Hyrum Neizer was a successful Salt Lake City truck driver and a happily married man until the headaches began. Then, suddenly, for no apparent reason, he was disabled by pain—pain so punishing that he often ended up in the emergency room. He sought help from physician after physician, but the experts were either stumped or skeptical. They either didn’t believe his pain was as bad as he said or, worse, they thought he was faking the headaches in order to get drugs. Even his wife grew doubtful over time. Finally, having lost his job, his home, and his dignity, he stuck the barrel of a gun into his mouth and poised to pull the trigger.
Neizer would be dead if his wife had not happened to walk in at that moment. At her urging, he renewed his efforts to find an answer, and, finally, another expert ran some tests that no one had run before. The tests revealed that he had two aneurysms: ballooning arteries in his brain. A surgeon operated that night and again soon after. And then the pain was gone.
Hyrum Neizer is one of millions of Americans who suffer from chronic pain. He is also a casualty in what Judy Foreman calls the Opioid Wars, in which the battlefronts are medical, economic, psychological, cultural, and political. And if Foreman is right, these clashes are leaving many Americans to suffer needlessly in an unrecognized public health epidemic.
The problem begins in medical school, where the nation’s future doctors learn—or, more accurately, do not learn—about pain. Foreman reports on the way pain biology is taught in medical schools, and what she finds is distressing. Pain is the leading reason why people go to doctors, and it accounts for more than 40 percent of ER visits; yet aspiring physicians get almost no instruction in pain biology or palliative care. According to a survey by the American Association of Medical Colleges, accredited medical schools offer only 8 to 16 hours of pain instruction—over a period of four years. Other studies suggest that the figure is far less. Indeed, only four American medical schools require a full course on pain. Veterinarians receive about twice the pain education physicians do.
This educational failure reverberates through the entire practice of medicine. Most people in pain are cared for by their primary care physician, but primary care physicians have not been taught the best practices in pain management. Doctors themselves know this: In one survey, only about a third said that they were comfortable treating people in chronic pain. What’s more, because their pain instruction is so hit-and-miss, young doctors have little interest in becoming pain specialists. As a result, there are only about 3-4,000 pain specialists in America—far too few for the millions seeking relief.
In short, medical education in this country is out of sync with the reality of chronic pain. So it’s not surprising that Hyrum Neizer had to shop unsuccessfully for so long before he found a physician who took his suffering seriously and had the skill to diagnose the problem.
But it wasn’t just ignorance of biology that Neizer encountered. He also collided with a potent, and completely unfounded, bias against pain medication—opiates in particular. Patients in legitimate pain, who seek relief from agony, are suspected of seeking mind-altering, recreational drugs. Not to put too fine a point on it, they are dismissed as deceptive, malingering drug addicts.
Foreman argues that there are in fact two public health emergencies—epidemics—in America right now, and that they are on a collision course. The more visible and obvious emergency is widespread abuse of narcotics—pain pills such as Vicodin and Oxycontin, as well as street drugs such as heroin. Abusers, often young people, have created an insatiable demand for these drugs, which can be addictive and life-threatening. The federal government, as a result of this abuse, is cracking down on illicit narcotics. But, ironically, this militancy spills over into the regulation of medical narcotics. This leads to an “opioid conundrum”: Street abusers have a plentiful supply of illegal narcotics, while people in chronic pain—often older people with no history of drug abuse—cannot get the drugs they need and would most likely use responsibly.
Much of this bias is rooted in a misunderstanding—and deep fear—of addiction. The image of the crazed narcotic addict looms so large in popular culture that it eclipses the truth about opiate addiction, which is that many people who take medication for chronic pain do just fine, even if they become physically dependent on the drugs: “They do their jobs, raise their kids, live their lives, maintain stable doses, and achieve reasonable pain relief for years.” Physical dependence and tolerance do not necessarily add up to maladaptive drug abuse, and until this view is altered, the millions who are in chronic pain will likely suffer more than they have to.
Today’s cultural collision has deep historical roots, but it has largely to do with the treatment of drugs and addiction as crimes. The pendulum of public attitudes has swung widely over the past century, from tolerance of illicit drugs to a strict law-and-order stance, and these shifts in attitude inevitably shape attitudes toward pain and its treatment. It was physicians themselves who recognized under-treatment of pain as inhumane and called for reforms in regulation. But there remains a pervasive suspicion about narcotics, which allows the epidemic of untreated suffering to continue.
Few would deny potent painkillers, even narcotics, to the terminally ill who are dying of excruciating diseases, including cancer. But the most sobering news in this account is that even powerful drugs are often not up to the task of pain relief. Opioids reduce pain by only 30 to 40 percent, and nothing, not even higher doses, completely eliminates pain. The result is that, even in hospice and palliative care programs, pain is quite common. Indeed, fully a third of people in hospice report pain right up to the end.
That’s bad news for people like Tom Fersch, who was diagnosed with esophageal cancer and endured 15 months of chemotherapy, radiation, and surgery to no avail. His cancer spread relentlessly and took over his stomach, chest, and back, causing constant pain. Fersch was fortunate to even have a palliative care specialist, but it didn’t help much. He was on fentanyl patches, oral Dilaudid, and oxycodone, but even that potent combination failed to provide relief.
Fersch died in pain.
A Nation in Pain comes to life with people who are dying or who wish they were dying. But Foreman’s account goes beyond its emotional appeal and makes some rigorously reported arguments about the failure of the palliative care enterprise in America. It starts with the National Institutes of Health, which, because of its very organization—one institute for cancer, one for heart disease, another for mental illness, and so forth—has orphaned pain. The often-intolerable symptom of many diseases and disorders lacks an institute, a constituency, and adequate funding.
This organizational neglect has other untoward consequences. There are many alternative approaches to pain management that might help where drugs come up short, but, according to Foreman, the medical establishment lacks the will and money to explore these possibilities in any rigorous way. She reviews the evidence, some of it very promising, on acupuncture, massage, nutrition, and other alternative treatments; she devotes an entire chapter to marijuana’s potential as a pain reliever, and another to exercise, which may, in the end, be the true magic bullet. Our doctors-in-training learn none of this. And yet, as Foreman argues, fixing the chronic pain crisis is a moral imperative. The failure to do so violates every principle of medical ethics.
Wray Herbert, writer-in-residence at the Association for Psychological Science, is the author of On Second Thought:
Outsmarting Your Mind’s Hard-Wired Habits.
