that it's not taught well at medical school. So, if you look at most textbooks, you look at medical school curricula, Pain Medicine is very poorly represented as a specialism, and a lot of the neuroscience that is taught in medical school around pain is quite outdated. I think, as doctors, we are very biomedically focused. There was a time where you had to have an Arts degree before you started studying medicine. So you first had to study humanity before you got to treat humans. And I think that is something where we're missing out. We don't really teach people enough psychology. We don't emphasize the behavioral sciences enough. We don't emphasize enough the impact that social problems, and the difficulties people are experiencing in their lives, how that impacts on them. I think doctors are often drawn from particular segments of society, where we've not really been exposed to the kind of suffering that the people who present to us have suffered with. We often don't have the same backgrounds. And I think we like to retreat into a biomedical model because it feels safe. Because it's manageable. I mean, much like I did, you know, when I moved from working in a trauma unit to wanting to be an intensive care doctor. That was an attempt to retreat from psychological and social issues, that I felt poorly capable of dealing with. But I think what happens is that: you want to treat; you want to... you want to win. And it's interesting, a colleague of mine came to see me in clinic. And there was an 80-year-old lady who had presented, having fallen at home. Lives by herself, fell at home, long-standing history of knee osteoarthritis and back pain. She was on the equivalent of 200 milligrams of Morphine a day, in the form of Oxycontin. She was on Gabapentin, and she was on Nortriptyline, which is a tri-cyclic antidepressant used for pain. And she'd fallen over. Not surprisingly. I mean, I wouldn't be standing upright if I was on that cocktail of medications. And she'd come into hospital on... under the medics, because she'd fallen over. And they'd asked for a consult, because she wouldn't get out of bed. And I said to..., "Look, this is not a pharmacological problem. You know, your job, in my opinion, is not to find that magic cocktail of medicines (because it doesn't exist) that will get her to get out of bed. This lady is not able to cope by herself anymore. Her not wanting to get out of bed is not a structural problem. It is a not being able to know where to move on to next, not having an exit strategy for living independently to living in a way that she really needs to." And the medics wanted bridging analgesia, in order to get her moving, because as far as they were concerned, she was fit for discharge. And I said to my colleague, "This is a psychological and social problem. And all of us are ill-equipped to deal with this. This lady needs a "best interest" meeting, where we need to engage with her about where she'll feel safe, and what care she needs. And there is no drug for that. I cannot convince the doctors I work with. I can't convince the spinal orthopedic surgeons. I can't convince the neurosurgeons. We are like their dirty secret, the pain clinic. They reluctantly send us patients that they don't actually want in their clinics anymore: "Oh, we'll send you to the pain clinic." Or, like "We'll send you to heaven," almost or "We'll send you to the other place," because they don't have the language to explain. If you have a hammer, anything that comes through your door - even if it looks like cheese - you'll magically, in your head, transform into a nail. Particularly if you've got a half-million dollar college debt to pay off.

Emily Silverman

I have seen that, and it's so hard. But, there are also things that we can do, and you teach about this in the book. Little things, to be more patient-centered, that we can wrap our minds around. So one example that you give is counseling patients about pain before an operation. And you talk about catastrophizing; you talk about pre-operative anxiety; you say it is the most consistent and predictable risk factor for the severity of post-op pain. And you talk about why it's so important to set expectations about pain before an operation. And so for me, as a hospitalist, I do some consult work with the Orthopedic service. So I do see patients before they go in for their operation. And a lot of people listening to this podcast, this is a scenario that they will be familiar with. So, what are some things that we can say to patients? Or how do we talk to patients before an operation, so they don't wake up with pain, and then start catastrophizing, and then make their own pain worse?

Abdul-Ghaaliq Lalken

I ask people what they think. So I ask people, "What do you expect is going to happen after you've had this operation? What do you expect to feel? What are you afraid of? What are your concerns? What are your expectations?" And then I proceed from there. And I say to people, "I can't give you no pain; no pain is not possible. If 10 out of 10 is the worst pain you've ever experienced, I can mainly do 4... 4 to 6." I said, "We'll do the best we can. You'll have an operation; you've consented to it. It is designed to make you better, but it is not designed to make you pain-free. And if you wake up and you feel something that doesn't feel pleasant, it doesn't mean that it hasn't gone right." Because if you don't say that, and the expectation, perhaps not voiced to you, is that there'll be no pain, and the person wakes up and their brain starts processing what they're feeling in their leg. And in their brain, It's "Why am I feeling in pain?" That starts the ball rolling. So then, the person believes something's gone wrong; it's not gone according to plan. One of the key things is to explain to people how pain works (which you can do fairly quickly), what modalities you're going to use to try and dampen down the loudness of that alarm, but what they can do to process the information. And I say to them, "Look, the aim isn't to be pain-free. The aim is to get out of bed, so you don't get a DVT. The aim is to breathe in and out, so you don't get a lung infection. So you're incentivizing, motivating, and managing expectations.

Emily Silverman

So let's talk about your pain clinic for a bit. You mentioned that patients are on this train to nowhere. And then they arrive in this dusty, undeveloped area out West. And they land with you. And a lot of them, as you said, are very frightened or very frustrated, have already suffered a significant amount of disability, depression, anxiety. And the first time you encounter somebody like that, from the provider standpoint, it can be very anxiety-provoking. And you've talked a lot about cognitive maps and how that helps people. And you put forth this sort of cognitive map for the provider encountering the chronic pain patient. As we're anticipating difficult interactions with these patients being the receptacle of their anger, being the receptacle of their frustration ....this is very scary for physicians. I definitely have had patients, where before I go in the room ... to take a deep breath. Or even patients where I wake up in the morning, and I kind of don't want to go to work, because I don't want to see that patient, because I don't know what I'm going to say to them. But this cognitive map, you think of it as a drama, and there's something called "Karpman's triangle" or "Winner's triangle". I just thought this was so fascinating, and I know that our audience is going to benefit from hearing your perspective on this. So tell us a little bit about this.

Abdul-Ghaaliq Lalken

So the idea is that if you're in a conversation with somebody, that feels like a drama... So, it feels difficult and, like you've talked about, you're anticipating conflict and you feel helpless. What's happening there is you're usually feeling like the victim. So the patient is persecuting you because they have unrealistic expectations and you have failed them. So then you feel like the victim. And that can then flip, where because you feel like the victim, you get angry about it, and then you can persecute them. Or alternatively, if the patient comes to you and goes, "I don't really know what to do, Doctor. You know, I've tried everything, and it's really bad and... and my pain is awful," then they are playing the victim, because they're not invoking their own agency. You can then make the mistake of rescuing them: "Oh, I've got this medicine. And you know, there's this drug..." And you know that it's not going to massively reduce their pain, but what you're doing is responding to their emotional state. When it doesn't then work, and they come back the next time, they think, "Oh, well, it didn't work; it didn't do what you said." And you then feel persecuted, so the roles have been flipped. So I think, when you feel that way, it's understanding that the patient is potentially assuming the role of victim, they're in a passive helpless state. And then you can move them to a state where you're both having a conversation that is based on the evidence for what's wrong with them. You're developing a map with them, in terms of... in the case of a pain clinic, how pain works; you're giving them information to reflect on. You're not judging; you're not rescuing; you're not persecuting. What you are is communicating in an adult-adult interaction. And I'm mixing all sorts of, you know, behavioral strategies, which I have had to go and seek out for myself, just to cope with, not burning out in a clinic. You know, if you, the idea would be that, in an aeroplane, you take off, you burn a lot of fuel, but then you level out, and you don't burn much fuel. But if you're engaging in that tension before work, and then that highly expressed interactions at work, it's like taking off and landing... taking off and landing, and every patient is a takeoff and landing. Whereas, really, you just want to be cruising, understanding where you're in, and what the place you're in as a person, centering yourself and being truly empathic about what that person must be going through, but not wanting to rescue them. Because I think that kind of authenticity is good for the patient, and it is very preserving of the physician. So Karpman's drama triangles is just a way of understanding those consultations that feel dramatic.

Emily Silverman

I'm so glad that you put it in the book. And there's so much in what you just said, that really, really feels true to me. My husband works in tech, and he'll go to work and come home 12 hours later, and I work at San Francisco General Hospital, I'll go to work and come home 12 hours later, we've both worked a 12 hour day. And he's full of energy and ready to do things, and I am laying on the couch like a pancake. And now you've given me a different way to think about it, which is that he's been in "cruise control" all day. And I've been taking off in the plane and landing and taking off and landing, twelve times in a day. And it just burns way more energy. And this idea of the triangle: the persecutor, the rescuer, the victim. And how to recognize when you're being tempted into the rescue role, or when you're feeling victimized, so you're being tempted into the persecutor role. I find that whole framework to be really helpful, and I'm not sure exactly how I'll use it moving forward, but it gives me something to grab on to. I just have so many patients who are in pain, and they're asking for opioids. And you talk about this in the book, of course, the problem that we have in this country, and in the world, around opioid prescribing. For people listening, who are internist or PCPs, how do we apply this idea of Karpman's triangle to the patient who is suffering and is asking us; "Please, please... give me an opioid to take my pain away"?

Abdul-Ghaaliq Lalken

The place I always start at is not at the treatment end, which is the opioid end. I start out at the problem end. I don't think you can ever help anybody with a problem if they don't understand the nature of it in the first instance. So you formulate the problem, rather than reaching a diagnosis. What are the factors that influence the nature of your pain: good days and bad days, overactivity, under-activity, cycling? What's the evidence? I show patients scientific papers. They're on my desktop and I open them up, and I say, "Look, these are the findings from asymptomatic people with MRI changes, and therefore the MRI changes you have, for your age, are present in asymptomatic people. This is not a structural problem. This is a neurological issue. It's the way nerves function. It's influenced by your behavior, by your circumstances." And then we'll talk about opioids and what they are. I say, "Look, opioids affect the way that your brain perceives these signals. It isn't magically stopping them. It's merely changing how you react to them." And I say to them, "Opioids have been called the perfect "whatever" medicine because, like, teenagers often go, you know, "whatever" when they want to be dismissive." The patients with chronic pain will tell you, "I've still got my pain. I just don't care as much." And then I very gently bring up the idea that it impairs your immune system, that it affects your hormones. I bring up the idea of addiction. I say, "Look, people use these drugs to manage their distress. That's why they drugs of abuse. And so magically thinking that just because you were using it in pain for you, that you can't become addicted, that actually isn't true." So you're giving information. You've also given them an understanding of what chronic pain is, and the other things that can influence it, and you're highlighting to them the harms of this therapy. And, so what you've done is you've moved the conversation from: "Me, Doctor, You patient. I'm going to help and save you" to "Walking alongside one another here. I'm not going to pull you and I'm not going to push you. I'll walk next to you, but you've got to walk."

Emily Silverman

For whom do opioids make sense? I mean, obviously, if I get my arm, you know, caught in some machine and I'm bleeding out of my arm, "Yes, we're gonna give opioids." Or if I've just had a surgery, I'm going to wake up and. "Yes, I'm gonna have opioids." But beyond that, situations of trauma - acute trauma, is there anyone for whom opioid medications make sense in the medium to long term?

Abdul-Ghaaliq Lalken

The only group where the evidence is that they may benefit from low-dose opioids are people with osteoarthritis. But then that has to be done with opioid contracts, where you're monitoring to see whether there is an improvement in function with the use of these medications. You quoted the example of trauma, but even in trauma in the perioperative setting these days, the aim is to use as little opioid as possible and to try and manage pain with regional techniques (with local anesthetics with multimodal analgesia, minimally invasive surgery), in order to avoid opioids which have quite negative effects on post-operative rehabilitation. You see, the thing about opioids is it's all we have. And if it's all you have, it's what you'll use. And I often reflect on the fact that with opioids, the harm is subtle. We all know the harms of anti-inflammatories. You only have to see somebody have a gastric ulcer once, and have hematemesis, for you to never forget that again. But we prescribe opioids because rarely do people actually have respiratory arrests from them, that we actually witness, and it may be remote and then linked to something else. So often, you know, the 80-year-old falls over and gets a fractured neck of femur, comes into hospital and gets pneumonia, and unfortunately dies. The cause of death is pneumonia, fractured neck of femur. Nobody's talking about why she fell. And the reason she fell is because she's got a 25 microgram fentanyl patch on, which was prescribed by a well-meaning family physician or pain doctor.

Emily Silverman

And you talk, in the book, how there are some therapies that work. For example, for neuropathic pain, there are some drugs that work. And then you talk a bit about nerve stimulators, and how they can actually be very life-changing for people. So just very briefly, can you talk about those interventions, because it seems like there is some promise there.

Abdul-Ghaaliq Lalken

So, neuropathic pain is pain due to disease or injury of a nerve, either peripherally or centrally. And spinal cord stimulation has been around since the 60s and has got better and better and... Essentially, leads are inserted in the epidural space. And the traditional type of spinal cord stimulation produces paraesthesia in the area of pain. The newer types of stimulators actually use a high-frequency electrical current, which stimulates a population of inhibitory nerves in the dorsal horn, and is probably the best treatment for peripheral neuropathic pain. The medications like Gabapentin and tricyclic antidepressants have numbers needed to treat of, sort of, 1 in 6 and numbers needed to harm of 1 in 11. They cause significant cognitive side effects. But neuromodulation, and spinal cord stimulation is an example of neuromodulation, can provide amazing pain relief. In our unit, we use high-frequency spinal cord stimulation, which can reduce pain scores of 8 out of 10 to 2 out of 10. And, in some cases, it can render people pain-free. But, of course, there's variable penetration of the therapy. In these conditions, there's variable provision, it is an invasive treatment. But actually, if I had peripheral neuropathic pain, I would definitely have a spinal cord stimulator, over Gabapentin, any day.

Emily Silverman

Earlier, with this scenario of the patient who's asking for opioids, and you said that your strategy is to have a conversation and really just to explain pain. And there's a sentence in your book that says, "The most powerful and therapeutic part of my role as a physician [healthcare professional] is to explain pain." Tell us a little bit about how these patients respond to your teachings. And why the teaching alone is so healing.

Abdul-Ghaaliq Lalken

So the analogy I'll often use is, pain is like a car alarm. Normally, it's designed to alert you that somebody is breaking into your car. And generally you'll go outside, you'll get rid of the perpetrator, you'll have the car fixed, and the alarm will switch off. But in some people, what they then find is that from time to time, or continuously, the alarm just keeps going off, even when nobody's breaking into their car. Clearly, they're not imagining it, because they can hear the alarm. But the problem isn't with anybody breaking into the car, the problem is in... And then I normally pause. And you know they've got it when they go, "the wiring of the alarm". And actually, once they sort of get their heads around that, it kind of de-escalates that tension and rage and anger. So then they go, "Is this something I'm going to have to learn to live with, Doctor?" And I go, "Yeah, because I can't, and I don't have anything that will switch the alarm off. I can maybe make it a bit softer. But a lot of the medicines that make it softer also affect your other nerves." And, they've usually had experience of the side effects. But I said, "Your brain is really powerful in influencing that alarm, because you can change how you respond to it. Instead of rushing out all the time to the car, and checking if anybody's breaking in, you eventually accept that it's a faulty alarm. And so you learn how to continue doing what you need to do. Sometimes you can ignore the alarm because you're distracted and you're busy with something else. But then there are times when something else is irritating you and suddenly that alarm seems really loud and intrusive." And they go, "Ah, I have good days and bad days." And I go, "Absolutely." So you use the patient's experience of their disease, in order to make sense of it by bringing their experience and your knowledge together.

Emily Silverman

You say in the book, "As a taxpayer and clinician, I find myself thinking, "This patient could be rehabilitated if they only wanted to be," but then, I consider the extent to which our society facilitates chronic pain in so many ways." So talk a little bit about that. As a society, how have we let this happen?

Abdul-Ghaaliq Lalken

You can't be a doctor and not really think about the fact that when you go into a supermarket, there are about two aisles of food that you should eat, that is known to be good for you according to studies. And then there are like several aisles of refined sugar and various other substances that you know will have a negative effect on your health. And you look at how binge-watching TV series has become something that we just accept we should be doing, but actually sitting for prolonged periods of time has been associated with negative health outcomes. We also look at how societies that are quite materialistic, where people wanting more and having more is considered success. Whereas we know that if you look in centenarian populations, where there are high proportion of people who live a long time, that actually what keeps you well long term is social cohesion, having purpose, being rooted within a community, and yet we all lead such fractured, isolated lives. And so, I think all of that has neurobiological consequences. We damage our nervous systems; we produce a significant stress response. And chronic pain is merely one disease that arises from the way we currently live, in the pursuit of more. So I think unless we as a society reorientate our priorities, we're unlikely to make a significant change - particularly in a disease process like chronic pain.

Emily Silverman

In the book, you say, "The Buddha is often quoted as having said that pain is inevitable but suffering is optional. In recent times, we have all but reversed this prioritization." And you say something about how the scientific paradigm is not always as helpful as we'd like to believe. And how, when it fails, we no longer have the emotionally comforting and meaning-making mythologies of ancient China, India, or Egypt to fall back on. And then when I heard you say, at the beginning of the conversation, that your whole journey actually started with a study of comparative religion, I can't help but notice things coming a bit full circle. And I wonder if you could reflect a bit about what the role of religion and spirituality or philosophy might play in helping our society get back in touch with its priorities.

Abdul-Ghaaliq Lalken

I think religion and spirituality are almost seen as separate pursuits. But religion, to my mind, is all deeds and all reflections. I think religion has been hijacked by people who have their own agendas, but those agendas are usually not congruent with the articles of faith of those religions. If you look at all world religions, they preach kindness, compassion, collaborative working, moderation, a sense of purpose, and living in community with others. In my view, if you look at religion, there's concentric circles. In the middle, you have what God wants us to be: he wants us to be kind, he wants us to be compassionate, turn the other cheek, be of comfort to others, be meek, be humble. Then the other circles are how we achieve those. So Muslims might pray five times a day, and fast, and go on a pilgrimage to relive a journey. Christians might go to church, and reflect and ask forgiveness. But we get too hung up on the outer circles of how faith manifests, and the different actions, and less focuses on the inner circles of those virtues, which produce cohesive societies. And I think... I think it was Nietzsche who said that human beings can be any "why" if they have a "how", and I think what religion and spirituality potentially does is it embodies or gives you a life philosophy, and a purpose that isn't rooted within material gain. Because we are organisms that, ultimately... we die. And I think if you understand that you will die, you will have to ask yourself, "Okay, well then, what would this life have been worth?" And I think, as a doctor, when I... when I have been seduced by the speaking engagements, or I've been seduced by the... even the admiration of people I've taught, or patients... You realize that if you chase that, it's transient and unhelpful, but if all you do is serve in the best way you can, then actually, that's what's made me feel well, on a more consistent basis.

Emily Silverman

Well, you're definitely serving your patients in your clinic and serving us by writing this book, which, as I was reading it, I just kept saying, "This is so good. This is so good." It's a must read. It's thoughtful; it's intellectual; it's spiritual. And it taught me a lot about how to think about chronic pain and the people who suffer with it. So it's called An Anatomy of Pain: How the Body and the Mind Experience and Endure Physical Suffering. Dr. Abdul Lalkhen, thank you so much for speaking with me today.

Abdul-Ghaaliq Lalken

Thank you very much, Emily. And thank you for having me on your show.