Thomas Goetz (4:35)
This is Drug Story. I'm Thomas Goetz. Today's story is about a brand new drug, one that has promises for Paul and so many other people, but it's really about the broader issue of chronic pain and how we treat it. Pain is probably the oldest problem in medicine. It's the way our bodies tell us that something is wrong here, but it's long been considered a symptom. So when medicine can't find what's wrong or when medicine can't fix the pain, well, that's usually the end of the story. And that's left a lot of people suffering in silence. After all, pain is invisible. It doesn't show up on an X ray or a CT scan. So is pain real? Is it all in your head? Well, in a way, yes. That's where the brain is. Only in recent decades, like the past 50 years, has pain started to be recognized as a condition itself, something beyond a symptom that is worthy of research and study. In today's episode, we'll learn why pain was one of the greatest mysteries of medicine, one of the most challenging conditions to diagnose, to measure, and hardest of all, for people like Paul to treat successfully. And we'll explore why the worthy effort to bring pain into the light, to make it real, that inadvertently created one of the biggest public health crises of the last century. We'll also look into what new methods might finally be available to help. That's all ahead on Drug story. But first, here's a commercial for Cobroxen, a discontinued homeopathic pain reliever. The active ingredient supposedly was cobra venom. So yeah, they're selling snake oil. And I hope I do not need to say this. Not a sponsor of Drug Story. Sometimes the pain is so bad it keeps me from doing the things I love. I've consulted physicians, considered prescription drugs even surgeries, and it seems like the only treatments that would work could end up costing me thousands of dollars. Recently, my friend told me about a new remedy called Cobroxan. He said it was a miracle. After spraying it into his mouth for a few days, it worked. Cobroxin is more powerful and longer lasting than prescription medicine, and you don't even need a doctor's visit. It's non narcotic, non addictive, over the counter and even sponsors the Arthritis Foundation. Drug Story is sponsored by Goodrx. Every prescription has a story, and for many patients, affordability is a defining chapter. Goodrx makes it easier to find lower prices on prescriptions from GLP1s to flu meds, so cost isn't a barrier to care. Trusted by nearly 30 million Americans and over 1 million healthcare professionals each year, Goodrx offers savings at more than 70,000 pharmacies nationwide, helping people start and stay on the therapies that keep them healthy. To start saving, go to goodrx.com drugstore that's goodrx.com drugstory GoodRx is not insurance. Each episode of Drug Story has three parts the diagnosis, the prescription, and side effects. This is part one, the diagnosis, where we look at the disease behind the drug and how that disease emerged. In modern days, pain has been part of the human condition. Well, since there were humans and even before we know that all mammals feel painful and almost certainly all animals that have vertebrae, brains and spines sense pain. Today, pain is typically described as acute pain or chronic pain. And there are many kinds of chronic pain. There's back pain, joint pain, arthritis, migraines, fibromyalgia, and so on. So where do we start? Well, let's try this. Let's visit the small city of Binghamton, New York, on a summer day in 1941. There or a wrestler named Johnny Bull Walker enters the ring against Jesse James, the light heavyweight champion of the world. They grapple and tussle, and soon there is a new champion, Bull Walker, the new light heavyweight champion of the world. Bull Walker was an alias. The wrestler's real name was John Bonica, born Giuseppe Bonica on an island off of Sicily, Italy. Not only did he have a fake name, but he had a double life, because when he wasn't wrestling, he was in medical school, learning to be a physician. Wrestling was a good way to make money, but it also brought him great pain. Personally, wrestling left him with cauliflower ears, where the cartilage is broken and disfigured. It was extremely painful, and he would have four surgeries to fix his ears. Injuries in his hips and shoulders would lead to another 16 orthopedic surgeries in his later years. After graduating from medical school, Bonica left wrestling behind and focused on anesthesia, the science of managing pain during and after surgery. By 1944, Bonica was serving as an army doctor. He was appointed chief of anesthesiology at Madigan Army Medical center in Fort Lewis, Washington. There, thousands of soldiers were sent after being wounded in action in the Pacific, many of them with debilitating pain from their injuries. Among his discoveries was the use of blocks, injections in the spine that eliminate pain in targeted parts of the body. These injections happen while the patients are awake. These include epidurals that are commonly used during childbirth. Thousands of people benefit from nerve blocks every day. One of Bonica's other innovations was less technical but no less significant. He began to get different doctors together, different specialties, to consult on a patient with severe pain so that they could discuss the case and share ideas. Yes, he invented talking with colleagues, but it worked. As colleagues talked over a case, they often made new observations or came up with ideas that might suggest a different course of action. They called this a pain clinic, and it helped more than 10,000 soldiers who had been wounded in action. In 1953, Dr. Bonica gathered these ideas into a new book, the Management of Pain. This was the first textbook on pain treatment in any language, and the first book in medicine that really took pain seriously, not as a symptom of disease, but as a condition that needed a new understanding and a new way of treatment. Part of Bonica's concern was that pain was typically the province of the anesthesiologist, a physician trained to administer blocks and anesthesia to neutralize the perception of pain, typically in a hospital setting. But Bonica was aware that many patients complained of pain outside of the hospital in their daily lives. This was a Different kind of patient with unique kinds of needs. This was pain management, and it required a different approach than anesthesia. Dr. Bonica's book became known as the bible of pain. But he was convinced that there was more to do. In May of 1973, Dr. Bonica invited 300 leading researchers to a former convent in Issaquah, Washington, a town about 20 miles east of Seattle. They talked for six days about how people hurt. To outsiders, this would have sounded like just another week of doctor talk and presentations. But in its own way, this symposium shifted the ground. For one thing, Bannock had gathered all the right people. Leaders from the National Institutes of Health, big name neurologists, psychiatrists. They were all in the same room at the same time. And it was the first time that the term chronic pain was used to describe a specific affliction. By the end of the meeting, the group had come to a consensus. Pain was a distinct condition, not just a symptom. It was itself worthy of much more intensive study. They agreed to form a new body, the International association for the Study of Pain, and to publish a new journal called, appropriately, pain. Years later, Dr. Bonica called the meeting the proudest accomplishment of his life, even more than the light heavyweight wrestling championship. That meeting just over 50 years ago, was the start of a new, more modern, more medicalized understanding of pain, especially chronic pain. And now that there was a respected journal dedicated to publishing research about pain, well, the understanding and sophistication of treatments could grow and develop. A discipline of pain science began to emerge. Today, scientists understand a lot more about pain as a distinct condition. For one thing, it's now understood that chronic pain is a combination of physical and mental experience. It's not just a physical injury, nor is it all in someone's head. In fact, in chronic pain, pain doesn't necessarily mean there is a current physical injury at all. Instead, it's generally accepted today that chronic pain is a malfunction of the central nervous system, where nerve receptors become over sensitized to pain signals. To oversimplify, think of what it's like to get a sunburn and then take a warm shower. It hurts even though the water isn't burning your skin, but the nerves in your skin are just super sensitive to any signal. But where a sunburn will heal and the nerves will calm, in chronic pain, the pathways remain at high alert. These receptors are always on ready to flare up. This creates basically a neurological feedback loop that makes people with pain increasingly sensitive to it. What's more, chronic pain is intertwined with other conditions. Like depression and anxiety, which makes sense. If you're always in pain, always on the lookout for pain, it's reasonable that you'd experience some depression and anxiety. But these conditions then reinforce the pain and can make it worse.
