Monty Lyman - The Painful Truth: The new science of our aches, agonies and afflictions

The Remarkable Life of the Skin:
An intimate journey across our surface

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First published in Great Britain in 2021 by Bantam Press

Copyright Monty Lyman 2021

The moral right of the author has been asserted

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The checker-shadow illusion, copyright E. H. Adelson, 1995.
The Thatcher Illusion: image manipulation copyright Rob Bogaerts CCO.
All other text illustrations by Global Blended Learning.

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ISBN: 978-1-473-55534-1

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For Hannah, my wife

The pain pathway according to Descartes Treatise of Man, 1664.

Descartes updated: the nociceptive (danger) pathway.

The checker-shadow illusion.

The Nav1.7 receptor.

The Thatcher illusion.

Emotional processing of pain.

Reward circuitry and pain relief.

Pain and peripheral inflammation.

Pain is a universal human experience. It is also a deeply personal one. I believe that one of the best ways of communicating the deep truths of pain is through real stories. Everyone interviewed in the research for this book has given their express permission to be included. For those whose stories I came across many years before conceiving the idea to write about pain, I have applied a double-lock of confidentiality: their name has been changed and the location of meeting moved. If you think you can identify yourself, I promise that it is pure coincidence. All doctors owe a duty of confidence to their patients, a principle that goes back to the Ancient Greeks. The Hippocratic oath states, What I may see or hear in the course of treatment or even outside of treatment in regard to the life of patients, which on no account one must spread abroad, I will keep to myself.

I am not an expert in a specific field of pain, and have no financial incentive to promote a particular treatment. Through research, experience and interviews with pain experts and people-in-pain alike, I have developed opinions on treatments for persistent pain and I express them. But, while I want to communicate the principles of pain, and really hope that my understanding can be of genuine help, my opinions and reflections in this book should not be read as medical advice.

Sticks and stones may break our bones, and words can literally hurt us, so I try my best to avoid the words of war and language that might exacerbate pain. Painkillers will be in most cases termed pain relievers. I must also make an important clarification about the words we use for long-term pain. Persistent pain and chronic pain are the same thing. My preference for the use of persistent over chronic reflects it being a better descriptor for the condition; it is also more readily accepted by individuals and is now becoming widely used. Chronic simply means long-lasting, deriving from the Greek word for time, chronos. But it is not common parlance and means different things to different people, with the most dangerous interpretation being permanent. So while I prefer to replace chronic with persistent, it must be noted that chronic pain is the most widely used medical terminology. We have to be comfortable using both of these terms interchangeably.

The good news is, theres nothing physically wrong with you

E VERYTHING WE THINK we know about pain is wrong. Thats quite a bold statement. But, by and large, its true. By we, I mean us as a society; I mean most people in and outside the medical establishment. We misunderstand the nature of pain and this misunderstanding is ruining the lives of millions.

And now I as a freshly minted junior doctor was witnessing the consequences of this misunderstanding.

It was nine in the evening, and I was coming to the end of an exhausting day shift on the acute medical unit. The sun had long gone down and the ward was bathed in sallow, artificial light. An acute medical unit is a hard place to forget: all the chaos of a low-end department store on Black Friday, soundtracked by a disjointed symphony of beeps and groans. All day, the juniors had been seeing new patients in Accident and Emergency (A&E), who would then be moved into the acute medical unit for further tests and assessments. Later on they would be seen by a consultant, who would make the final decision as to whether the patient needed to stay in hospital or not. Clutching bundles of files in one hand and jotting down barely legible notes with the other, I trailed the on-call consultant as he strode from bed to bed, assessing the days patients. He was clearly an excellent clinician, albeit a slightly rushed one, and just as Id finish scribbling down each action plan Monitor renal function Bladder scan Organize family discussion he would vanish, searching for the next patient on his list.

I dumped the notes and scurried across the blue linoleum floor, trying not to bump into speeding tea trollies or busy nurses. I scanned the next bay, searching for my consultant among the forest of curtains and drip stands. And there he was, already pulling the curtains around our next patient: Paul.

Paul was an IT consultant in his late forties. He lay on the hospital bed with a pillow wedged under the small of his back. He sported a well-worn grimace. Beads of sweat dotted his bald head, occasionally setting off along the ridges of his furrowed brow. Paul had lived with persistent low back pain for the past few years, attributing it to a conked-out office chair. His pain, originally short, sharp twinges confined to a small area of his lower right back, initially came and went. But over the course of the past year, it had become constant and much more intense. Paul had gradually retreated from society: first he gave up on golf, then on seeing friends at the pub, and now he rarely left the house, having taken extended sick leave. His personal life was collapsing in on him as well: his father had died a couple of months previously and last week apparently unrelated to his pain his wife had left him. Over the past few days, Pauls pain had spread to the left side of his back and down the side of his right leg. This morning, the pain had been so severe that he couldnt get out of bed. He said he never saw the same GP at his local practice, and felt that they didnt understand his pain; so Paul had bypassed this by getting his son to drive him to the hospital. The A&E doctors had seemed a bit perplexed by elements of his history, so they had erred on the side of caution and ordered an MRI scan. This was to rule out cauda equina syndrome, a rare condition in which the nerves at the base of the spinal cord are compressed.