A Nation in Pain: America’s Hidden Epidemic

Judy Foreman

Judy Foreman

Judy Foreman is an award winning journalist and a former nationally syndicated health columnist. Her struggle with chronic neck pain and the “eye opening” experience she had going from doctor to doctor seeking relief led her to write A Nation in Pain: Healing Our Biggest Health Problem.

Foreman spent five years researching the book, which takes a sweeping and often critical look at how chronic pain is treated and perceived – not only by the medical community – but by policymakers and the public.  She hopes her book will help change the way the “hidden epidemic” of chronic pain is viewed in America.

National Pain Report editor Pat Anson recently spoke with Foreman about A Nation in Pain.

Anson: You say chronic pain is our biggest national health problem. What makes you say that?

Foreman: Because chronic pain really is a bigger problem than cancer, heart disease and diabetes combined, at least in terms of the number of doctors’ visits and the expenditure. The cost of treating heart disease, cancer and diabetes together is less than chronic pain, which the Institute of Medicine (IOM) report says costs upwards of $635 billion a year. So it’s a very expensive problem, although I don’t think most people realize it.

Most people think pain is a symptom of something else and if you could figure out that something else, you’d have the whole thing nailed. But often it isn’t that easy to figure out what’s going on. And doctors tend not to believe people who are in pain, with the result of people going from one doctor to another, which gets very expensive. There’s a lot of lost productivity. And sometimes the caretaker of someone in pain winds up having to quit or cut back on their work to take care of the person in pain. So it winds up being a complicated but very widespread problem.

Anson: And it’s a problem that’s going unaddressed?

ForemanPainBook5Foreman: Absolutely unaddressed.  I have two big infrastructure points in the book. One is that medical schools do not teach pain. There was a big study by Johns Hopkins in 2011. They did a survey of 117 medical schools and found that the median number of hours that students get learning about pain is nine. That’s over four years of medical school! Even veterinarians get more hours on pain education than doctors.

Next time you go to your doctor, ask in a friendly way how many hours of pain education did they get in medical school. A lot of them will say one or zero. They really don’t know the neurobiology of it. They don’t know the types of pain very well. They certainly don’t know a lot about how acute pain transforms into chronic pain, which is a whole complicated nervous system problem. The nervous system essentially gets revved up and gets better and better at transmitting pain signals. So it becomes a self-fulfilling thing, a self-perpetuating problem. It’s now known that cells derived from the immune system, called microglial cells, also contribute to this revving up problem. So it becomes a disease in its own right and most doctors don’t really know that.

The other big infrastructure issue is that the feds spend almost no money on it. Only about 1% of the massive National Institutes of Health (NIH) budget gets spent on pain research, which is crazy given how prevalent chronic pain is. It’s a complete mismatch between what patients need, what medical schools teach, and what the federal government funds or doesn’t fund.

Anson: One of the things I’ve learned as editor of National Pain Report is that the whole discussion of pain and how to treat it is dominated by health care practitioners, pharmaceutical companies, government regulators and law enforcement. It seems that pain patients, when it comes to setting policy, really don’t have a seat at the table. Would you agree with that?

Foreman: That’s absolutely true. There are two committees on pain at NIH and in the government. They meet very rarely and they have almost no budget. There is one pain patient advocate on one of those committees.

You’re completely right, patients have no voice. They even have no voice when they go to an individual doctor. The burden of proof is sort of on the patient to prove they have pain, not on the doctor to believe them. And that’s really ass backwards.

Pain patients don’t have any money. And their lives are already constricted if they have bad pain.  But it’s going to be up to them, I really believe, to change the system because medical schools are so entrenched in the way they approach things.

There is some thought to getting medical schools to do things differently. And that’s if you start putting questions about pain management and the neurobiology of pain on the exams that med students take to get out of medical school and on continuing medical education exams and things like that. If the questions are on the exams and the students start flunking because they don’t know the answers and haven’t been taught, that’s the leverage to get medical schools to start teaching it.

It’s kind of heavy handed, but it’s the only way to get things happening.

Anson: You say it’s up to pain patients to change things. What can they do?

Foreman: The reason I think it’s up to pain patients is that, first of all, there’s a lot of them and they are really not being treated well by the medical system. I’ve been a reporter for 40 years and most of that time as a medical columnist. I’ve watched people with AIDS, breast cancer and disabilities getting political, getting active, taking to the streets, going to scientific meetings, going to Congress, lobbying and basically making their voices heard. And it’s only because of that political pressure that anything happened.

Things have to happen in medical schools and in Congress. Congress gives the money to NIH. Frankly, I think there should be a whole Institute for pain at NIH. There’s an Institute for everything else, but not pain, even though it’s a bigger problem than a lot of things that do have Institutes.

I think there has to be political pressure. And I think patients are potentially the most powerful group in terms of being believable. They’ve got the problem.

Medical schools are entrenched in the way they do things. The NIH is entrenched in the way they do things. I think it’s going to take an outside force like patients to make anything happen.

Anson: But that takes time and resources. And for a lot of pain patients, just getting out of bed in the morning is hard, much less writing to a Congressman.

Foreman: Absolutely. People are so beaten down by this. They go to a doctor and the doctor disses them and they go home and cry.  It is asking a lot. But there are some patients who I’ve met who very articulate, are willing to come forward and have gotten really good at managing their own pain.

It’s a shame. It’s like you have breast cancer and you’re supposed to become a politically savvy lobbyist with no money? It is asking a lot of people. But given the vast number of people who have chronic pain, there are probably a handful who are willing and able to do it.

Anson: Isn’t part of the problem is that pain groups are broken up into silos? You have a silo for fibromyalgia, you have a silo for multiple sclerosis, another for people with back pain. Everyone is locked into their silos, when they should all be one entity.

Foreman: I couldn’t agree more. In fact, I organized my book to be silo free. It’s not a book about arthritis or back pain or fibromyalgia. I mention those problems, but from an overall political point of view, I think you’re completely right. They are definitely in silos and people identify with their own disease and not other people’s, when really there is a lot of commonality. They have more in common than not.

Anson: What do you think of medical marijuana?

Foreman: I have a whole chapter on it. I think it can be very, very helpful. I’m in favor of it, if you need a short answer.

I was so intrigued by the research on medical marijuana. I have a whole lot on the biochemistry of marijuana. We have more receptors in our bodies that we are born with for own endogenous marijuana-like substances, that you have to think this is an important chemical for the body’s survival.

It is incredibly safe. Marijuana alone has been linked to zero deaths. And it’s much less addictive than a lot of the other stuff we take, including tobacco and alcohol.

There is a little preliminary data that it has a positive synergistic effect with opioids, meaning you can take lower doses of opioids if you also inhale marijuana, and you’ll get the same pain reducing effect. That is important because with a lot of urine testing, especially for military veterans, if you have a positive urine test for marijuana they won’t give you the opioids. Which is actually probably backwards to what they should be doing.

I think medical marijuana is great. I do talk about some of the potential harms. There’s sort of an unclear risk of schizophrenia and some potential cognitive risk for young people. But some of the data that comes from young recreational users doesn’t apply to older medicinal users. It’s kind of like two separate populations. The older people with pain I don’t think should be penalized because young people may get into trouble with it.

There’s a good argument to be made that our war on drugs has basically failed. It hasn’t been a success from a law enforcement view and it certainly hasn’t been a success from a medical point of view.

Anson: You’ve called the debate over opioids “public hysteria”?

Foreman: I have. First of all, there’s a difference between addiction and dependence. Dependence is inevitable if you take opioids for any of period of time, but it’s not necessarily harmful. Many people do very well taking opioids responsibly for years and years without upping their dose or without abusing the drug.

People get off the drugs every day. They have surgery, they take opioids to control the pain and they get off them without any trouble. It’s true that some people do have trouble getting off them. But there are ways to use other drugs to help people ease the transition off from opioids. The main thing is to do it very slowly. A lot of people try to do it cold turkey and that’s when they get into trouble.

Anson: You say opioids are both overprescribed and under prescribed.

Foreman: Yes I think that’s true. It’s a little weird, but I think it’s true. They are certainly under prescribed for a lot of legitimate pain patients who use them responsibly.  They may be overprescribed in some cases. Again, that gets back to how little doctors really know about basic pain mechanisms and how to treat it.

Anson: What do you hope to accomplish with this book?

Foreman: I’d like to put chronic pain on America’s radar screen. It’s really a huge problem and it is under addressed by medical schools and under addressed by the federal government. People with pain are really dissed, because doctors don’t know what to do with them. They often say it’s in your head and that’s really not true. I’d like for pain patients to be believed and medical students in particular to learn about it in medical school.

The IOM report calls for a cultural transformation, which I think is correct. We really do need to take a much different and much more sympathetic view of people in pain  and have our assumption be that they are telling the truth and need help, not to have our assumption be that they’re making it up or that they are drug seeking.

Anson: Thank you, Judy.

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45 Responses

  1. Trudy McGee says:

    @Pat Anson, Editor, THANK YOU!!! This article/interview is about people in pain, and most of the remarks are EXACTLY why people in pain REMAIN in pain. Pure politics! They should be ashamed of themselves. Most of the contributors to this article have never suffered chronic pain in their lives, yet they insist that they are the so called experts in this field, and theirs is the only answer. Perhaps if they spent time listening to the patients that LEFT them, they might learn a thing or two.

    Thank you Judy Foreman for your book, and I look foreword to reading it. Perhaps, but probably not, I can get my pain doctor to read it too.

  2. Pat Anson, Editor says:

    @ Drs. Rodrigues, Quintner, Badgley, et al. As this is rapidly turning into a food fight that has nothing to do with Judy Foreman’s book, this will be the last post from the three of you on this thread. Thanks for your contributions!

  3. John Quintner, Physician in Pain Medicine says:

    To all who follow this discussion with interest.

    This is not a simply contest of male medical egos. The issues that have been raised go to the very heart of what is so strikingly wrong with the current medical management of people with chronic musculo-skeletal pain.

    We all well know that opiate medications prescribed for chronic pain are analogous to a “double-edged sword”. This website has chronicled the issues currently being debated.

    But Dr Rodrigues is now championing what he sees as an alternative remedy – that which is currently being referred to as “myofascial release therapy with hands on and needle options ..”

    In my opinion, this is yet another pseudo-scientific fraud of huge proportions that is being foist upon untold numbers of pain sufferers by many health professionals, including my medical colleagues. In simple terms, patients are being extensively “rubbed” and “needled” for money.

    Of course, if they are paying the bills, they are entitled to make their choice of clinicians and treatment. Third party payers may take a different view and insist on scientific evidence being provided by those who are administering such treatment.

    To borrow again from Dr Oliver Wendell Holmes, in my opinion such practices “are ruinous to professional advancement and the dignity of the profession.”

  4. @Quintner
    Laurence Badgley, M.D. does not owe an apology to anyone!!! He is stating facts!
    The facts are this site is a place to garner hits for marketing and sale purposes ONLY.
    The site or the editors are not interested in an intelligent dialogue of ideas past, present and into the future. I have noted that and have discussed this with the editors. The response was “you are harassing me.” And then they block a lot of my comments, even if I am preaching. :)

    I preach what I have read in my textbooks. I would not have put all the pieces together if not for their contributions. Most of what I stated are the digested, tested and assimilated parts of what I have read. Each author evolved in sowhat Isolation but if you blend all them together you get a better picture of what is the best therapeutic option for a particular case.

    Dr. Quintner you are a naysayer and have not offered any ideas or experiences except to destroy. It is odd that you disavow my experience and the testimony of all my accounts of my patients. That is destructive and vengeful, why … discount “my/our” accounts? All you have to do is ask for a few cases that you can evaluate (actually a few you can talk to personally if you so desire. I have hundreds. What can you offer in a constructive way to help some of the readers?

  5. John Quintner, Physician in Pain Medicine says:

    @ Dr Badgley. I think you owe a sincere apology to the Editor (and his staff) of National Pain Report. Your accusations are entirely unfounded.

    By the way, I see that you have made what you seem to think is an important contribution to the understanding of the enigmatic condition called Fibromyalgia. Let me share some of this this speculative nonsense with the readership of this website:

    “FM is a multifactorial disorder due to advanced musculoskeletal deconditioning and widespread chronic muscle spasm leading to the development of countless muscle trigger points …”

    I can now see why you would rise to the defense of your colleague Dr Rodrigues, who thinks along similar lines.

    Yes, the words of Oliver Wendell Holmes still ring true today. Let me repeat them: “… but it always does great harm to the community to encourage ignorance, error or deception in a profession which deals with with the life and health of our fellow creatures.”

  6. Pain is not a static term.
    Pain is individual, personal and can not be graded on a scale or verbalized with consistency and clarity. Pain is more like a phantom, an apparition, an illusion as in a dream image, mirage,
    completely hidden from view. Did you know that “pain in the knee” more than likely is not in the knee proper but somewhere from the lower back to the calf? Did you know that pain is not what you think it is or where you think it is or that pain will evolve, devolve and migrate.

    @Nattional Pain Report writers and bloggers;
    If you keep reading the same info, data, opinions and slants, you will never break out of your present paradigm.
    If you are so certain that you “know” beyond doubt that you “know” or the system that got us in this present paradigm will get us out or not be open to what clinical practitioners have to deal with then “thou shalt be done.”

    @All
    Let me tease out some of the misunderstanding;
    This is not just about Acupuncture or Travell or High/Low technology or my experiences, this is about a combination therapy that includes at it’s core Myofascial Release Therapy with hands-on and needle options. It is a blend of therapeutic options, so it is not just a pill, or Acupuncture, or massage, or stretching or minerals … it’s a combination of options dictated by the person in pain.

    I try not to be biased towards any discipline and try to be inclusive of what works and does no harm. Opening up the skull, joint replacement or back surgery for pain are not on my list of options anymore. In 2014, I would consider offering those procedures without first introducing hands-on and needles malpractice.

  7. John Quintner, Physician in Pain Medicine says:

    Dear Editor.

    I wish to clarify my post of Feb 3, 4.16 pm.

    Permit me to add an observation – in much of the medical discourse that I have read, pain as a lived experience is being reified (i.e. made into a “thing” or concrete entity) that has been awarded the property of being able to cause structural changes within the body (including the brain). This is of course an impossibility for such an experience.

    But most pain sufferers think this way about pain and I cannot blame them for this. Being in pain sure changes one’s behaviour.

    However, problems arise when well-intentioned health professionals decide to attack this “thing” called pain by using whatever weapons are at hand. Such an approach was always doomed to fail and this is what disillusioned pain sufferers have been telling us medicos for some time. But we have not been listening!

    In my opinion, it is this misconceptualization of pain that has to be addressed at all levels.

  8. John Quintner, Physician in Pain Medicine says:

    @ Dr Badgley. Thank you for asking. I represent myself. If you detect a public advocacy role, it is solely for people in pain. No funding support has ever been asked for, or received, by me. As for people “purchasing” any of my recommendations, they are freely available in the peer-reviewed medical scientific literature. Some of this recent work is downloadable from the website of Painaustralia, the peak not-for-profit organization in Australia.

    I am currently retired from medical practice and work part-time as an unpaid volunteer for Arthritis and Osteoporosis WA. My projects involve the delivery to consumers and health professionals of educational programmes in matters related to chronic pain.

    Does this satisfy your curiosity?

  9. Laurence Badgley, M.D. says:

    Dr. Quintner, I never impugned your integrity for you are clearly integrated; with an ostensible highly funded presentation. Would it be appropriate to ask the identity of your funding agencies. In that you provide a forum and advocy for a collection of commercial interest, it would be interesting for lay persons to know who your financial supporters are before they purchase your recommendations.
    @doctorbadgley at Twitter

  10. John Quintner, Physician in Pain Medicine says:

    @ Dr Rodrigues. A detailed response to your hard-won “truths” is beyond the brief of this website.

    However, you and the vast majority of our fellow medical practitioners (including the past icons you have discovered in your reading) have fallen into the huge trap of believing that you, and they, are treating an independent “thing” or entity called “pain”.

    As we have painfully come to understand, we are dealing with a lived experience that is NOT reducible to any such entity. This is why we have all failed to effectively come to grips with the enormous problems that Judy Foreman and others have identified for us.

    As I see it, the fact of the matter is that we are all attempting to help our fellow human beings who seek us out because they believe that we possess scientific integrity and up-to-date knowledge of the mechanisms responsible for their biological predicament.

    That which you preach time and time again about mythical changes within muscles is arrant nonsense and can be relegated to the dustbin of failed medical therapies that were once in vogue.

    You may not agree, “but it always does great harm to the community to encourage ignorance, error or deception in a profession which deals with with the life and health of our fellow creatures.” [from: Holmes OW. Medical Essays, 1842-1882, page 8. Available at: http://www.gutenberg.org/ebooks/2700 ]

  11. Laurence Badgley, M.D. says:

    Thanks for giving me a platform. It took guts to leave my post up.

  12. @National Pain Report and Ms Levy, we all see things differently which is the human experience, your view is from a patient and advocate’s perspective and mine is from a clinical practitioner’s who has had tens of thousands of patient encounters, thousands with complex pain.

    Over my career and life I have collected a few universal and personal trues that will withstand the test of time. (excuse the lecture)
    >If you want to find the truth about chronic pain, don’t believe me or your prior doctors or the scans, the truth can only be discovered by the therapeutic journey.
    >Have a health amount skepticism and try not to be dogmatic.
    >Modern medicine is flawed and will fail many cases.
    >My jaw dropped with reading a textbook from the last century by Burke, Travell, Edwards, Hackett making statements that; “you have to treat pain, the x-ray designated terms like disc protrusion, misalignments subluxations, desiccation should be change because they have no bearing on the how to treat a patient. They noted that their colleagues are rushing to do invasive surgeries.”

    These failures may all have a common thread connecting them masquerading as a consistent, paradoxical, predictable, enigmatic conundrum. But, “When you have eliminated the impossible, whatever remains, however improbable, must be the truth. Sherlock Holmes and Spock.”… the IT is in the muscles.

    Besides, if modern medicine is correct in it’s portrayal of exceptionalism then all surgeries would be 100%, every Pill would cure and there would be no discrepancies on biopsy, test or scans. And everyone would be healthy, happy and well.

  13. Dave says:

    John- Yes we agree- it is up to people in pain to trouble the sleep of politicians and medicine in America when it comes to improving pain care. And it will take quite a lot of effort to trouble their sleep for they do not wish to be troubled.

  14. John Quintner, Physician in Pain Medicine says:

    @ Dr Badgely. Please get your facts straight before you launch a totally unjustified and inappropriate attack on the integrity of this website and those who are responsible for it.

    “Dr. Rodrigues, you are wasting your time on this site, which supports Pain Intervention and all the massive expensive work ups and treatments which you so eloquently disavow. This is a forum for the Big Medicine Machine; check out the support staff. I will be interested to see how cordially you are received.”

    Dr Rodrigues may well be wasting his time but he has been given a forum for his views, as have you.

  15. Laurence Badgley, M.D. says:

    Dr. Rodrigues, you are wasting your time on this site, which supports Pain Intervention and all the massive expensive work ups and treatments which you so eloquently disavow. This is a forum for the Big Medicine Machine; check out the support staff. I will be interested to see how cordially you are received.

  16. John Quintner, Physician in Pain Medicine says:

    @ Dave. Thanks you for responding in such detail.

    Yes, I agree that you do have good grounds for your pessimistic outlook for pain care in the USA. To shift medical thinking beyond endless diagnostic procedures, prescribing potentially harmful drugs, and pursuing invasive interventions will cut across the fee-for-service imperative that drives current practice in Pain Medicine. Turning around the Titanic just before it hits the iceberg would seem like child’s play compared to this task.

    However, may I refer you to these words of Philip Pizzo, Chair of the Institute of Medicine’s Committee on Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research:

    “These recommendations serve the goal of creating a comprehensive, population-level strategy for pain prevention, management and research. The scope of the problems in pain management is daunting, and the limitations in the knowledge and education of health care professional are glaring. The medical community must actively engage in the necessary cultural transformation to reduce the pain and suffering of Americans. Importantly the cultural and social transformation needed to alleviate pain in America will require the collaboration of the healthcare provider community with patients and their families who are suffering from pain, including their communities, professional societies and advocacy organizations as well as state and federal government. New public private partnerships and a broad concerted level that addresses pain as a public health initiative as well as an individuals source of suffering will be necessary if we are to make progress in alleviating pain. We must all be part of the dialogue and the solution.”

    Surely his words and Judy Foreman’s research and subsequent book must be seen in this light. I hope Judy’s desperate call for political pressure, as called for in the above interview, does not fall upon deaf ears:

    “I think there has to be political pressure. And I think patients are potentially the most powerful group in terms of being believable. They’ve got the problem.

    Medical schools are entrenched in the way they do things. The NIH is entrenched in the way they do things. I think it’s going to take an outside force like patients to make anything happen.”

    In fairness, it also needs to be said that such Pain Medicine luminaries as John Loeser and Dan Carr have made the same call.

  17. John Quintner, Physician in Pain Medicine says:

    @ Dr Rodrigues. Thank you for summarizing your assumption:

    “The assumption that I make is if a patient has chronic stubborn aches, pains and stiffness that fails medications and the surgeon’s blades then they have Myofasical (sic) Pain and Dysfunction until proven otherwise. With or without, Migraines, Pelvic pain, MS, Lupus, RA or the like, they have been seeded with TrPs which have corrupted the muscles and the muscles have corrupted the associated neurologic, vascular, lymphatic, movement and metabolic functions.”

    You have not produced a shred of scientific evidence to support your fanciful assumptions, yet you choose to inflict more pain upon your gullible patients.

    As I have repeatedly made clear to you, the teachings and practices of past icons such as Janet Travell, David Simons and Chan Gunn, have failed to withstand scrutiny.

    The fact that there are so many health professionals who also worship at the Temple of the Trigger Point can only be explained by the fee-for-service imperative that drives medical practice in your country.

    I know these are strong words but some one needs to say them out loud.

  18. dave says:

    John- i made a mistake in my last comment. Pain costs the U.S. 3.5X what it costs per capita in the EU. The focus in medicine is not on saving money but on money making. Politicians in the U.S. have only recently begun to understand that medicine is more than money making venture-and perhaps that is why Medicare payments for pain intervention have been slashed-and perhaps why the U.S. is restricting the supply of opioids- as pain care is viewed by politicians as art class is in schools-there is likely to be further cuts in pain care in the U.S. for politicians in the U.S. believe that no one dies of pain-and that only those dying or suffering from life limiting illnesses like COPD, or AIDS deserve palliative care and access to medical marijuana. And this is why it is always so easy to blame poor pain care on the moral deficits of medicine and politics- just as Dr. Virchow said- there are two causes for disease- pathological and political(and moral).

  19. carol levy says:

    Dr. Rodriguez, I don’t know what patients with whom you have spoken with MS and CRPS, as a start but I can tell you the pones with whom I have had contact will tell you they are not in minimum or moderate pain but severe pain.As someone with trigeminal neuralgia you are wrong on that. Doctors repeatedly find compression on MRI’s. My tn is the result of a very visible neurovascular birth defect. (i.e. also compression)
    Most of us living with chronic pain do not have “chronic stubborn aches, pains and stiffness that fails medications and the surgeon’s blades then they have Myofasical Pain …”
    We have severe bebilitating, often disabling pain. The fact that use the terms of aches and pains minimizes what those in chronic pain suffer with and belies an understanding of what chronic pain truly is.

  20. dave says:

    Dr Shank- its important to fight back and not allow the morally and mentally lazy powers that be get away with it. As the saying goes the only way for evil to flourish is when good people do nothing. And those who do nothing are overconformed to the status quo-almost as bad as the morally and mentally lazy leaders in health care and pain specialists. In my experience, lazy bigshots quickly run out of steam-after all theres not much to their orientation and much that they don’t know and can’t do.
    We all have a choice- I am involved in pain care because a woman in pain got to me with her suffering. I have made a choice and nailed myself to the cross of helping people in pain-and frankly learning about pain care brings me no pleasure- for knowledge brings sorrow as they saying goes-but when it comes to dealing with politicians or so called pain experts I don’t back down and don’t give up.

  21. dave says:

    John- it is well known the Australians have a plan to move pain care forward and tghat pain care in Canada and Europe is superior to pain care in the U.S. The IOM report on pain care failed to mention that pain care costs the U.S. 3.5X more per capita than it does in the U.S. Hows that for an inconvenient truth-and so we know U.S. surgeons don’t want to have registereies like their Swiss counterparts-no doubt they would be embarassed by such. Doctors in the U.S. make 2X as their EU counterparts. Pain care in the U.S. is a figment of capitalism. Pin specialists in the AAPM and APS- are under federal investigation for taking money from pharmaceutical companies and promoting opioids- i expect very soon Senator Grassleys Committee will complete their investigation. But all one has to do is go to the web sites of the APS and AAPM to see they are not visionaries or planners. Doctors are not software engineers and dont have specific training in modeling as engineers they wont use tthe theory of constraints when standard preparations fail for people in pain, they wont do adaptive intervention research, they have failed to data mine patient authored texts in pain, Hadoop and mapreduce, TPS, dynamic system development models-are foreign language to them. Frankly, I half belive that it was my many criticisms of the AAPM that got Dr. Webster to finally (and briefly) call for a new vision for people in pain. As the Bible says people perish through want of vision. Doctors and pain specialists work with machine language and quickly process people in pain. HAving gone with people in pain dozens of times to see their doctors I have always been successful only for the reason that the doctor didnt want to take his time to fight with me- for time is money and that is of paramount importance to many doctors. Wasnt it Dr Fishman in a book a few years ago who stressed the importance of taking the time to communicate fully with people in pain-but he misses the point for in the U.S. time is money-and so I understand Dr Shank’s comment about doctors being punished for being punished for taking the time to deal effectively with people in pain. For time is money and doctors in the U.S. dont have time for the pain.
    There’s an old Chinese saying that when you light a fire you had best get out of the way before you get burned. Pain specialists lit a fire with opioids and drugging pin- now some of them are burned-as are many pain sufferers in the U.S. It is of critical importance to explore alternative paradigms so one doesnt get burned by the fires one has already lit. That is why I explore many different views of health and disease. I use three basic tools- telescope, microscope and dreams. With a telescope I explore things far away from what i know, with a microscope i explore what i know in greater detail and with dreams I imagine ideals that are yet to be.

  22. That is the perfect question and observation so I hope to do it justice.

    MS is a mostly neurologic disease, minimal amounts of pain. w pain levels <3. AND
    MS can be seen on MRI and thus a visible pathologic cause.

    SLE is a between type of disease RA-like, FM-like with pain levels 5, POTS, RSD/CRPS, Facial neuralgia, Occipital Neuralgia and TN Plus all of the failed back, neck shoulder, thoracic outlet, hip, knee, wrist, thumb, foot and toe ALL may have a single thread of commonality. ALL have NOT visible or detectable cause on scans or in blood testing. Most have pain >5. Most are on a quest to find a cause, find the right pill, or a deactivating fix or switch. Most have been told that “we can’t find anything wrong.”

    Travell/Simons and Gunn noted this 50 yrs ago that it was erratic muscular functioning that drives this pain and disability. This thread of evidence are errors of repair in the muscle design called a Trigger Point or if you disagree with that term I made up one and call it Pain and Dysfunction Generators (PDGs).

    The assumption that I make is if a patient has chronic stubborn aches, pains and stiffness that fails medications and the surgeon’s blades then they have Myofasical Pain and Dysfunction until proven otherwise. With or without, Migraines, Pelvic pain, MS, Lupus, RA or the like, they have been seeded with TrPs which have corrupted the muscles and the muscles have corrupted the associated neurologic, vascular, lymphatic, movement and metabolic functions.

    There is a lot more to the story but that’s it in a nutshell. I don’t expect physicians (esp non-physicians) to grasp this concept in a single bite. It took me decades to link the tiny bits of thread. They are definitely there if you take another look you may see what will aways be. The proper way to engage my thoughts are to ask for clarity and not to blame me. I’m here to help.

  23. dave says:

    Ms. Levy- yes progress in medicine is made by leaps and bounds- the work of Semmelweis, Fleming and Wall and Melczak- is proof of such. Calling for more of the same biomedical research in the hope of some biomarker being turned into an effective and safe medication for pain is a failed strategy- 90% of drugs that go to clinical trials never become fda approved and 8% of drugs are removed every year. In an official AAPM publication in 2013 Deere et al indicated in the last 20 years there has been few new drug entities for pain-and they also indicated in the foreseeable future they dont believe there will be new drug entities in pain. You fail to understand it doesnt matter how fast youre going if your on the wrong road. And while you and MS Foreman may take comfort in believing more biomedical research is the answer- as far as i can see the evidence is clear- the biomedical model is a failure- doing more of it is a waste of time-i dont make money off criticizing bigshots in pain care-its because i care about a better future for people in pain that i am opposed to current practices and the “delusion of exxaggerating the power of drugging” as Oliver Wendell Holmes indicated over a century ago.
    I am well aware of the bias against woman in pain care- as well as Blacks, Latinos, Children and elderly- a woman in pain got to me-and that is why i have gotten over 27 legislators to sign on to legislation in NYS to improve pain care.

  24. carol levy says:

    Dr. Rodriguez, I am not sure what your reason is for denying MS, Lupus, cranial and peripheral neuralgias, CRPS and so on where muscles are not the primary/often not present at all as the cause of chronic pain. As a physician you seem to be blinded to anything other then your myopic view of muscles as the culprit. This is the sort of bias that many of us in chronic pain find when we go for diagnosis, treatment, etc. It is the parable of the elephant. The 3 blind men touching parts of the elephant and not being able to see past the area that they felt.

  25. carol levy says:

    Dave, you don’t make progress by leaps and bounds but by step by step. Calling for more research and dollars put into research and caring for those in pain is certainly beyond where we are now. In fact the House passed the pain Care Act many years ago with the senate just letting the legislation languish with no action, obviously believing there is no big or time important issue relating to those in pain. I would rather see some legislation and acknowledgement then nothing at all.

  26. carol levy says:

    Dave, there is also proven bias against women when it comes to pain care and being believed, receiving appropriate treatment and medications, and being diagnosed – despite women having higher numbers of disorders that have pain as the main or sole complaint.

  27. John Quintner, Physician in Pain Medicine says:

    Dave, amongst other things you have stated:

    “The APS and AAPM do not have the vision or care enough about people in pain to jump over the shadows of pain care to create the symbols of a new day. They are stuck in the biomedical reinforcement loop. So, frankly no one who really cares about progress in pain care would think much of the NPCPA for it serves the occupational strategies of pain specialists and essentially will do very little for people in pain.”

    As I am attempting to contribute to this discussion from another country, may I ask you to provide the information upon which have you based your pessimistic opinion?

  28. Who is the masked marvel “dave?”

  29. @Dave:

    Either I was woefully unclear, or you completely misread my comment.

    Physicians who appropriately manage pain are punished, because the powers-that-be have decreed it so.

  30. John Quintner, Physician in Pain Medicine says:

    @ Dr Rodrigues. Repeated assertions of the type that you make are a poor substitute for scientific evidence.

    Let us all heed the words of one of the world’s most profound thinkers:

    “Those who are enamoured of practice without science are like a pilot who goes into a ship without rudder or compass and never has any certainty where he is going. Practice should always be based upon a sound knowledge of theory.”

    Leonardo da Vinci [1452-1519] – Manuscript G, Library of the Institut de France (tr. by Edward MacCurdy in The Notebooks of Leonardo da Vinci, Vol. II, Ch. XXIX.

    Need I say more?

  31. John Quintner, Physician in Pain Medicine says:

    Attributing the “hidden epidemic” to the failure of clinicians to detect peripheral (soft tissue) “pain generators” is stretching the bounds of credulity to breaking point. That such a nonsensical proposition is being advanced in a serious discussion such as this is most disappointing, to say the least.

    Why in the absence of a shred of scientific evidence are these tissues presumed to be guilty? In my opinion, basing such a verdict solelyupon the clinical finding of mechanical allodynia (tenderness) betrays a profound ignorance of the science of pain mechanisms.

    When it is eventually formed, the previously mentioned Society for the Prevention of Cruelty to Innocent Muscles may need to extend its brief to include “other soft tissues”.

  32. dave says:

    Dr Shank- when I go with one of my clients to see their doctor regarding my clients pain- it is yours truly who has to educate the doctor about what tests need to be done and what treatments need to be considered. When it comes to pain care doctors will blame anyone and anything but themselves for the pitiful and parlous state of affairs in pain care. But don’t we know that doctors have actively fought against legislation in states like NY to have education in pain care- and the most frequently mentioned barrier to pain care is lack of physician education. But as you suggest it goes deeper than that- for doctors lack caring for people in pain- as Dr Scott Fishman has indicated-and we know about the prejudice toward Blacks and Latinos in pain care. Unfortunately, until doctors take responsibility for pain care instead of blame poor pain care on insurers, people in pain, their colleagues, their lack of time, their not being enough research, or that the DEA wont let them treat pain-then piss poor pain care will continue.

  33. dave says:

    Ms Levy- even if the ACA were religous with the NPCPA- I certainly wouldnt be satisfied. THe NPCPA was orchestrated by pain specialists to promote their occupational strategies under the guise of the public good. And their vision was to do more of the same- how that would inspire anyone or help anyone in pain is beyond me. Now organizations like the APS and AAPM- who were very much part of the 2011 IOM report are now under federal investigation for opioids- for their focus was and still is on drugging pain. If you read the IOM report it clearly states they don’t believe in cures for pain and that people in pain are catastrophizers. The APS and AAPM do not have the vision or care enough about people in pain to jump over the shadows of pain care to create the symbols of a new day. They are stuck in the biomedical reinforcement loop. So, frankly no one who really cares about progressin pain care would think much of the NPCPA for it serves the occupational strategies of pain specialists and essentially will do very little for people in pain.

  34. @Levy and Quintner … If I know anything I am certain that defective muscles generate the most overwhelming pain known to man. Which is the reason we can not see it with a scan, MRIs, blood test and can’t fix it with a pill or surgical blades.

    A defective rogue muscle or group of muscles can spasm, bind and contract at 10-90% effort relentlessly for weeks and months compressing associated nerves, vessels, joints, cartilages and lymphatics to wreak havoc. With all this pain and misery, nothing will show on a scan or in the blood. If left unaddressed the muscle will get reprograms due to muscle memory and become a stubborn hybrid.

    So if you treat anything other than the muscles you are deceiving yourself and committing the patient to unnecessary suffering and misery. That is a ludicrous incongruous violation of our oath to do no harm.

    The National Pain Care Act will suffer the same faith as our present policy, if every one denies Trigger Points, Myofascical Pain and Dysfunction, Acupuncture, dry/wet needles, massage and all hands-on manual tissue release options.

  35. These are the issues and this is why we will not make any headway to solutions. Everyone has an idea and invalidate everyone’s else’s.

    Stalemate.

    The best way to break a stalemate is to acknowledge that all of us have witnessed pain in various ways and have formulated ideas and concepts. These concepts are valid with some flaws. But if we blend all of our valid views we can come up with a list of truths to benefit all of these patients in pain.

    My trues have been collected over 10 yrs of trials, errors, success and failures. Thanks to thousands of patients who put their trusted my abilities and tens of thousands of patient encounters, I have a summary of what these experiences have uncovered.

    Absolutely nothing new!!!!

    All the concepts, ideas, explanations, insights have already been known, practiced, vetted and available for at least a century.

    Now if we can get over the some human natures of wanting to be completely correct, egos, agendas and dogmas we should be able to make progress.

  36. carol levy says:

    Stephen seems to think that muscles are the cause of most chronic pain. Look into the numbers, diseases such as CRPS, Lupus, MS, trigeminal neuralgia and nother neuropathies are not simply waiting for the magic of muscle therapy.
    The ACA has incorporated much of the National Pain Care Act into its amendments. The act calls for money and research into pain. Hopefully some of what Judy and so many others are calling for will come to pass through this part of the ACA.

  37. Laurence Badgley, M.D. says:

    A major factor in the current epidemic of chronic pain is that most physician are inept at diagnosing soft tissue (fascia, muscle, tendon, and ligament) pain generators. Too much reliance is placed on imaging studies, which are relatively ineffective for discovering injured and dysfunctional soft tissues. The most effective pain detector is a trained physician who uses his/her brain, ears, eyes, and fingers to discover clues to dysfunctions of these tissues. On my Pain Syndromes board at Quora.com, I present several methods of diagnosis of soft tissue dysfunctions that cause chronic pain.

  38. Judy Foreman, your critiques are far too simplistic. If a physician thoroughly educates himself, scrupulously follows all of the rules and recommendations, and makes use of best practices to document and treat pain effectively, he risks not only (1) being punished for following those rules and recommendations, but (2) being publicly ridiculed for doing so and for “wasting so much time” documenting that he did so.

    The State does not care about the evidence, so long as it can pay a physician to testify, “In my professional OPINION . . . .”, even if she repeatedly acknowledges that she did not even read “most” of the records, and demonstrably has no idea either what the records say or what the law and medical standards are.

    Sadly, until physicians can safely treat pain in good faith, there is no reason for them to know anything about it.

  39. John Quintner, Physician in Pain Medicine says:

    @ Stephen. You continue to assert that “A stubborn disbelieve (sic) that muscles can not cause such a devastating amount of pain” is an issue that we keep glossing over.

    One reason for this could be that the simplistic remedy you propose is to inflict yet more pain upon sufferers through the use of stainless steel needles. In defense of this treatment you continue to invoke past icons (e.g. Travell, Simons, Gunn, etc.) whose theories suffer from a lack of both logic and science.

    David has already noted the ironic situation where opinion leaders: “… do not understand that such (a cultural transformation) means giving up their cherished biomedical paradigm and limited orientation and limited solutions to pain.”

    I entirely agree with him. Surely it is now time for you (and others like you) to sheath your needles and cease championing the many failed “solutions” to the enormous problem that is the topic under discussion.

    Perhaps one day someone will found “The Society for the Prevention of Cruelty to Innocent Muscles”. I will happily sign up!

  40. david says:

    Kudos to Ms. Foreman for a thoroughgoing documentation into the problems with pain care-the book would make an excellent introductory text for a course on pain.
    I would say the problem with pain care starts from a lack of vision from leaders in the field and leaders in government. The doctors and researchers who were involved in the IOM report on pain care were correct in saying we need a cultural transformation- but ironically they do not understand that such means giving up their cherished biomedical paradigm and limited orientation and limited solutions to pain. When it comes to pain care the measure of intelligence is of course the ability of change-and it is tragic that our leaders and professionals essentially call for the same failed solutions and same lack of vision.

  41. An Excellent account of the plight of Pain in the US. She did a lot of research in all the available and obvious places.

    There are few issues that “we” all keep glossing over again and again because
    1. Humans want to know without a doubt the “Thing.”
    2. The belief that scientist will find the answer in further research.
    3. A stubborn disbelieve that muscles can not cause such a devastating amount of pain. Which leads one on a perpetual journey of the “on and off” switch so the pain will go away.

    We have pain therapy that is safe, vetted over 100 years and effective. The tools are under our noses in every doctors office. All we have to do is take the time and effort.

    One other reason is who will pay for pain therapy? Insurance will pay to get a knee replaced but will not pay for a massage. This is because of resentment the some people that it’s a luxury and has to come out of your own pocket. “I ain’t paying for those people to get spa treatment”

    I’m sure if we all work together we can began to blow down these barriers. (actually I’m not certain that we can work together which is the problem.)

  42. Joy H Selak says:

    Absolutely brilliant interview. Hooray, hooray for Judy Foreman! Count me in to speak up for patients. I can’t wait to read it. If we pair it with Laurie Edwards ‘In the Kingdom of the Sick’, and make both required reading in med school we may have some hope.

  43. John Quintner says:

    Judy, if for a moment we accept that pain (as a sensory and emotional experience) can become a disease in its own right, what name is to be attached to this disease? Calling it “chronic pain” would be quite confusing, as 20% or so of the population would fall into this category of having an incurable disease. One of the lessons learned from our 25-year experience with the Fibromyalgia construct is that eventually such labels can become meaningless. What is your preferred name for the disease? To date, this has been an important but still unanswered question.

    Anyway, I look forward to reading your book. Congratulations.

  44. Carole, CRPS/RSD says:

    Thank you Judy.
    Is it possible for you to send every Congressman/woman your book?
    Can’t wait to read it.

  45. Dennis Kinch says:

    AMEN Judy! Finally, a book every professional in the field needs to study. Thank you for the Truth!

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