Pain, Still Undertreated and Misunderstood

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A Nation in Pain: Healing Our Biggest Health Problem

What makes pain a most compelling subject—one that we want to read more about—is its universality: Every human suffers pain and is fearful of it.


Title: A Nation in Pain: Healing Our Biggest Health Problem
Author:  Judy Foreman
Publisher: Oxford University Press
Publication date: May 1, 2015
Price: $19.95, paperback; 464 pages

The subject of pain has been written about extensively, from the intriguing sociopolitical history of opium to the current national convulsions over the growing abuse of “pain pills” by recreational drug users. Over the past few decades, the oncology community has had its own introspective discussions about the clinical challenges of undertreated cancer pain. But what makes pain a most compelling subject—one that we want to read more about—is its universality: Every human suffers pain and is fearful of it.

Although our scientific knowledge of the causes and treatment of pain has grown at an exponential rate, vast numbers of people still suffer needlessly from untreated or undertreated pain. Remarkably, there are whole countries in the developing world where opioids are not available to assuage the suffering of cancer patients.

According to a new book called A Nation in Pain, the lack of adequate pain control is one of the most urgent health problems in America. And although the book doesn’t center on cancer pain, it is a worthwhile read for the oncology community in its thorough examination of undertreated pain.

Personal Story

Encyclopedic in scope, this new book on chronic pain also tells the personal story of the author, Judy Foreman, a Boston-based, nationally syndicated health columnist. When she developed chronic neck pain, Ms. Foreman’s savvy medical background and reporter’s skills were little help. According to the author, she suffered the same stigmatizing it’s-all-in-your-head reaction that many chronic pain patients experience. Finally, an MRI showed the arthritis, bone spurs, and sliding vertebrae of her cervical spine that caused her agony.

Ms. Foreman spent 5 years interviewing experts, reviewing the literature, and talking to patients to summarize what America is doing about pain. The answer? Not nearly enough—despite a 2011 report by the Institute of Medicine of the National Academies of Science revealing that 100 million Americans live in chronic pain. 

The book leads off with an informative section called “How to Read This Book,” which is a nice touch, rarely seen. Ms. Foreman understands that when writing for an audience of mixed preferences, not everyone will choose to tackle her book with a cover-to-cover approach. She writes, “If you’re a patient who’s outraged at the way you’ve been treated—or not treated—for your pain, Chapter 1 is a must-read…. If you … absolutely hate science, just skim through Chapter 2 on how the body turns acute pain into chronic pain and Chapter 3 on the genes that rev pain up or damp it down.” Sound advice.

Informative Discussions

The author’s discussion on the genetics of pain, although written in layperson prose, is informative and spot on. She’s done her research, and it shows in one of the subchapters called “The Hottest Genes to Watch.” She takes the reader through some of the nation’s most dedicated pain-gene research laboratories, such as the Pain Genetics Lab headed by Jeffrey Mogil, PhD, at McGill University.

At last count, Dr. Mogil and his associates have found roughly 370 potential pain genes, with new ones being discovered almost daily. Dr. Mogil says that the task “is like putting together a 1,000-piece puzzle, and we are nowhere near putting it all together.”

Another chapter that will be interesting to The ASCO Post readership centers on the relationship between chronic pain and depression. Her consideration of pharmacologic treatments for pain patients suffering concomitant depression adds little to the discussion. However, a more interesting topic is fleshed out in a subchapter called “Catastrophizing,” which is defined as “a maladaptive cognitive and emotional habit that leads to focusing obsessively on pain, imagining all sorts of worst case scenarios and generally believing that the pain will be endless, life-wrecking, horrible, and unfixable.”

To counter “Catastrophizing,” the author runs through a litany of self-reporting methods, acupuncture, biofeedback, meditation, and other “distraction techniques. The author makes it clear that pain is associated with a number of psychological issues related to depression, fatigue, and anxiety, all of which are overlooked far too often by medical professionals, some of whom still perpetuate the age-old stigmatization of pain.

Unfortunate Missteps

Ms. Foreman follows this thoughtful chapter with two chapters on opioids that are unfortunately poor. The author spends the better part of these chapters discussing drug abuse, citing story after story of people “inadvertently addicted” to life-destroying opioids. In hyperbolic prose she writes, “Because the issue of drug abuse is so heated and the emotions it generates so raw, the rhetoric often becomes extreme. Some law enforcers have likened [pain] doctors to terrorists and the Taliban and have called [oxycodone] in particular a ‘seductive, deadly menace.’”

Then there are disjointed sentences such as, “Opioids are kind of like airplane food: not that great—but for some people with pain, impossible to get enough of.” This leads to a section called, “How Effective Are Opioids Long Term?” Seemingly intent on downplaying the effectiveness of opioids, she interviews a young man dying of esophageal cancer who is in intractable pain. His exact clinical scenario is never fully laid out, but she segues into a section stating that physicians who treat cancer pain should “err on the side of caution.” This is the kind of philosophical dead end that has long exacerbated the undertreatment of pain.

Moreover, a couple of chapters are one-sided to the point of hype. For instance, she totally advocates the use of cannabis for the treatment of pain, suggesting that it be sold as a dietary supplement and suggests that it is as effective as opioids for the treatment of pain. In contrast, she gives short shrift to some important therapeutic advances, such as mixed serotonin-norepinephrine reuptake inhibitors like duloxetine and venlafaxine. And her chapter on the immune system’s contribution to chronic pain is equally one-sided and dubious.

Good Information

Ms. Foreman does regain her footing with a surprisingly good discussion on chemotherapy-induced neuropathy, noting that painful peripheral neuropathy is the most common reason patients have to stop their treatments. Here she explains with confidence the biochemical causes of neuropathy and some of the interesting research in this difficult setting.

A Nation in Pain concludes with several short chapters on accessing information and resource support for pain patients. It’s good information, because people in pain often feel they are being judged by a society bombarded in the lay press with stories of prescription pain pill abuse and deadly overdoses.

Abuse of opioids is a serious problem, but these drugs have an appropriate role in pain control. Hyperbolic language calling pain doctors terrorists or the claim that oxycodone is a “seductive deadly menace” only adds to the undertreatment of pain. Ms. ­Foreman has written a good book, but like many other writers, she drops the ball when discussing opioids.  ■