Get two taps into any mindfulness meditation app, and you’re bound to encounter the expression “Pain is inevitable, suffering is optional.” Rooted in Buddhist philosophy, it means that while we can’t escape hurtful experiences, we can learn to respond to them in a way that makes them more bearable. As I explored and eventually embraced its ancient insight, I realized how well it aligns with contemporary science’s understanding of pain resulting from physical injury.
In concept, such pain is an ugly monolith: solid and uniformly bad, something always to fear, avoid, assuage. But examining the actual experience of it, we find it comprises both physical and emotional effects, varies widely in quality and intensity, and can flicker on and off. It also teaches us to avoid danger and prompts us to care for ourselves and others—healthy and compassionate impulses, however unpleasant their genesis.
Given these observations, the neural underpinnings of pain make sense. Imagine that you accidentally kick the leg of your bed while shuffling to the bathroom in the middle of the night, breaking the little toe on your right foot. Which I have done, twice. You feel a short, sharp pain in the toe and, a couple of ticks later, a diffuse, burning sensation engulfing the whole top-right corner of your foot. Then, if you are like me, you cuss vigorously at the unpleasantness while hobbling to the kitchen for a bag of frozen peas to remedy it.
Both waves of physical pain, the sharp and the burning, are triggered by nociceptors, a class of sensory neuron that detects tissue damage and potentially harmful levels of heat, cold, force, and/or chemical irritation. Detecting the impact of your toe-bed collision, nociceptors send data about it into the central nervous system, where its processing causes automatic withdrawal of your foot from the bed and assessment of the event’s existential significance to you. At some point during all this activity, by means shrouded in the mysteries of consciousness, you become aware that you are experiencing the sensation that you have learned to call “pain,” and you are not happy about it.
Why do the two waves of pain feel different? Part of the answer lies in how data collected by different nociceptors travels to, and through, your brain. Some data races toward it through roomy, insulated sensory axons at up to 150 miles per hour. It arrives before any other neural news of your mishap, thus triggering the first wave of pain. And you feel that pain clearly concentrated in your toe because the data is processed in the brain by the somatosensory cortex, which precisely analyzes its source in the body. This precision is essential because the purpose of that first wave of pain is to enable your removal from immediate danger, and the central nervous system needs to know exactly which part of you is endangered in order to do that.
Other nociceptor data travels through narrow, uninsulated sensory axons at the pokey pace of about two miles per hour, so the pain it triggers blossoms after the first wave, the length of delay positively correlated with the distance between the data’s source and the brain. This second wave of pain covers more territory than the first because the parts of the brain that initially process the slow nociceptor data don’t precisely localize its source in the body. They don’t need to, as the second wave’s purpose is to prevent further injury by motivating you to protect the toe by a wide margin, for instance by keeping pressure off the right part of your foot while walking.
While the first wave of pain lasts mere seconds, the second persists for minutes or hours. And, alas, you’re not off the hook even then, because your broken toe also leads to inflammatory pain. This takes hold when your immune system releases a deluge of chemicals into the injured area to combat pathogens that may have entered the body there, and to initiate repair of damaged tissue. These chemicals cause the warmth, redness, and swelling characteristic of inflammation, and some of them activate nociceptors, which in turn trigger a burning pain much like the second wave.
Inflammatory pain differs from acute pain in several important ways, however. It is exacerbated by normally innocuous stimuli (like light touch or mild heat), because the body’s immune response lowers the activation thresholds of some nociceptors. It spreads more broadly, as nociceptors firing in the area of injury set off those in adjacent, healthy tissue. And it persists for days or even weeks, in part because the nociceptors involved don’t simply react to their environment. They change it by releasing chemicals back into the injured area, which assist in the healing process but also help sustain the very conditions that cause them to trigger pain in the first place. Oh, the costs of your midnight trip to the bathroom! But in making you reluctant to touch or burden the affected area, inflammatory pain performs the valuable function of keeping your toe safe until it has fully healed.
Along with their physical manifestations, both acute and inflammatory pain bring a liberal lacing of unpleasant emotion—pain’s power to anger, worry, sadden, and demoralize us. This is the kind of suffering to which the popular meditation expression refers, and its cleverness in this context lies in the insight that the emotional and physical aspects of pain may seem completely inseparable, but they are not. If we pay very close attention, we can discern between them.
You can try, right now. Close your eyes and sit or stand as still as you can. Scan your body for some unpleasant sensation—sore feet, backache, period cramps, anything. If none presents itself, yet you’re keen to experiment, flex one of your biceps and give yourself a hearty pinch on the top of it. Now concentrate on the resulting sensation for a minute. Can you describe its location, quality, consistency, or intensity?
Next, tune in to your mental state. Can you discern a particular attitude toward the sensation—perhaps annoyance, curiosity, or indifference? If you can answer both these questions in the affirmative, you have perceived the distinction that exists between what we feel and how we feel about it, which is also reflected in the distinct ingredients and processes by which the brain creates our sensations and emotions.
Why bother? Because we can sometimes exploit these distinctions to our relief when pain arises. Like all our emotions, those accompanying painful sensations are the product of various nonemotional ingredients, including bodily feedback (such as nociceptor signals), our attention to particular sensory stimuli (that burning, broken toe), and facts and personal history stored in memory that shape how we interpret the significance of a given situation. By consciously tweaking some of these, we can alter the quality of our emotions.
Many of us do this intuitively, perhaps turning our attention from a sore muscle to a pleasantly engaging conversation, or reflecting on the long-term health benefits enabled by an unavoidable surgery, instead of dwelling on normal postoperative pain. Such tactics may have little impact on the physical experience of pain, and they are no substitute for its professional, evidence-based treatment, where appropriate. But they can lessen pain’s overall burden by reducing the unpleasantness of its emotional component, and that’s a real mitzvah in our unavoidably painful lives.
Every one of us experiences pain differently, and would, even in the impossible event that we sustained the exact same injury. Biological factors like genes and health status contribute to the differences, as do psychological and environmental factors like mood and cultural beliefs about the meaning of pain and “appropriate” responses to it. The variability of the pain experience, and the fact that an individual’s experience cannot be objectively measured, means that patients and physicians never have precisely the same definition of the problem to be solved, which complicates effective treatment. Often-cloaked causes make it hard to treat, too, as in the case of pain related to damaged nerves. As one anesthesiologist summed it up for me, “It is difficult to reliably influence what one does not understand.”
However heterogeneous the individual experience of pain, its clinical management is highly standardized and pharmaceutical-centric in the Western health systems in which I have received care. During a long or tricky surgery, like the one to replant my hand, anesthesiologists typically administer a trio of drugs intended to keep the patient pain-free, perfectly still, and blissfully ignorant of all that transpires during the procedure. A painkiller, or analgesic, blocks the flow of nociceptor signals to the brain from tissue damaged by injury and surgery, thus limiting the information available for translation into unpleasant sensations and emotions. The analgesic also triggers release of chemicals that cause feelings of pleasure and well-being in a conscious person, causing that “no place I’d rather be” euphoria I enjoyed in the ER.
A drug in the edgy-sounding hypnotic category renders the patient unconscious, thus not only unaware of their context but also incapable of voluntary movement. By precluding the wakeful self-awareness that many neuroscientists believe is a prerequisite for pain and other mental states, like pleasure and fear, the hypnotic also reinforces the analgesic’s effects. Finally, a paralytic drug reinforces the action of the hypnotic by relaxing the patient’s muscles, thus preventing involuntary movements like gagging on a breathing tube. Outside the operating room, where patients generally need to be conscious and mobile, the acute pain management regimen can be simpler. Mine mainly comprised opioid analgesics—morphine in the hospital ER and recovery wards, and hydrocodone at home.
Researching pain, I noticed how mine had evolved over the course of my injury and recovery. I’d felt none until reaching the hospital—apparently a beneficiary of the brain’s natural opioids, which can block pain-triggering sensory nerve signals en route to the brain in times of extreme stress, as described in chapter 2. When pain finally took hold of me in the emergency room, it felt unlike any I’d experienced: throbbing, searing heat and viselike pressure engulfing my entire hand—the hallmarks of inflammatory pain, plus some secret-sauce sensations my brain cooked up just for me. The analgesics dialed it down, but never enough to let me forget about it for long. This concerned Dr. Vargas, but he didn’t deem it prudent to prescribe higher doses of the drugs. He had to balance the benefit of relieving my pain with the risks of blunting its protective qualities, and of addiction. And after all, I could bear it. So it persisted, intensifying between drug doses, after OT exercises, and other times for no apparent reason at all.
The pain aroused my worry and wonder in equal measure. My hand is supposed to be healing, I thought, so why does it hurt in exactly the same way as it did before surgery? What if the pain never stops, and I get addicted to the medication? How alive this poor thing is! What is going on in there, to cause this relentless, raging sensation? As designed, the pain also reminded me of my hand’s fragility so that I would protect it. I did this with wearying gusto, monitoring my movements to spare it careless knocks and jolts, strictly adhering to my OT and drug regimen, and enlisting neighbors to perform essential but risky tasks—mainly opening new jars of peanut butter, food of the gods and staple of my one-handed-meal repertoire.
Just as inflammation spreads from injured to healthy tissue, that sense of fragility spread from body to spirit, causing me to question my capabilities and belonging—everything that normally makes me feel safe and hopeful. Such doubts didn’t win much of my stretched mental bandwidth in daily life, but they pervaded my dream world. There, I embodied a Japanese man, and had just dug myself out of a suffocating avalanche, but my wife didn’t believe me. There, I had prepared extensively for a violin recital, but my teacher and friends refused to attend, insisting I wasn’t ready. There, I had never learned to skate, but was forced to compete in the Olympic ice dancing finals. The morning after such dreams, my most urgent self-care task was to shake off their poisonous messages: You are not yourself. You are not like anybody else. You are alone in this trial, and you may not be equal to it.
Looking back, I find these dreams achingly poignant, and more than a little comical in their hyperbole. But their counterpoints whipped up by my subconscious made me laugh out loud, even at the time: Sex dreams! Sex with cute guys I knew. Sex with cute women I knew. Sexy partners, outfits, and moves I could not imagine engaging with in real life. The dreams were racy and absurd. But in them, I was physically and emotionally whole, in sync with humanity, and oh so capable. Awaking from them, I felt a fleeting sense of my healthiest, pre-accident self.
Eventually, as my ravaged tissues healed, the chemical soup they’d stirred up dissipated, nociceptors in the area became starved of fuel, and the physical pain they triggered diminished. I needn’t have worried about addiction to the hydrocodone; as the virtuous circle of healing accelerated, I simply began forgetting doses until I’d stopped taking it altogether.
The pain didn’t completely disappear, though. It still burns and throbs today, and often comes with an aching stiffness and muscle fatigue. Fortunately, it never quite reaches its former intensity. And it has generally been more off than on since my hand healed—though ironically, it is more persistent now while my right hand spends most days gripping a pen, or tensed over my Mac keyboard, drafting pages for this book.
When the pain exceeds my patience for it, I run my right hand under cool water, or cradle it in the crook of my left elbow and encourage it to go limp, which seems to offer a little relief (though I couldn’t say why; must research that). Sometimes instead of trying to chase the pain away, I let it hold my attention. I turn it over in my mind and tease apart its threads, curious about its expression du jour. I remember when the pain made me feel completely broken, yet breakable still, and just how much effort it took for me to distinguish between those feelings and my actual, improving prognosis. Now the pain reminds me of all that I have survived, and all that I have gained from my accident. It hurts, and I like it.