Wednesday, January 1, 2014

Another Book About Pain; Only Much Better

A Nation in PainOf nearly 240 million adults in the United States, more than 4 in 10, or about 100 million, live with chronic pain of some sort. Yet, the professional and popular news media focus more on abuses of pain medications than the dreaded conditions the drugs are intended to treat. Meanwhile, the suffering of untreated or mistreated patients with pain is largely overlooked.

In her new book — A Nation in Pain: Healing Our Biggest Health Problem — author Judy Foreman provides a deeply researched account of today’s chronic pain crisis and reasons behind it, and she discusses some solutions that could be within reach. Far more than just a symptom, Foreman explains, chronic pain can be a disease in its own right, and the failure to manage pain better in the U.S. and other countries worldwide may be tantamount to torture.

A great many (perhaps, too many) books have been written on the subject of pain; all are well-intentioned and often they are self-published. While some of the books are of interest, most appear to be riddled with personal opinion, biased perspectives, and/or misinformation rather than being guided by facts and solid evidence. As a journalist and investigative health reporter, Foreman has done a noteworthy job of crafting easy-to-read text that also is excellently documented with enough citations of her evidentiary sources to satisfy even the most skeptical readers — which is quite rare for a book intended for both lay and professional audiences, as is A Nation in Pain.

The 464 page book, published by Oxford University Press, is ambitious in scope, covering in a mere 14 chapters subjects ranging from the nature of pain to genetic, age, gender, immune system, and mind-body influences. Foreman also examines various traditional, newly discovered, and alternative therapies for chronic pain.

She says that her research for A Nation in Pain spanned 5 years, during which time Foreman consulted a library of books and hundreds of scientific papers on pain. She also interviewed nearly 200 scientists and physicians, as well as countless patients, a few lawyers, and a handful of government officials. [Full disclosure: This writer was one of those persons consulted, and we can attest to the depth and relentless probing of her inquiries.]

A most appealing approach of the book is that it is simultaneously a textbook providing research insights and hard evidence, an investigative report replete with stories of affected patients and their families, and a personal memoir relating Foreman’s own experiences with chronic pain and its treatment. Certainly, this juggling was no easy task, but the genre makes for fast-paced, informative reading while captivating even a casual reader.

Overall, Foreman suggests that there is an appalling mismatch between what people in pain need and what healthcare providers know about pain and its treatment — chronic pain in particular. She found that physicians in the U.S. typically receive only about 9 hours of education specifically on pain during 4 years of medical school — even veterinarians are better educated on pain management.

Systematic failure is equally evident at the federal government level; for example, in 2012 the U.S. National Institutes of Health spent only about 1% of its vast $30.8 billion budget on pain research, Foreman states, despite the fact that chronic pain was (and still is) a bigger problem than heart disease, cancer, and diabetes combined. At the same time, chronic pain in the U.S. conservatively costs as much as $650 billion per year in direct medical costs and lost productivity. Shamefully, there is no National Institute of Pain; yet, there are other Institutes addressing diverse health conditions that are important, but affect far fewer citizens and with less burden on the economy.

One of the more startling chapters in A Nation in Pain discusses the mismanagement of pain in pediatrics. Among other revelations, Foreman discloses how as recently as the mid-1980s in the U.S. healthcare professionals believed that young children, especially newborns and infants, seldom needed medication for pain relief and tolerated discomfort well. She recounts the particularly disturbing story of a newborn boy who was subjected to open-heart surgery without anesthesia — a practice that apparently was commonplace at the time, but somewhat of a dark secret known only among medical insiders. In general, management of pain in children of all ages has been deficient worldwide, as Foreman reveals in an examination of the research evidence.

Foreman devotes 2 chapters to the destructive "Opioid Wars," which have led to a misguided demonization of prescription opioid analgesics. Her discussion of this highly controversial topic is among the most fairly-balanced and evidence-based that we have seen. She observes that there are 2 separate public health “emergencies,” sometimes called “epidemics”: (a) undertreated pain influenced by some degree of limited access to opioids, and (b) the abuse of opioid analgesics for illegal or nonmedical purposes. She stresses, “whether the term ‘epidemic’ truly applies here is debatable.”

Foreman recognizes that there are many sides to the ongoing debate and relatively little hard evidence one way or the other. As she states, “The complex truth is that opioids, especially opioids for long-term use in chronic non-cancer pain, are probably both under-prescribed for some patients and overprescribed for others.” Opioids are not a solution for all patients or all types of severe pain, she acknowledges, and at best the pain relief they afford is only partial. She accordingly emphasizes:

“Opioids, in other words, may be necessary, but they are rarely sufficient. What I am saying is that government drug policy seems to be lopsided, politicized, stacked against legitimate pain patients, and fueled by public hysteria over abuse of prescription pain relievers. That hysteria, in turn, is fueled by often-misleading media coverage.”

Those few sentences say a great deal about what has gone awry with concerns about opioid analgesics today. In support of those statements, Foreman laces her discussion with references to relevant research studies, while also distinguishing between good- versus poor-quality evidence — an objectively analytical perspective that is missing in most other books and articles on the subject.

As Foreman observes, the controversy over prescription analgesics is a “highly emotional struggle in which much of the ‘debate’ is driven not by scientific facts but by dueling anecdotes of horror.” She aptly denounces a misguided popular press, prejudiced bureaucrats, and a small cadre of fear-mongering medical professionals for trying to foist a negatively slanted view of opioid pain relievers on the public as well as on the healthcare community at large. In balance, Foreman also tells how over-exuberant marketing by drug manufacturers has contributed to problematic analgesic prescribing and use.

Throughout the book various therapeutic approaches for managing chronic pain are discussed, including new developments still in preclinical or clinical trial stages. Additionally, a whole chapter is devoted to marijuana (“The Weed America Loves to Hate”) and another focuses on exercise (“The Real Magic Bullet”). A range of CAM (Complementary & Alternative Medicine) therapies also are covered, with balanced discussions of pro and con research evidence for each.

Challenges of effective chronic-pain management are complex, with many obstacles to overcome on the path to finding practical solutions. As the diverse stories of patients with pain in the book demonstrate, pain often cannot be extinguished altogether; yet, it almost always can be better managed and patients can live more fulfilling lives. Foreman offers some suggestions for action — such as expanded pain education in medical schools, reforms of federal policies across the board, and increased funding for pain research — but it would require a separate book to do justice to such proposals. Meanwhile, for healthcare providers, researchers, policy makers, and patients and their loved ones, A Nation in Pain is highly recommended reading.

Here is ordering information…..

A Nation in Pain: Healing Our Biggest Health Problem
Judy Foreman; Oxford University Press; ISBN-10: 0199837201 | ISBN-13: 978-0199837205

Release Date: January 29, 2014
Hardcover (464 pages); List Price $29.95 USD (discounts often available).
Prepublication ordering available at (here) or at other booksellers.
See video trailer here:

Judy ForemanAbout the Author… Judy Foreman is a nationally syndicated medical journalist with 40 years’ experience. She was a staff writer at The Boston Globe for 23 years, from 1978 through 2000, and a medical specialist and science writer since 1985, covering diverse health issues: fitness, aging, cancer, heart disease, pain, nutrition, and basic biological sciences.

Foreman graduated Phi Beta Kappa from Wellesley College in 1966. After 3 years in the Peace Corps in Brazil, she earned a Master’s degree in Education for General Purposes from Harvard University Graduate School of Education. Through the years, she has won more than 50 journalism awards from groups such as the American Society on Aging, the American Heart Association, and the Arthritis Foundation, among others. She won a Knight Science Journalism Fellowship at the Massachusetts Institute of Technology in 1989-1990, was a Lecturer on Medicine at Harvard Medical School, and a consultant/patient advocate at Beth Israel Deaconess Medical Center from 2001 to 2004.

While at The Boston Globe, Foreman’s weekly Health Sense column was syndicated internationally. Since 2000, working as a freelancer, the column has been featured in The Boston Globe, The Los Angeles Times, The Dallas Morning News, and many other media outlets, including foreign distribution. She has also appeared on WBUR radio, the NPR affiliate in Boston, and has been the host of a weekly, call-in webcast on health issues for She now blogs regularly for WBUR’s Cognoscenti and Commonhealth Websites. Foreman’s own website can be visited at

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Mark S. Barletta said...

It seems lately all I have heard is the negative side of the treatment of chronic non-cancer pain. The FDA has been petitioned by groups of people who want all opioids basically not used for those suffering with ongoing non-cancer pain. They say we have no proof long term use of opioids are safe nor effective in the treatment of chronic pain. But if your the one in chronic pain you reach for anything to stop the suffering. It seems there is no compassion from certain groups of people who think opioids are evil.

After 10 years of suffering I found relief of the chronic pain I have in my cervical spine with the use of a long lasting opioid.
I was slowly titrated upward till I found my level of relief. I had to combine this with Mind and Body Meditation , exercise and keeping a positive attitude. Now things aren't half bad but I don't understand why doctors made me suffer for so long when the answer to my intractable pain was available but not used till I almost died of not eating right and not sleeping correctly.
I plan on reading this book as soon as possible.

Thanks to Judy Foreman for her hard work writing this book. I know a lot of compassion has gone in to it. I tried writing a book on what I went through over the past 24 years and its really hard for me putting in to words what I wanted to say.

Janice Reynolds said...

I am also very excited by this book; I have already put it on my Kindle apps and look forward to reading it.
One thing not mentioned in the summary of the book (and it may be in there) is the prejudice and contempt that has developed for people in chronic pain. If you read the comments after articles on MedPage that have to do with pain or opioids, seen the comments on Facebook after supposedly “funny” postings by All Nurses as well as similar sites, and even in letters the editors in magazines, newspapers, and journals as well as the difficulty finding a provider who will take a person with persistent pain; its presence is disturbing. As a pain management nurse I was frequently appalled by what nurses would say to me in report (I say me because even if I hadn’t specialized in pain management their comments should have been offensive (“She likes her pain meds a little too much,” “he couldn’t be in that much pain, etc.). All people with persistent pain (including those in a cancer setting have experienced at least one health professionals disrespect, disbelief, or outright contempt. Is it because there is so little appropriate professional education that much is learned from the media? Certainly the general public’s contempt comes from there.
It is well and good to talk of the different methods of helping to relieve pain instead of or in addition to opioids yet one of the biggest hurdles is lack of insurance coverage. It is certainly important to know of them and understand a multimodal approach but if the person can’t afford it and especially if it’s an instead of situation the person is left in pain. I know I have spoken of my plan in the past (I have persistent post craniotomy pain) which is a long acting opioid, short acting for breakthrough, acetaminophen, a tricyclic antidepressant, and massage therapy; I still have bad days or nights occasionally and if one component is off, I will hurt. Recently breakthrough medication hadn’t touched it but it happened to be the day of my massage therapy and as my therapist worked draining lymph and doing her cranial sacral thing I could feel the pain receding. Yet my insurance does not pay for it and if our finances got worse I wouldn’t be able to do it.
Hopefully this book will get into the hands of those who need it and she is not just singing to the choir. Thank her for writing this book.

the stockbroker said...

I have been in constant pain for over 10 years (12 fractured vertebra) and for many years it was so difficult to explain or understand, I read Judy's last book and it was a real eye-opener. I bought a copy for my pain mgmt. Drs. and even they said it was fabulous. I hope this is even close to as informative as her last. Taking numerous Methadone a day along with some Norco and I'm "existing"

SB. Leavitt, MA, PhD said...

@stockbroker -- I didn't know that there was a previous book on this subject by Judy Foreman. What was the title? Or, perhaps, you are mistaken? --SBL

Sandy Miller said...

I sure understand. I had a right thalamic hemorrhage 13 yrs ago and as a result was left with a condition called "Thalamic Pain Syndrome". There is no cure and it's PAIN, 24 hours a day, 7 days a week. I didn't know what a thalamus was! But, it sure can mess up your life. (brain stem sensory processing area). I was lucky and found a great neurologist who diagnosed the condition within months, and then 2 yrs. later, he left the area, I went thru a terrible time trying to find a Dr. Who understood. I worked for lawyers who helped me find information on the Internet about the condition, printed it out and took to neurologist and pain doctors, but they just thought I wanted pain medication.
I didn't want a doctor who was going to start out accusing me of wanting drugs. I understood, but hey give me a chance! Talk to my employer who knows who I am, you see my files sent over to you, you see the pain I've been in.

Since the stroke I had been on several medications, so while looking for a Neurologist or Pain Dr. who would take my file, my Primary dr. had taken over some of my medications that I had to keep taking, like antidepressants,Neurontin, which I have to take, along with others I needed, to work with them, but no pain medication. I don't understand why some doctors immediately think when you are in pain, you just want drugs. I explained the entire situation. I just needed a good doctor who knew what my disorder was and to treat me accordingly.

Finally, I called my Neurologist who had closed his office, and was working, semi-retired from his home office. He knew everything about me and the brain. He had co-authored a medical book for medical students and had taken care of me for years for my back, carpal tunnel and was now taking care of a few patients, and would take care of me too. He knows when people are in pain. He said doctors are fearful of prescribing pain medications, but if they know their patients, there should be nothing to fear. He only had one other person in the 40 years of practicing with the thalamic pain like I have and my husband filled him in on everything and he couldn't believe what all I had been through, how strong a person I was.

We have to be, don't we folks, because we never know when our world is going to fall apart again...... He couldn't believe I took such little pain medication. It was what little I had and I been in such pain and was doing nothing much except just staying in bed. He knew I didn't take meds the wrong way, I have the upmost respect for them, I just want to be able to be with my family, grandchildren, and enjoy them. Why can't doctors understand there are real people in real pain! I hope this book Ms Foreman has written will help support us in our endeavor to sort through people and see we really are in PAIN. We don't want to be this way. We need help and I pray none of them ever have to go through what those of us in PAIN endure each and every day, 24/7 ...Please understand. Thank You So Much.


Pamela G.Garrisi said...

I have chronic pain and this subject is one of great concern to me. Although I do not like being on the opioids, I don't see another choice. I have been through a pain program and it helped sooo very much. I am off the morphine I once was on for 7years. I have Scoliosis and have lost 4 inches in height in 6yrs.I used to be 5ft7 1/2in. I am 5ft 3 1/2 in now. My spine is twisting and rotating to the left. My rt hip is touching my right ribs. So if the Dea or Fbi were to take away my pain killers they would be sentenceing me to a life of being unable to get out of bed. I would have no life.I barely have one now with the drugs. So if you are listening, please have mercy on those of us that really do need the pain meds to have a life.
Sincerely, Pam Garrisi

Lisa said...

A review I posted on Goodreads:

A Nation in Pain: Healing Our Biggest Health Problem is a detailed and well-researched book, highlighting the conflict between those fighting to severely restrict access to opioids, and Pain Patients, who often depend on these medications to maintain even a modicum of relief from chronic, even life-long intractable pain. Unfortunately, in the "Opioid Wars," Pain Patients are often the last consideration on everyone's list but their own. Judy Foreman changes the discussion by focusing on the crisis in treating pain in our country, and around the world, siting needless suffering from under- and non-treated pain.

An earlier review states that Foreman prescribes "pills" as the only solution; my take-away suggests he and I read two different books. In my reading, the author recommends a multimodal approach (albeit one that is difficult to achieve in today's healthcare climate,) as often as possible. She presents detailed information on how pain works, how acute pain becomes chronic, and what methods work well to treat pain of different types.

You may have noticed my capitalization of Pain Patient. I have done so in honor of Judy Foreman, who stands up for those who are often afraid to make their voices heard, in fear that there might be reprisals, that they would jeopardize their access to one of the few tools that make their lives tolerable -- their opioid pain medications. As Foreman points out, very few true pain patients are addicts. Being dependent—as opposed to addicted—a critical distinction, on a medication used to treat a medical condition, in the same way that diabetics need insulin, should not result in a person being demeaned and treated like a criminal. Somehow, in this war, we must separate the true abusers from the pain patients. Otherwise, there will be a monumental amount of collateral damage, people in pain, forced to suffer what would be for many a fate worse than death.