Needless Suffering: How Society Fails Those With Chronic Pain

Book Title: Needless Suffering: How Society Fails Those With Chronic Pain

Author: David Nagel

Publication Information: Lebanon, NH, University Press of New England, 2016, 343 pp., $15 paperback/ebook

America has a pain problem. Estimates indicate 100 million people suffer from chronic pain. What is our way forward? Dr David Nagel, a 28-year veteran of treating pain, has written a comprehensive treatise on this subject. He gives the clearest account I have read of our country’s on-again, off-again approach to pain management and how these pendulum swings have harmed patients. He covers everything from the politics of health care to our current dilemma of undertreating pain.

Each chapter begins with a quotation like this one from the Oath of Maimonides: “May I never see in the patient anything but a fellow creature in pain.”¹ Dr Nagel makes it clear through statistics and anecdotes that patients with chronic pain have been mistreated. For example, too often learners witness role models talking about patients as “drug seekers” and then misapply this lesson. For that reason, this book should be read by medical students, residents, and clinicians to challenge them to thoughtfully treat those in pain.

Nagel offers clear recommendations for the system, medical education, and clinicians alike. Readers may be surprised to see a review of our health politics (his review of this subject is accurate and succinct), however, his analysis quickly reveals the trickle-down effect of such politics on pain patients. Without changes at a macro level, clinicians can’t improve care of individuals. Late chapters give specific recommendations for office-based care. His ideas are classics, yet his emphasis is appreciated in this technologic era—listen to the patient, conduct a proper physical exam, communicate well with patients and team members. Don’t expect to find an alternative approach to treating pain. The author reviews the evidence on herbs and supplements and rules against them. He is committed to proof; it is unfair to offer snake oil. His advice will resonate with those that know there are no shortcuts; treating chronic pain meaningfully requires commitment, teamwork, engaging family, and exercise.

Nagel does not mince words. Interventions have been overused without evidence of success. He strongly recommends the publication of more “negative results” studies. He writes that too many physicians have made money on the backs of patients’ desperation. Patients need honesty—they will always have pain; there is no cure, only management. Realistic goals should be set focusing on function; this is done through tough love, self-awareness, and compassion. He advocates for a system with real rehabilitation putting people back to work in new jobs based upon evolving abilities. Opioids are often part of the plan and should be used with compassionate pain agreements, prescription monitoring systems, and toxicology screens. Cancer does not have a monopoly on opioids in his world. He also explores the promise of marijuana and encourages more studies.

The author has seen it all, and has powerful insights: patients fear losing their medications and lament their loss of being useful, while providers (somewhat inappropriately) fear losing their license. This is a terrible dichotomy. Nagel implores us to stop treating these patients like modern day lepers, making them jump through hoops to “prove” their pain. He provocatively challenges traditional notions; patients on opioids aren’t addicted to opioids, they are addicted to pain relief! His lessons are clear: chronic pain is different from acute pain, and it is not a character flaw. He is sympathetic to patients. Likewise, he is sympathetic to clinicians. Their education has focused on cure, they have not been trained well in this topic, and they need more time and reimbursement.

My one criticism is that the book needs more editing. Some of the information early in the book is repeated in more detail later in the book. That being said, the reader will find the book an easy read because of the balance of evidence, stories, and opinions. Some readers may be put off by the mild religious undertone. He declares it up front. It does not undermine his message, and I found the quotations from the likes of Mother Theresa about caring for the least among us in our own backyards to be inspiring.

Dr Nagel is a rebel. He does not accept the status quo and challenges current medical models. He takes aim at the “business of medicine”, the disability system, and the impersonal electronic health record. This is contrasted with affirmative recommendations about changing primary care training and incentives for treating chronic pain. His ideas about patient care will inspire readers to hold fast to concerns about our medical system and to advocate passionately for patients with chronic pain and other difficult-to-treat illnesses. I personally have adjusted my approach to treating chronic pain after reading this book.