How Medicine Is Failing a Nation in Pain

; Abraham Verghese, MD; Haider Warraich, MD


May 20, 2022

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol for Medicine and the Machine. I'm with my co-host, Abraham Verghese, and we're delighted today to welcome Dr Haider Warraich, a physician and author extraordinaire. Even though he's quite young, he's already published three books, the latest of which is The Song of Our Scars: The Untold Story of Pain. Dr Warraich is a cardiologist and heart failure specialist at Brigham and Women's Hospital in Boston, but his new book is not about heart failure; it's about pain. Welcome, Haider. Tell us how you got into this whole story of pain.

Haider Warraich, MD: Thank you, Eric. I got into pain on a random weekday when I was a medical student. I was in the gym, lifting weights, and suddenly heard a loud click in my back. Everything stopped moving and before I knew it, I was pinned under the weight. My friends rushed me to the emergency room. I was in excruciating pain. I was given IV painkillers and was told by the emergency room physician that I would soon feel better and over time I would keep getting better and better until it would all go away. That's what I believed, but that's not how things panned out.

In fact, pain became a constant part of my life. Indeed, it took over the trajectory of my life. For a while I wasn't sure I would ever finish medical school. It took years of physical therapy, lots of support from family, friends, and attendings, who would let me leave early or make sure that they weren't torturing me too much in the operating room. But as I got better, I realized that there was a bigger story to be told, not just about me but about the sensation that we call pain, which is the most common reason people seek help from physicians yet remains so poorly understood.

I also happened to be an internal medicine resident at the peak of the opioid prescription epidemic, at a time when we hadn't realized the consequences of that practice. So much has been written about the opioid epidemic — it has brought the issue of pain to the fore — but we know comparatively little about the reasons we had that epidemic to begin with, and where we go from here as we realize that opioids are not a great treatment for this, especially not for chronic pain.

Abraham Verghese, MD: Haider, thank you for being with us. I had the pleasure of hearing you at Grand Rounds at Stanford and I had a burning question for you: How is your pain now? I imagine that your own evolution with pain mirrors the understanding we have of pain that you reflect on in your book.

Warraich: My pain is much better. On the face of it, I have pretty much a normal life. I still have to be extremely careful how I sit, how I sleep, and so on. That has all been changed permanently. But the specter of pain always remains in my life. My injury happened more than 10 years ago, and it took me a few years to return to a state of normalcy. I used to be in the cath lab as a cardiology fellow. I love doing procedures. I love the lab, but my back just wouldn't let me pursue that as a profession.

The other strange thing was that while I was writing this book, all sorts of aches and pains came back. Most people think writing can be a pain in a metaphorical sense, but what happened to me was something I didn't expect. I would wake up with all sorts of joints refusing to work. I got shingles — I had no idea how that happened. Just the writing of the book itself, in some way, resurrected the pain. I am better now, although I do realize how lucky I am. It takes a lot of good fortune for chronic pain to abate to whatever extent it can. Many others aren't as lucky as I have been.

Verghese: For me, that was the most interesting part of the book. I believe that as physicians, we tend to think of pain as cut and dried. You have it or you don't. Then we put people with chronic pain into another category, and, as you know, there's a lot of prejudice around that. Your book was a revelation to me in terms of the pain vs our degree of appreciation of pain depending on the circumstance, the subjectivity of it and all the ways it can be affected. Tell us more about that.

Warraich: As someone who has lived with pain and has been writing about pain for over a decade, I believed I knew a lot about the subject. Yet, as I started researching for the book and talking to experts, talking to patients, I realized that I've had the chance to take a deep dive into so many fields in medicine but pain remains the one that I feel is most unsettled, the one that still needs to come together in a creative way. The medical profession isn't geared up as well for something like this. It is so multidimensional and needs so much collaboration and so many different people to come together — scientists, clinicians. Many medical conditions fall under the rubric of chronic pain, and the siloing of medicine has not allowed that collaboration so far.

One thing I wanted to do with the book was to connect all these dots and bring these voices together into something cohesive. What is chronic pain? If you look at the definition of chronic pain, it's defined as pain that you have intermittently or continuously for 3-6 months. But if you look at the science of chronic pain, it shows that, from a neurologic perspective, it seems at times to be a whole different process from acute pain. This is why many things that work so effectively for acute pain just don't have that same type of effectiveness for chronic pain. Opioids are a great example of one of those interventions.

So much of the emphasis has been on how pharmaceutical companies, specifically Purdue Pharma, affected prescription patterns and clinical practice around opioid prescription. What hasn't been appreciated is just how many of the myths and, frankly, lies that were introduced in the medical literature were taught at their behest and still continue to this day. That is something the medical profession needs to reckon with and reverse. We need to make sure we don't allow ourselves to be used in the way that Purdue and their partners did.

Topol: For those people listening who have not yet read your book or seen Dopesick, the TV series that brought this alive, it was an extraordinarily despicable way in which Purdue and the Sackler Foundation seeded the country with OxyContin. This was purposeful marketing, to keep raising the doses of the painkiller; people dying left and right, becoming addicted; it ruined millions of lives. Even now, the highest number of deaths in the United States is from the opioid epidemic. Can you frame this ugly part of our history?

Warraich: The playbook for the current opioid epidemic was first created at the end of the 19th century, beginning of the 20th century. After the Civil War, we had these innovations — morphine and the hypodermic needle. Morphine was used quite a lot during the Civil War, but then it crept out into society. Many physicians, in fact, were at the forefront of the overprescription of morphine. A company then came out with a new product and, similar to the OxyContin story, it was marketed as a drug that was less addictive than morphine and, in fact, was prescribed for the treatment of morphine addiction. That drug was heroin. We know how all that played out.

If you look at the Sacklers, the patriarch of that family, Arthur Sackler, is in the Medical Advertising Hall of Fame. The first drug he marketed was Valium. He made Valium a billion-dollar drug at a time when anxiety was not even a well-understood diagnosis. The same strategy that was used to market those drugs at that time was replicated for OxyContin further down the road.

So much that we saw with OxyContin being so successful, such as the relationship between Purdue Pharma and the US Food and Drug Administration (FDA) and regulators who helped pass extremely generous labeling, was not only seen with OxyContin but was also seen with previous products they brought to market. That has been going on ever since for other drugs, such as Aduhelm, the recent Alzheimer's drug. So the playbook for OxyContin was well developed. I don't believe we have all the safeguards in place to make sure something like that doesn't happen again.

We've been in a rush to pin all the blame on this one evil family and evil group without taking stock and responsibility for the fact that every one of us in the health system had a part to play, large or small, in the perpetuation of this crisis. The people who suffered the most are patients. First we were overprescribing these opioids to patients at a rate so much higher than any other comparable country, and when we became sensitized to the fact that these drugs can be quite dangerous and frankly, not effective for chronic pain, then with almost similar zeal, we started getting people off these drugs without offering an alternative, without offering them the support they might need to deal with the dependance and the tolerance their bodies had developed. That's when we saw the diversion toward illicit drugs, such as fentanyl, which has now led to the skyrocketing opioid epidemic that killed more people last year than any other year in history — more than 100,000 people for the first time.

I believe our entire medical community needs to pause and think about how we can make sure something like this doesn't happen again. I'm not convinced that we've learned the lessons of this crisis.

Verghese: For me, one of the biggest insights from your book was the understanding that the original pain that led someone to take the painkiller has no connection with their pain many, many years later. In fact, there's a line in your book that the injury itself has no value, quoting one of those researchers. I hate to admit this, but it was a revelation to me. We make the assumption that people are in chronic pain because of the initial injury. But, wow, it may have nothing to do with that. And pain begets pain, as you say. And that culturally, we in the United States could be so different from people in another country in terms of these things when we have the same human bodies. Expand on that.

Warraich: Everyone in pain has their origin story. My origin story started in that gym. For me, the image that captured my pain was not so much a wound or a scar that I had, but it was this MRI scan that was performed, which showed a series of horrific-sounding abnormalities. In fact, that MRI was discussed in one of the weekly radiology morbidity and mortality conferences at that time. That really stayed with me. If anyone ever doubted why it hurt, I could show them that image: Look at this MRI, look at this prolapse, look at all the degenerative changes.

Yet, we know that MRI abnormalities have no correlation with the severity of pain. They have no correlation to show which person's acute pain will turn into chronic pain. And the severity of the initial injury has no bearing as to whether acute pain transforms into chronic pain. All of this is very well-established knowledge. A lot of what I'm bringing in this book is novel information to readers, but a lot of this is well understood in the scientific fields by the pain experts. Yet, there is a big gap between getting that knowledge to patients as well as to clinicians.

Pain is so central to our mission as physicians. As a cardiologist, when I'm rounding, up to a third of patients hospitalized on a general cardiology service will have a chronic pain diagnosis and will be getting opioids or some other treatment. So it isn't a phenomenon that is just being seen by one specialty. Every specialty is seeing pain in one form or another. And there are these simple facts and truths about pain that are missing.

The other thing is this idea that chronic pain is a uniquely American phenomenon, which is also untrue. Some very poorly performed studies have suggested that Americans feel more pain than people in other societies, but that has not been borne out. In fact, in most European countries and even around the world, the prevalence of chronic pain is fairly similar among different societies. It is how we respond to that pain, how we live with pain, and how we clinicians treat pain that seems to be an area in which the United States tends to be an extreme outlier in regard to how aggressively we treat pain.

One thing that's happened is that treatment of pain and those patterns that we've developed culturally have had far-reaching consequences. One of my favorite studies found that Americans have a stronger response to placebos than people in any other country or society that has been studied. And that placebo effect is increasing over time because the belief we've instilled in the average American patient, that their suffering is going to be relieved by a pill, by a prescription, has been so effective that it's making it difficult for new therapeutics to break into the market because they can't show a benefit over this profound placebo effect that our patients feel.

So, yes, there is a rich cultural aspect, there's a clinical aspect, and it isn't a purely medical phenomenon. Pain is something that is as human as it gets. To understand pain, we can't just be focused on the biology; we have to have as wide a lens as possible when it comes to understanding this.

Topol: You mentioned a couple of times that we don't want to ever see this happen again, but we have left it wide open to happen again. Why weren't any of the people leading the companies that knowingly did the Hall of Fame marketing ever locked up? Why was the FDA, which was complicit in these labels, why weren't they ever singled out and found in contempt? And why wasn't the medical community, that told doctors they need to prescribe more opiates and ablate pain, why wasn't the medical community, the National Academy, why weren't they taken out? Nothing has been done. No one is accountable. It's just extraordinary to me.

Warraich: It's infuriating. Another book I would highly recommend is Empire of Pain, by Patrick Radden Keefe. He wrote a blockbuster article for The New Yorker that formed the basis of this book. Really, we have come close in the past. The lawmakers came close to pinning down the Mafia-like techniques that the Sackler family had mastered in controlling every aspect of the pharmaceutical supply chain, starting from production and research all the way to affecting clinical practice. During Congressional hearings in the early 1960s, Senator Estes Kefauver listed, line by line, the entire strategy, and yet they always seem to slip by.

I just don't think we ever had the attention span to focus on these issues. Even now, we're seeing that 100,000 people are dying every year, yet the entire focus is simply on how we can punish this family. How can we make this one family accountable? We can't even do that. But if you look at the role of all these other players — everyone has been making excuses. Everyone's been passing the buck. The medical societies have taken no responsibility for deciding how we are going to manage conflict of interest differently, how we are going to make sure that our medical students are not taught all these lies that are manufactured by companies without any scrutiny or any type of pushback.

The National Academy of Medicine put out a report without having a conflict-of-interest policy in place, and the majority of the people on that panel ended up having strong relationships with all these companies, none of which were disclosed at the time of the publication of this report. I remember this vividly because I was an internal medicine resident at that point, and I was getting calls about all these drugs. That was something new to me because I had gone to medical school in Pakistan, which, like most countries other than the United States, giving out prescriptions for opioids was not something I commonly used to do. So I was struggling with what we are doing here.

I read the whole report, and it was as if it was a marketing brochure for all these companies. Yet we have never looked back. There have been some repercussions, but they've been nothing more than cosmetic. Consider what happened with Aduhelm; essentially the same playbook has been repeated in regard to the FDA and this drug. That came out because of a Stat News inquiry. The current leadership at the FDA is Rob Califf, someone who cares about the opioid epidemic and how it's affected American society. I hope he will also look at the drivers at the FDA that allowed this epidemic to get ignited.

One of the most shocking aspects concerned this line that was written on the label, which basically said that because of its formulation, OxyContin was less addictive than other narcotics. That was based on no data. In court testimony, Purdue Pharma said that sentence was added by FDA officials, not by Purdue Pharma. The lead FDA reviewer for OxyContin became an executive at Purdue Pharma a couple of years after that. We've done nothing to close the revolving door. We've done nothing to make sure that the FDA can operate outside the influence of an industry it is working to regulate.

Despite all the things that are vying for our attention in medicine and in public health, I hope we can pause and honor the people who are affected by this terrible crisis and also think about how we can make sure this doesn't happen again. My worry is that our rush to move on and pass the buck and shift the blame is going to prevent us from actually having the sort of reckoning that we need.

Verghese: I used to practice in Appalachia, in Tennessee. A decade or so after I left, the opioid epidemic ravaged those same parts of the country that I had described in the early HIV epidemic. Going back and visiting, talking to my colleagues, I was impressed that it wasn't just that pharma was pushing it, but also that once you had a group of patients who were addicted, there was intense pressure from them. You almost had to be willing to go to war if you wanted to say no. What do we do about the population we left addicted, by our own fault, in a sense? How do we serve them? How do we get them back to normal?

Warraich: This is such a huge problem. A recent Medicaid analysis showed that if you have people who are on chronic opioids and you continue opioids at the same dose or increase the dose, their risk for an overdose goes up. But if you try to cut back on the dose or reduce the dose, or you deprescribe the opioid, then the risk for suicide goes up in these patients. We know that much of that is because people are moving toward illicit drugs such as fentanyl. What's been happening is that even deprescription of opioids often has been rushed and the decision can be quite arbitrary.

I believe the way forward is to allow more time for patients and physicians to work together, spend time together, really think through and make a shared decision. One of the things I strongly believe in is offering alternative therapies for chronic pain. Most of our health system has not done that, because there is little incentive for it. Our health system primarily offers patients prescriptions because they are fast and procedures because they are profitable. But we know that an interdisciplinary pain management approach can be successful. For example, the VA has been very good at including access to exercise, psychotherapy, and addiction resources. That is the gold standard for pain management. Yet because we've had no real incentive, very few facilities offer something like this.

This is a tough question, and many patients out there are extremely angry, at the health system and at physicians who believe that opioids are a kind of wonder drug for chronic pain. There are some patients for whom that may be true. But the mountain of randomized trial evidence we now have suggests that for people with chronic pain, opioids are no better than other alternatives such as nonsteroidal anti-inflammatory drugs or ibuprofen. The best evidence suggests that people who have been prescribed opioids actually have more pain at 1 year follow-up.

For me, the most important thing is that decisions about opioids, especially in regard to deprescription or reducing doses, should be shared by patients, families, and their clinicians. We need more resources for substance use and addiction for patients who have been prescribed opioids and whose bodies are now extremely dependent on these medications. And we need to provide additional resources, nonpharmaceutical resources for people with chronic pain, to help with the underlying conditions. These are tough patients.

There is also a significant role for drugs like buprenorphine. The government has made it a bit easier for more prescribers to use these medications. But again, we need an all-hands-on-deck approach. We need a sense of urgency with this problem because there are so many people who are suffering right now.

Topol: I can convey my "N of 1" experience in profound pain. I wrote about it in Deep Medicine. When I had knee surgery replacement, I had such pain, I couldn't function. I couldn't sleep. I tried all those alternative therapies and none of them worked. None of them provided any relief. Cold laser. Hot laser. Acupuncture. You're so desperate, you say, "I'll take the opiate, I'll take anything. I can't live with it." The temptation to become addicted is profound.

But I want to turn to a positive thing, which is the future of pain management. There are people with genetic mutations who can't sense pain. Obviously, that is a problem because it puts them in jeopardy when they get hurt and they don't know it. But because of this, we have identified all the receptors and pathways through which we could ablate pain and fashion new drugs that are not addictive but work on that pathway. Could you comment about where this field is headed and how we get out of addiction and to potency?

Warraich: When I started writing this book, I wasn't very optimistic about where I would land at the end of it. But after speaking to so many experts and seeing all the research that's being done, I am much more hopeful today than I have ever been. In part because of the opioid epidemic, the focus on finding those nonaddictive therapies for pain is greater today than it has ever been. The science of pain is more mature today and more well developed than it's ever been. Within the pain field, we have learned many lessons about avoiding the conflicts we've had in the past between the drug manufacturers and the advocacy groups and organizations.

One of the things that's starting to happen now, especially for chronic pain, is that in the past we've been resistant to accepting the fact that pain is extremely complex. It happens in your mind as well as in your body. It is not a purely musculoskeletal phenomenon but is as much a neurologic or psychologic phenomenon as anything else we experience.

One of the most promising therapies for chronic pain is something called pain reprocessing therapy. This has been tested in randomized trials, one of which was recently published in JAMA Psychiatry. Therapists work with people who have chronic pain to try to eliminate the fear aspect that pain elicits within them and try to get people to focus more on living their lives to the fullest rather than trying to control their pain at all points. This trial was conducted by some of the leaders in the field and the results are stunning. It's that type of work that gives me hope that we are now starting to put all the pieces together and are moving toward a holistic approach for pain, especially chronic pain.

Having said that, I do believe that we remain in a kind of gray area where many therapies are doing well in clinical trials but haven't yet made it into practice. And the desperation to find something that's going to work is at an all-time high. For example, look at what's happening with ketamine. Ketamine is a dissociative anesthetic. There's been some evidence that it helps people with depression and posttraumatic stress disorder. But now you have all these ketamine clinics opening up all over the country at which people pay cash to get ketamine infusions, despite the fact that we have little evidence for ketamine and chronic pain.

We're at that phase where physicians, researchers, and regulators have to walk a fine line between trying our best to make sure we provide our patients relief while not making the same mistake we made with opioids, where we jumped the gun. We also need to avoid introducing treatments into our practices before we have the right type of research.

Verghese: It feels like we're just scratching the surface of a very complex subject. The part that reassures me is the notion that things like placebos can be so powerful, and within the placebo area, the ritual of someone seeing a patient, the ritual of someone being present, putting hands on them and how that can help. In this podcast, Medicine and the Machine, we're always working that binary of hardcore science vs the fact that we're human and embodied beings. Thank you for shedding light on that dyad.

Warraich: Pain lives at the border of physical sensation and emotion. You have to put all the pieces together. For many people, the subjectivity of pain creates anxiety because we've become so focused and so used to having biomarkers and imaging and all that to guide medical decision-making. But when it comes to pain, we're left to our most ancient tools — looking the other person in the eye and listening to their story. If anything, we need to create more avenues for that to happen. We need to ensure that we're not just having a health system that is focused on maximizing profit and being most efficient. We also need to think about how we can train healers as opposed to mechanics. Pain is sort of the test subject because if we can do well with pain, then we can do well with other conditions for which we may not have that magical diagnosis or a test that can provide a shortcut to clinical reasoning and decision-making that we may need for something that's a bit more complex.

Topol: Haider, you've already written three books at a young age. Modern Death, State of the Heart, and now The Song of Our Scars. It's pretty remarkable. You obviously love to write, love to do the research and the writing, and then you put it into human context; you're a great storyteller. What's your next book? What do you recommend to listeners about getting into writing? Because obviously you are a smashing success.

Warraich: Thank you so much. You had me on this podcast a couple of years back and you asked me the same question. I told you I was thinking about writing a book on pain. And here I am a couple of years later. Right now, I'm so focused on this book and this work that I haven't thought about the future. The pandemic has opened so many fissures that have given us a hard view of where medicine stands and where medicine and society stand in regard to each other. The misinformation epidemic has been revelatory. It shows that evidence and facts alone are not going to cut it, and that how we think in clinics and hospitals is very different from how people make medical decisions.

I don't think I'm ever going to write a book about the pandemic itself. This is something I would rather learn from people like you and others. But the need to be able to communicate what we see in medicine has never been more important. We're seeing that the role of storytelling is, in fact, as important, if not more important, than showing people research, showing people data, showing people fancy graphs and charts. More than ever before, we see how important the act of storytelling is. Storytelling is really the heart of medicine. The pandemic has shown both successes and failures in how well we have told those stories. Some people have done it quite well, but there are so many people we haven't been able to reach because we just don't know how to frame what we see in ways that can really touch their hearts or help shape how they feel and think.

I believe the need for writing and storytelling has never been more important. If done well, it can be among our most impactful practices as physicians and clinicians. I hope listeners will see what people like you and Dr Verghese have been able to do with the pen or the keyboard and take heart, because stories are an integral part of what we do. No amount of clinic visits can match the impact of effective storytelling.

Verghese: The book is The Song of Our Scars. Haider, thank you for being with us today.

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