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Join L. Joseph Parker, a research physician, as we delve into the biases and challenges faced by health care professionals in diagnosing and treating chronic pain, particularly in marginalized communities. Joseph sheds light on the evolving landscape of pain medicine, addressing topics such as medical pareidolia, gender disparities in pain care, and the impact of trauma on pain experiences. Through insightful anecdotes and expert analysis, we explore the urgent need for a more holistic approach to pain management, one that prioritizes patient-centered care and acknowledges the real physiological basis of pain.

L. Joseph Parker is a research physician.

He discusses the KevinMD article, “Real pain deserves real treatment.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome back L. Joseph Parker. He’s a research physician. Today’s KevinMD article is “Real pain deserves real treatment.” Joseph, welcome back to the show.

L. Joseph Parker: Thank you very much.

Kevin Pho: So Joseph’s been on multiple times in the past. Go to KevinMD.com/podcast and you can search for his name and prior episodes. But today let’s go into this one, about real pain deserves real treatment. For those who didn’t get a chance to read it, tell us what this one’s about.

L. Joseph Parker: I have found, over several decades of going from emergency practice to general practice, primary care, which always involves pain management, and then addiction medicine, I’ve come to see, both in myself and in my colleagues, a tendency to develop frustration at the complicated patient, the patient whose problem you can’t cure, and who seems to have this vast array of symptoms. And there is a tendency to flip that around and blame the patient as being unreasonable in their list of complaints. And this has really taken a sharp increase with the recent, I’ll say, demedicalization of pain treatment.

Kevin Pho: And what are some of the root causes, from your perspective, as to why clinicians would tend to blame the patients in complicated cases?

L. Joseph Parker: One is just that the most common error in science, of course, is confusing correlation with causation. Two things happen at the same time, therefore one caused the other.

A good example is erectile dysfunction. For a long time they said, well, this patient’s depressed, obviously their depression is causing their erectile dysfunction, instead of understanding that perhaps the erectile dysfunction, the relationship issues it was causing, was contributing to their depression.

So you get a patient that comes to you after years of suffering severe chronic pain, and they’re almost always depressed, and they almost always suffer from anxiety, and if an accident or injury caused it, their PTSD. And this is being flipped around on them.

I just went to a conference where an addiction psychiatrist was basically convincing the crowd of practitioners that all chronic pain is a mood disorder, it’s just in their heads, and that treatment with anything other than psychotropic medications is unjustified.

And I think they’re getting that flipped around, just like how they thought that prescription medications were causing the opioid crisis because the two lines paralleled. Then they cut opioid prescriptions to 1993 levels with draconian practices, and the overdose rate dramatically increased, so the lines completely diverged. But instead of changing course and saying, oh look, we were wrong, they’ve doubled down.

Human beings have a tendency to do that. They have a tendency to, when they’re wrong, deny the evidence right in front of them and to blame the person who’s suffering.

You remember when schizophrenia was blamed on refrigerator mothers, because the psychiatrist would say, well, look how cold the mother is to that child. Well, the mother’s not demonstratively affectionate to the child because the child can’t stand it, the child doesn’t like it. And so they were getting things flipped around.

And I think that’s really happening today. I almost want to call it a medical pareidolia, where we’re seeing things that aren’t there because we expect to see them. And nowhere is this seen more than in women with severe chronic pain syndromes that don’t have a clear physical injury as a cause.

Kevin Pho: So you were at this conference where you saw an addiction psychiatrist forward the argument that chronic pain is purely psychological in origin. Do you think that was a bias because this person was in fact a psychiatrist, or do you think that’s more of a mainstream thought that is becoming more pervasive?

L. Joseph Parker: No, I think it’s absolutely a bias that we all as human beings have, and we all as physicians have. As physicians we like to believe that our decisions are evidence-based, but while our decisions are informed by evidence and science, we still make emotional decisions and then justify them with the left half of our brain.

I think that’s to a degree what he’s doing, because as effective pain medications are being restricted from the market, and doctors are being penalized for treating patients with them, other areas of medicine are quickly jumping in and saying, acupuncture will cure pain, yoga will cure pain, nutrition will cure pain. And the psychiatrists are saying, hey, give it all to us, we can cure it all.

Now, the fact is that there are psychological and psychiatric conditions that generate indistinguishable pain syndromes, and that is valid. Acupuncture helps some people, yoga helps just about everyone. Is it going to relieve your pain to the level that you can function and have quality of life? None of those individually is going to do that. And it quite often takes appropriate pharmaceutical intervention, which is what everyone is trying to get away from because of this opioid panic.

Kevin Pho: So with this movement towards more psychological theories behind chronic pain, what are some examples of how that’s affecting patient care today?

L. Joseph Parker: They laughingly say, and I have seen them laugh when they say this, that if a woman has suffered any trauma, and they specify women, that it is inappropriate to treat any woman with an opiate medication if she has suffered a trauma in her childhood, because apparently women just can’t handle trauma.

The argument is that these chronic pain syndromes are being generated from the trauma of childhood. Now, men experience trauma in childhood too, and probably 90 some odd percent of the population has experienced something in their childhood that was traumatic, even a fractured limb or something. But they’re specifically talking about physical abuse, sexual abuse, things like that.

They’re saying that if a woman has experienced that, you cannot treat her with these medications, depriving 25 to 30 percent of the female population of this type of medication on the assumption that they can’t handle it.

We all know as physicians that women handle pain better than men do. If men went through the pain of childbirth, we would die. If you did not anesthetize a man for childbirth, we would almost certainly be dead. A few would make it through, but not many. Women actually tolerate pain better than men do, because it’s mainly men making these judgments.

We have gone back to the 19th century, to a degree, where we’re calling everything related to pain addiction or drug seeking. If the patient comes and says, my medication’s not working, you put me on gabapentin for this nerve pain, it’s just not doing it, do you have anything else? Well, that’s drug seeking, now we know you’re asking for opiates.

And they’re losing sight of the fact that most of these individuals, very few of them are actually trying to trick you and divert medication, or have a true addiction. They’re just trying to get some relief.

And the stress of severe chronic pain can cause very serious physical problems, inflammatory conditions, heart attack and stroke. A recent study even showed that that chronic stress can reactivate Epstein-Barr virus, and that this is related to some of these serious autoimmune mediated pain conditions where you hurt all over.

That’s the worst thing a doctor wants to hear. I know personally, in the ER, in the clinic, when a patient would come in and say, I hurt all over, I would say, where do you hurt worse? You get frustrated, I can’t solve, you hurt all over. And we go from, I can’t solve, you hurt all over, to, how dare you suggest that you hurt all over, you can’t possibly hurt all over, you must hurt somewhere, because then I can focus on that and I might be able to solve it.

We get frustrated when we don’t know what’s wrong with someone, and when we get frustrated and angry, we don’t make the best decisions.

Kevin Pho: To your knowledge, are there studies or data that support a psychological theory behind chronic pain, or some of the theory that’s forwarded by psychiatrists who say that trauma has a role in chronic pain? Any data to support that?

L. Joseph Parker: Absolutely, there are clear studies that show that childhood trauma sensitizes the patient to pain. You become more sensitive to pain.

There are epigenetic changes that can take place from your mother when you’re in the womb. If your mother is undergoing a lot of stress, there are epigenetic changes that will activate sort of anxiety producing genes, deactivate calm producing genes, and also increase your sensitivity to pain. Basically your brain is getting ready for a more dangerous world. It says, be ready for pain, get away from it, move from it, this is a dangerous, stressful place you’re going into.

And so you can be born with these epigenetic tags because of your mother, or even your grandmother or grandfather’s experiences. It usually doesn’t proceed past three generations.

And so you may be born with a high predisposition to anxiety. So you end up in the military and a combat situation, and the guy next to you doesn’t end up with PTSD and you do. Or you get a shrapnel injury and he gets better and he’s walking fine and everything, and you can’t sleep at night because you’ve got constant pain. This is due to the changes even in something called, I think it’s P2, which is kind of a mediator of chronic pain, of chronic inflammation. It causes nerve overgrowth.

These epigenetic predispositions are clearly there. So there is some truth to what they say. But whereas there is a small contribution, they’re saying it’s the entire thing, and that’s not true.

And we also have to respect the individual’s right to a reasonable quality of life. We can’t laugh when they’re crying and miserable, which is what some of these doctors are doing. They’re almost gleeful talking about firing patients who ask for more than two increases in their medication.

Well, how are you supposed to start low and go slow if you get two guesses? You’re either going to have to start low and go high, or start low and go medium and then high. It’s impossible, because it’s so variable for each patient.

So the politicization and the criminalization of medicine has made us so cautious that we just don’t want to treat these patients at all. And these physicians are rising up to tell us, you don’t have to, it’s not your fault you can’t cure them, it’s their fault.

Kevin Pho: So if we’re in the exam room with a patient with chronic pain, one of those complex patients, how are you supposed to tease out what maybe is increased sensitization due to psychological trauma versus a more physiologic origin of pain, and what to do next? So how can you tease those out in the exam room?

L. Joseph Parker: You do not have to separate it into a clear dichotomy. You can comfort them and give them the psychological support that they need at the same time that you try a reasonable remedy with a reasonable chance of helping them feel better.

I fully advocate that every patient on chronic controlled medication therapy should be receiving counseling from a qualified counselor, someone experienced with pain, so that they can be helped to deal with this. I think psychiatrists absolutely have their place, because the mental strain of dealing with this constant pain is unimaginable.

And about 25 percent of our population has chronic pain at any one time, and 16 percent of those over their lifetime try to commit suicide, because that pain is not treated adequately, because of the suffering they’re experiencing.

And a good percentage of those will use their medications to do that suicide. Then you’ve got an overdose death, and then you’ve got a doctor being prosecuted because a patient died of an overdose, when actually that was the patient’s intent, that was how they took themselves out.

Others shoot themselves, and the doctor’s not blamed when they shoot themselves. But every patient that shoots themselves because they cannot tolerate their pain is an indicator of a failure of our system to respect what they were going through, to help them with what they were going through.

This is very, very prevalent in women and minorities, because their complaints of pain are ignored to the point that they die in hospitals. African American women will have childbirth or have a surgery and say, hey, it’s hurting worse and worse, and they’ll be ignored.

And we need to re-evaluate the assumptions we make. It’s fine to think in general it might be this, but in specific you must focus completely on that individual patient, and not assume that because they are a certain sex or a certain color or perceived racial demographic that they are a certain way.

Kevin Pho: We’re talking to L. Joseph Parker. He’s a research physician. Today’s KevinMD article is “Real pain deserves real treatment.” Joseph, as always, we’ll end with some of your take-home messages to the KevinMD audience.

L. Joseph Parker: When you feel frustrated or angry at a patient because you can’t figure out what’s going on with them, stop. Comfort them verbally and refer them to someone else, get a second opinion. Don’t make a rash decision to abruptly stop their treatment, or to make them feel bad about what they’re telling you, when they’re doing their best to communicate what they’re going through.

Health insurance companies and the federal government are kind of joining together to push these patients off to the side because they cost a lot monetarily, and we need to fight back against that. Doctors need to maintain their autonomy and their right to practice medicine, as they’re the only ones that are certified to decide who needs which medication. We can’t abrogate that to corporations or authorities.

Kevin Pho: Joseph, once again, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

L. Joseph Parker: Thank you.