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?
Foreman: 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.