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- [00:05]
Paul
I was laying in bed next to my wife and dog. Just a lazy Sunday afternoon was a rainy day. Dog was asleep in between us. She was only about 18 pounds. She was a pretty small dog. Somebody slammed a car door outside. She jumped up. And the best I can describe it is she sort of springboarded off my left testicle. And it sort of felt like somebody had hit me in the nuts and it just never went away. Sort of felt like I was in a vise. And then a couple of times a minute, it kind of felt like I was getting hit by lightning. It would be so sharp that I couldn't breathe.
- [00:45]
Thomas Goetz
Oh, my God. A couple times a minute you said yes. And this was going on for years.
- [00:54]
Paul
Yes.
- [00:55]
Thomas Goetz
This is Paul. He lives in Connecticut and has had chronic pain for about 15 years. Oh, my God. So, I mean, I've had. I've been kicked in the nuts before and I know what that feels like.
- [01:09]
Paul
Yeah, so it was definitely that, that first day that she had jumped on me. Unfortunately, we were leaving for vacation that following day, but. So I was in South America for two weeks and then got back and saw a doctor, but there really wasn't much of anything anybody could do.
- [01:27]
Thomas Goetz
I assume you went to, you began kind of medical treatments and seen doctors and stuff like that.
- [01:33]
Paul
Oh, I actually have a list written down here.
- [01:35]
Thomas Goetz
Oh, I'd love to hear it.
- [01:37]
Paul
I've had three spinal cord stimulators. Basically, they implant a battery under your skin and they run leads into your spine. And the idea is it kind of overwhelms the nerve with a signal that should kind of block the pain. Unfortunately, it didn't. Didn't work for me. I've had two different surgeries to sever that nerve. I've had a nerve ablation that hurt so bad I actually almost passed out on the table. I've had physical therapy, pelvic floor, physical therapy, talk therapy, pain reprocessing therapy. Everybody always recommends yoga. Yes, I've tried that. Medication wise, I've tried antidepressants, anticonvulsants, gabapentin, pregabalin, opioids, muscle relaxers, thc, cbd, about a thousand snake oils. I've got drawers full of pills. Basically, if anybody said that some supplement helped them, I tried it. Really the only things that have worked, opioids kind of take the edge off. THC kind of distracts me from the pain. I haven't said no to a medication or a treatment because as you can imagine, it's pretty desperate for a solution.
- [02:50]
Thomas Goetz
As you can Hear. Paul has struggled for years with chronic pain. Pain that just doesn't go away. In his case, he knows exactly when it started and how it started. This sad story about his dog. For many people with chronic pain, though, how or when it started is more ambiguous, but no less real. About 20% of all Americans live with chronic pain today. According to the CDC, that's more than 50 million people.
- [03:24]
Paul
The thing about chronic pain that I think most people don't really understand is that you have to fake it. You know, normal people would be, you know, rolling on the floor or screaming. It's just not an option because that's all you'd ever do. And it doesn't really help to relieve pain. So you kind of have to just fake your way through life, kind of pretending you're not in pain. I had to quit my job because my body just couldn't handle it anymore. But, yeah, it affects every, every aspect. You never really rested. You're never comfortable. Sleeping is very difficult. And we're met with a lot of distrust. You know, I can't tell you how many medical professionals, how many nurses have kind of treated me like I'm a drug addict. So I was actually in the hospital recovering from a major spinal surgery. I really had to beg him to just get my normal dose because my regular pain was worse than the fusion pain.
- [04:36]
Thomas Goetz
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.
- [15:13]
Dr. Antja Barveldt
I always tell my patients that as pain goes up, anxiety goes up, and as anxiety goes up, pain goes up. So they kind of feed off of each other. And then if we overlay that with a trauma experience, other life stressors, we know that if those are not well managed, then it's really hard to also have a good handle on the pain.
- [15:32]
Thomas Goetz
This is Dr. Antja Barveldt. She is an expert in pain treatment, a leader in the field, and she follows directly in the footsteps of Dr. John Bonica.
- [15:42]
Dr. Antja Barveldt
I am chief of pain medicine at Newton Wellesley Hospital in Newton, Massachusetts, part of the Mass. General Brigham system, and president of the American Academy of pain medicine. 41st president and first woman ever in 41 years.
- [15:57]
Thomas Goetz
Oh, awesome.
- [15:58]
Dr. Antja Barveldt
Yeah, so those are kind of my main. My main gigs.
- [16:01]
Thomas Goetz
I wanted to speak with Dr. Bar Veldt because she has such a good way of explaining why pain treatment is so complicated, both for physiological reasons as well as logistical and economic reasons.
- [16:14]
Dr. Antja Barveldt
Pain is so pervasive, and it extends beyond just an orthopedic issue or having arthritis. It goes to every single organ system. And then it also, of course, affects not only just our bodies and our brains, but it also affects really our social interactions, our ability to work, to be able to participate with friends and family, and really to feel like we are human. For so very long, we've focused our medical education and teaching really, around disease states such as the cardiovascular system and diabetes, and thinking much more about preventative strategies in regards to other organ systems. But we've never really put pain at the focus of our treatment and preventative strategies because it was just sort of a little bit, I would say, forgotten or thought to be less important and reflected in ways such as underfunding of NIH research. And so I think for a long time, it's really that pain just didn't necessarily have a home. And it took many champions within the discipline of pain medicine to really highlight the opportunities that we have around not only pain treatment, but pain prevention. And for so much in medical education, we focused on diagnosing pain, but not necessarily how to make it not happen and how to make someone feel better.
- [17:40]
Thomas Goetz
This issue of medical training is a big deal because there are really two distinct camps in medicine, researchers and clinicians. The researchers work on the science. They run studies and experiments to understand what are the root causes of disease and how best to treat disease. The clinicians are the frontline doctors providing the care. They are the ones putting the research into practice. Ideally, these two groups work hand in hand, putting the latest scientific understanding to work. But sometimes the training that doctors get in medical schools and in hospitals and clinics, it lags behind the state of science. And then you have clinicians treating patients with outdated knowledge or practices. This is called the knowledge practice gap, and it's a real thing. It happens with a lot of specialties and diseases. It can take years for practice to catch up to the latest research, around 17 years, it's been estimated. And for chronic pain, this gap has been an especially persistent problem. This first became a known issue in 1990, when Dr. Mitchell Max, the president of the American Pain Society, wrote an editorial in the Annals of internal medicine. Dr. Max lamented how pain was consistently under recognized and undertreated in everyday practice. Pain was too invisible. Unlike vital signs, Dr. Max wrote, Pain isn't displayed in a prominent place on the chart or at the bedside or Nursing Station. Dr. Max's suggestion was to make pain more visible. Doctors should routinely ask patients if they were experiencing any pain, and doctors should be more accountable for treating their patients pain. A few years later, Dr. Max's organization, the American Pain Society, went a step further. The organization called for pain to be recognized as the fifth vital sign, after blood pressure, temperature and breathing, and heart rate. There is no thermometer to measure pain, though, so doctors were instructed to simply ask their patients if they felt any pain during a routine examination. They should rate it on a scale of 0 to 10, where 0 equals no pain and 10 equals the worst pain imaginable. The idea caught on fast. It seemed like an overdue recognition of a patient's true experience and a huge breakthrough in legitimizing and treating pain. The Department of Veterans affairs signed onto the idea in 2001, which mattered because chronic pain was much more common among the military. Soon it became accepted practice throughout medicine. And here's the but as much as the fifth vital sign helped bring pain out of the shadows, it also proved to be far too simplistic for a very complicated problem. Here's Dr. Barveld.
- [20:37]
Dr. Antja Barveldt
Our patients with chronic pain, they always live at a high level of pain. And just because my patient is quietly talking to me and looks pretty relaxed, but they're saying their pain is 10 out of 10, and then I have another patient who's writhing and barely able to hold a conversation, they say their pain is 6 out of 10 it's relative to everyone. Right. So it's not a particularly useful tool. And unfortunately, the large part of the criticism towards pain as the fifth vital sign is that we were treating a number and not a patient. And that may have led to a potential over treatment with medications such as opioids because we were chasing that number.
- [21:16]
Thomas Goetz
And that is another problem with the fifth vital sign idea. Once pain has been recognized and logged, the physician is now obliged to treat it. And the prevailing wisdom at the time, this was the late 1990s, early 2000s, was that the best way to treat pain was with prescription opioids. And that created what surely stands as one of the worst fiascos in the history of, of medicine. We'll get into that after this break in part two. To take us there, here's an old commercial for one of the most popular pain relievers of the 20th century, Anacin. And no, they are not an advertiser. From doctors offices across the country come survey replies of what doctors recommend for headache, neuritis, neuralgia, pain. 3 out of 4 doctors recommend the ingredients in anacin. Doctors know with most headaches, pain mounts up. You feel dull, depressed, tension puts nerves on edge. Now aspirin has just one pain reliever. Add buffering, you still get just one. Only anacin, of the four leading headache remedies has special ingredients to relieve pain fast, help overcome depression fast, relax tension fast. I feel great. Headache's gone and my stomach isn't upset. And no wonder. Anacin is like a doctor's prescription. That is a combination of ingredients, a particular combination that brings fast relief without upsetting your stomach. Remember, aspirin, even with buffering, has only one pain reliever. Take anacin with ingredients. 3 out of 4 doctors recommend anacin for fast, fast, incredibly fast relief. Welcome back to DRUG story. This is part two, the Prescription, where we learn about the medicines used to treat pain. As I've said, pain is surely the oldest condition in human health and it's likely the first that was treated with medicine. The first effective medications in pharmacology were pain relievers. Willow bark was used to treat pain in ancient Egypt. In 1899, Bayer began selling the active ingredient salicylic acid under the brand name aspirin. Anacin, which we just heard a commercial for that came along in 1915. Those secret ingredients that the commercial hinted at, caffeine and another pain reliever called phenycetin, turns out that phenycetin can cause kidney damage and it was removed from the market in the 1980s. And of course, there's acetaminophen, often sold as Tylenol, derived from coal tar, Acetaminophen was first introduced into medical practice in the 1880s. It reached the market as Tylenol in the 1950s. It has dangers, too. For some people, it is pure poison. It turns out that too much acetaminophen can cause liver damage, particularly for people with some genetic variations. There is no evidence of a causal link to autism, though. And there was heroin, an opioid drug that, believe it or not, is actually a brand name. Heroin was first sold by Bayer in 1898. It would be 25 years before the dangers of heroin, namely addiction and abuse, would come to a head, and it was removed from the market in the US in 1924. But the damage was done. Heroin would become one of the most abused drugs on the planet over the course of the 20th century. This peaked in the 60s and 70s, driven in part by the Vietnam War. That conflict opened new sources of heroin in Southeast Asia. The disaster with heroin didn't deter drug companies from developing other opioids for pain treatment. There was morphine and codeine and oxycodone, all effective for pain, but highly addictive. And in 1995, the FDA approved the use of OxyContin, an extended release version of Oxycodone. At the time, the belief was that since the drug was released into the body slowly, it would be less addictive and give less of a quick high. Oxycontin arrived just in time for the growing awareness of pain as a fifth vital sign. Purdue Pharmaceutical, the maker of OxyContin, launched an aggressive marketing campaign. It encouraged physicians to prescribe the drug for all sorts of pain, not just acute pain, such as after a surgery, but for chronic pain like lower back pain. And Purdue advocated prescribing OxyContin not just for severe pain, but even for moderate pain. And they began to train doctors to sell to other Doctors. In the five years after OxyContin was approved, Purdue held dozens of all expense paid pain management conferences at resorts in Florida, Arizona, California. The company recruited more than 5,000 physicians, pharmacists and nurses at these events. And they sent them out to pitch the benefits of OxyContin. As for abuse and addiction, Purdue trained its sales representatives to carry the message that the risk of addiction was less than 1%. Now, that factoid, it turns out it came from a letter to the New England Journal of Medicine, written by a doctor at the Boston University Medical Center. But that letter was just one paragraph long. It was not a proper study. And it conjectured the risk of addiction based on hospitalized patients who received one dose of narcotics or more, not patients taking the drugs at home for months on end. No matter. Purdue pushed the figure hard. Here's a clip from a 1998 promotional video made by Purdue. There's no question that our best, strongest pain medicines are the opioids. But these are the same drugs that have a reputation for causing addiction and other terrible things. Now, in fact, the rate of addiction amongst pain patients who are treated by doctors is much less than 1%. They don't wear out, they go on working. They do not have serious medical side effects. And so these drugs, which I repeat, are our best, strongest pain medications, should be used much more than they are for patients in pain. None of this was true. Oxycontin created a wave of addiction and abuse that destroyed communities, families and individuals. More than a million Americans have died of opioid overdose since OxyContin was approved in 1995. It is, without a doubt one of the greatest disasters of public health in the past century, a crisis created entirely by humans. There is a lot of blame to go around for the opioid epidemic, and plenty has been written about how it happened. Rather than rehash all of that, we're going to point you to some sources. I recommend the books Dopesick and Empire of Pain and the HBO documentary the Crime of the Century, which uncovers all the nasty stuff that Purdue did. So it took a long time for medicine and society at large to recognize the catastrophe of the opioid crisis. It wasn't until 2016 when the American Medical association officially recommended that doctors no longer treat pain as a fifth vital sign. They recognized that a 010 scale was subjective and flawed. The AMA president even acknowledged that physicians played a key role in the epidemic by over prescribing opioids. In 2025, Purdue agreed to pay $7.4 billion to all 50 states and five territories for damages caused by OxyContin. The company was then dissolved at last. Obviously, we are still dealing with the opioid crisis. A staggering 55,000Americans died of opioid overdoses in 2024, but that is down about 35% from the year before. In hindsight, though, OxyContin and opioids skewed the whole notion of pain. And how to treat offered what seemed like a safe and effective solution for both doctors and patients. That wasn't true, of course, but it did make the problem of pain, the reality of pain, visible.
- [29:42]
Dr. Antja Barveldt
Well, Unfortunately, I think it took the opioid epidemic for people to pay attention to pain. Prior to this, it just wasn't a priority in government funded research. And now there's a possibility that we may go backwards again. We may find ourselves back where we started, which was where opioids were a mainstay of pain treatment. Not for primarily malicious reasons. No one wants to hurt a patient, but it's what was pushed, it's what we had. And they're very effective. They just come with so many risks and consequences. We've been a pretty pill happy culture that we just kind of want a medication to fix everything and don't necessarily think about lifestyle changes and other decisions that we make. So it's going to take a system to not only look at pain, but also to look at health in America overall.
- [30:37]
Thomas Goetz
Which brings us back to Paul, who we heard from at the beginning of the episode. Several years ago, Paul's wife heard about a new drug in development from Vertex Pharmaceuticals, a non opioid pain reliever called Jornavix. So they followed the drug as it went through the approval process with the FDA until finally, in January 2025, Journavix was approved for moderate to severe acute pain.
- [31:03]
Paul
My wife is brilliant. She's a pharmaceutical drug development scientist, so.
- [31:10]
Thomas Goetz
Oh, that's handy.
- [31:12]
Paul
Yeah, yeah. She, she found out about this drug a few years ago and we've kind of been waiting for it to come out, but it, it has been a miracle. To say it's been a miracle has been an understatement. It is a very expensive medication. It's almost $1,000 a month.
- [31:28]
Thomas Goetz
Yeah, but you think you can go back to work, that. That's in the cards?
- [31:34]
Paul
Yeah, I'm doing so much better that I feel like I'm. I'm getting my life back. I was doing yard work this weekend, which I haven't done in who knows how long. And yeah, I had this, this moment during the first week where I realized I wasn't in pain. And it was just like this, this overwhelming feeling just washed over me that, you know, this is how normal people live their life. With chronic pain, it's always in the back of your mind and it's always kind of gnawing at you no matter what you're doing. It's that fire alarm going off and it just seemed like somebody had finally shut it off. Somebody had finally flipped that switch.
- [32:16]
Thomas Goetz
And that was the first time in how long that you'd felt that.
- [32:20]
Paul
Oh, probably close to 15 years.
- [32:24]
Thomas Goetz
Tronavix is the first drug approved to treat pain in 20 years and significantly, not an opioid. Here's the CEO of Vertex Pharmaceuticals, Reshma Kiwal Rahmani, back on January 31, 2025, the day the FDA approved the drug. It is a big day for patients, for society and for Vertex.
- [32:45]
Whitney Wright
This drug, Journavix, is the first new class of pain medicines in more than 20 years. And what a class of pain medicines it is. It only works on the peripheral system, the peripheral nervous system. That's to say it doesn't work in the brain, it doesn't work on those reward centers that lead to addiction. It is a non opioid. It has been shown to be effective, it's shown to be well tolerated, and this feature of it working in the peripheral nervous system allows it to not have addictive potential.
- [33:24]
Thomas Goetz
This is the kind of medicine we
- [33:26]
Whitney Wright
have been seeking to develop and I think it's the kind of medicine and society wants to be able to use for moderate to severe acute pain.
- [33:36]
Thomas Goetz
As she was careful to say, Jornavix is approved for acute pain, not chronic pain. But that hasn't stopped many patients like Paul from using Journavix for chronic pain. That is totally legal. It's called an off label prescription. Any physician can prescribe a drug for whatever purposes they think best, but the drug company can't market the drug for any purpose that hasn't been approved by the FDA. And insurance companies typically will only cover a 14 day prescription for Journavix, since that's what it was approved for. Any longer than that though, and insurance usually will not pay. That means that any patient taking Journavix for chronic pain is almost certainly on the hook for the full cost of the medication. That's more than $15 a pill, or about $30 a day. Vertex is actively researching how well or if Journevix works for chronic pain. And several studies are underway. Now their goal would be to prove that it is safe and effective to use over longer periods of time. If the evidence falls in favor, Vertex would go back to the FDA and apply for approval for treatment of chronic pain too. In the meantime, Vertex has created a patient savings program that provides a one month supply for just $30, a prescription that would otherwise cost $900. But that program only works for two months. After that, you're on your own. Which brings us to a practical question, a question of logistics. If you are a patient with chronic pain, how do you weigh the options? How do you work your way towards something that helps and will that treatment line up with what your insurance company will actually pay for. That's the million dollar question and we'll get to that in part three coming up. But first, here's a commercial for a pain clinic and this is not a paid ad. They are not a sponsor of this podcast, but it's a good example of the industry that exists to treat pain pain.
- [35:40]
Dr. Antja Barveldt
Many people will experience orthopedic or spine issues in their lifetime and the pain that goes along with that can make
- [35:46]
Thomas Goetz
you feel, well, like a shadow of yourself. At the new Orthopedic and Spine Hospital at UAMS Health, we are dedicated to providing Arkansans with a brighter future they
- [35:58]
Paul
deserve after years of dealing with extreme pain.
- [36:01]
Thomas Goetz
Thanks to visiting UAMS Health, I'm able to do things physically that I never
- [36:06]
Paul
thought I'd be able to do again.
- [36:07]
Thomas Goetz
Choose UAMS Health or a better state of health. Welcome back to Drug story. This is part three, side Effects where we explore the trade offs of treating a disease with medications or in the case of chronic pain, with medications and physical therapy and alternative medicines and on and on. There are many, many options for treating pain.
- [36:32]
Dr. Antja Barveldt
So yes, I'd be happy to kind of list. I always start with the medication category because that's the simple one. But medications don't mean just a pill. They also can mean topicals, they can mean suppositories, they can mean local anesthetics and that can include things like compounded therapies, of course, other sort of alternative medications or over the counter medications, supplements, things like that. Then I'll think about physical therapy and occupational therapy. And of course with that comes exercise, whether that's guided exercises or it might be swimming or being in a pool or being able to do Pilates or yoga or that might even include something like tai chi or chair yoga. I can put a needle pretty much almost anywhere and near most muscles and near most nerves. So though it may not give someone long lasting relief, its injections are not curative. They can give us also a diagnosis. And then I think about our behavioral medicine category. So cognitive behavioral techniques. So there's a lot of really amazing science on the power of different brain retraining exercises, cognitive behavioral therapy strategies, pain reprocessing therapy, mind body techniques. And then I sometimes will group things into our alternative medicine category, which might include things like acupuncture, chiropractic care, dietary measures, anti inflammatory foods. And then we think about our other consultants, whether that's immunologists or surgeons or gynecologists or maybe an orthopedic Surgeon where not only are we thinking about the potential for surgical benefits, which can be helpful. So thinking about pain medicine really is having that kind of comprehensive approach and then never forgetting the sort of social aspects of pain too. Identifying reasons that patients may have challenges to access.
- [38:31]
Thomas Goetz
While it is great to have all these options, finding one that is effective for your pain can be a real struggle, especially when many people who have chronic pain aren't dealing with just one thing. When the signals and pathways that develop with pain are set on high alert, pain can manifest in many ways throughout the body.
- [38:53]
Whitney Wright
It's like when you go to the doctor's office and you're filling out the paperwork and they have like sort of an outline of the body. You're supposed to circle where it hurts. It's just like I have circles all over. You know, I have two torn hamsters and torn meniscus and I tear in my shoulder. I can't throw a ball anymore, which is big drag. Bursitis and neuropathy. And like, just the list goes on.
- [39:10]
Thomas Goetz
This is Whitney. She has had chronic pain since her twenties.
- [39:14]
Whitney Wright
My name is Whitney Wright and I live in San Francisco. I'm 57 years old. I'm the mother of two teenage boys, and I am married to you. You asked me to be on your podcast because of my experience with chronic pain.
- [39:28]
Thomas Goetz
So, yes, Whitney is my wife. She has taught me a lot about chronic pain.
- [39:33]
Whitney Wright
When I was in my mid-20s, I started getting lower back pain and it just never left. You know, I think what has been frustrating over the years is that doctors didn't take it seriously. And doctors would say take Advil, or doctors would say get a massage. But they weren't equipped with an understanding of, you know, why is this happening to me? Like, I take really good care of myself. I am strong and I'm athletic and I shouldn't be having this. I remember this sports medicine doctor told me I needed to do more AB work. Well, this was after I was a Golden Gloves boxer. I was the best shape of my life. I was super strong and I still had back pain, so that wasn't the issue. I even went to a lower back specialist and it was no help. Nothing. I went to acupuncture. Nothing. I did even did, I guess it was Rolfing or something and hurt a lot. It didn't do anything.
- [40:40]
Thomas Goetz
For Whitney, for a long time, this felt more like a runaround than a process, and that's not uncommon. Here's Dr. Barfeld.
- [40:49]
Dr. Antja Barveldt
You feel very hopeless when someone says, well, there is no test to tell me where this pain is coming from, or your mri looks great, or, you know, the surgery showed there were no issues. And it sort of almost feels defeating to a patient to think like, well, then where's my pain coming from? Is this all in my head? Well, yeah. You know, the central nervous system does play a big role in perpetuating pain, but it's about also having that moment to connect with the patient and have that relationship so that someone can feel heard and can feel listened to.
- [41:19]
Thomas Goetz
The challenge of treating pain has led to the emergence of pain treatment centers around the country, Specialized facilities with a range of expertise and strategies. Now, I'm not talking about pill mills, the dubious pain clinics that sprouted up in strip malls during the 1990s and early 2000s, where crooked doctors prescribed copious amounts of opioids. Hundreds of doctors have been prosecuted in recent years for negligent opioid prescribing. In Florida alone, over 400 illegal pain clinics have been shut down by authorities. But even legitimate pain treatment clinics Often approach the problem from one particular point of view. Orthopedic and spinal centers, like the commercial we just heard, those typically focus on surgical treatments like spinal fusions. Other pain clinics focus on injectable treatments, like epidural steroid injections or nerve blocks. And then there are therapy clinics that focus on rehab programs and physical therapy. Each of these varieties is a different kind of hammer, and they usually treat pain like a nail. Academic pain management centers are typically more aligned to Dr. Bonica's model. They're legitimate clinics affiliated with a school of medicine. They take a holistic approach to helping people with pain. Ideally, these clinics follow the model developed by Dr. Bonica back in Seattle more than 50 years ago. Multidisciplinary, meaning different kinds of doctors all weighing in on what they think might be wrong and what might help the patient best. No. 1 hammer. It's a toolbox.
- [42:48]
Whitney Wright
So during spring 2020, I think for most people who have chronic pain, it got really bad. It got worse because of the anxiety of the pandemic. And that's at a time when my startle response, Such as a doorbell ringing, my body would. It would manifest as searing pain through my lower back. And I spent many days just lying on the floor. And I didn't know about pain clinics. I didn't know they existed. And it was actually, I had a dinner party at my house, and a friend of a friend was there, and she was a pain doctor, and she's the one who gave me the information. And I went to My gp. And I said, this is what I need. And even then my GP was like, I don't know. But I was, I was the perfect candidate for it. And I started with the Stanford Pain Clinic, Dr. Ryan Derby, and he was amazing. And for the first time, somebody got it, they understood and he knew what questions to ask and he knew what was happening in terms of, like, pain psychology and how it affects your whole being and how circumstances and culture can affect your pain, which seems weird because it shouldn't be like that, but it does. And then I started to learn about these, the neuropathways, and it's sort of like a path through grass that if you keep walking on it, it turns into a path and it's easier to walk on. That's sort of what's happening with the neuroplasticity in the brain, is it just keeps sending these signals, whether it's truly a manifested injury or not. It was amazing. I got trigger point injections in my lower back and the experience of getting them is not fun, but it was, it felt like I had a back transplant. It was amazing.
- [44:46]
Thomas Goetz
Whitney was lucky. We were lucky because our insurance covered most of this. For many people, that is not the case. Because there is so much trial and error involved with pain treatment. There is typically a lot of expense. And so insurance companies have developed lots of rules and requirements for who qualifies for which kinds of treatments. Here's Dr. Barveldt again.
- [45:10]
Dr. Antja Barveldt
If I tell my patient, oh, I think it would be really important for you to be in an exercise program, physical therapy. Let's also consider some alternative therapies, diet, Think about some, again, more, more preventative approaches. A lot of times it's just not affordable if you're, if you're going to be paying 50 to $100 every time you see a physical therapist. And if a nutritionist is not part of your health plan, which it almost never is, and acupuncture is not covered or not covered, service in your state and other alternative therapies are not covered. Where should the patient turn? And in my world, as an interventional pain doctor, I more and more over the years see how, how I am restricted and what my patients can access for their care. So it's not just procedures that may be expensive, but it really is. It's almost like the insurer is directing care. I didn't become a physician to be told what I can and can't do by an insurance company, but that's how it feels. The worst part is when I make a recommendation to the patient and say, I think this would be a reasonable thing to try, and then be told, oh, I'm sorry, your insurance won't cover it.
- [46:15]
Thomas Goetz
And is that because those are more expensive courses of action? Or. I mean, this is the denial culture, right?
- [46:22]
Dr. Antja Barveldt
Yeah, Correct. I recently had a patient who was really doing very well. She's on Medicaid with acupuncture, but all of a sudden, the rules changed. And so because she doesn't have back pain, she can't get acupuncture because it's only covered for back pain and not for the pelvic pain that she has. So it's one of those things where I feel that we're constantly having to either take things away from patients or not even really give them any other options because it's unaffordable.
- [46:53]
Thomas Goetz
And you feel like that's gotten worse in the last few years?
- [46:56]
Dr. Antja Barveldt
Absolutely. Absolutely. And I see that in talking with all of my colleagues and through my work with the American Academy of Pain Medicine, that's sort of on the forefront of us is accessible. We're just slowly more and more being told, no, no, no.
- [47:11]
Thomas Goetz
Cost and coverage are real issues for people with chronic pain. It's just another thing that makes dealing with pain such a challenge and such a frustration. The bright side is that Journavix suggests that there are still new ideas out there and new treatments to be discovered. Hopefully, Journavix is just the first of several new treatments for pain, Things that really work, drugs or otherwise, because there are millions of people out there suffering in silence, trying to cope, trying not to let their pain show. They could use some comfort. You know, I'm going to be smart here and give Whitney the last word.
- [47:51]
Whitney Wright
You know, when you have a broken arm, you have a cast on it, and so you can say, oh, your arm is broken. Oh, now I see why you're not doing such and such. But with pain, it's invisible. So most people I know have no idea that I cope with chronic pain. I don't talk about it. I don't. I try not to complain about it. I try not to define myself around it, but it's definitely a huge part of my life. Just keep in mind that we. We don't want to be in pain. I want to be out hiking. I want to be doing things that I can't do. You know, I wish I could be a windsurfer.
- [48:27]
Dr. Antja Barveldt
It's not gonna happen.
- [48:29]
Whitney Wright
I guess I want some patience when I can't do something.
- [48:39]
Thomas Goetz
All right, well, thank you for being on this podcast with me.
- [48:42]
Whitney Wright
I'm happy to be on this podcast. I would love to be able to, for my experience, to help other people with chronic pain because it's a total pain in the ass.
- [48:53]
Thomas Goetz
All right, all right. That was good. Thank you, wife.
- [48:57]
Whitney Wright
Welcome.
- [49:03]
Thomas Goetz
That's it for this episode of Drug Story. For an annotated list of our sources for this episode, visit Drugstory Co. Drug Story was created, written and hosted by me, Thomas Goetz. Molly Warner is our research director. From Reasonable Volume, Rachel Swaby produced and sound designed this episode with assistance from Audrey Ngo. Elise Hu was the editor. Mark Bush is our engineer. Drug Story was produced with support from the University of California, Berkeley School of Public Health. Special thanks to Claudia Williams and Dean Michael Lu. Thanks also to Paul Dr. Ansha Barveld and Whitney Wright. Drug Story is in independent production. If you'd like to support our work, contact us at Drugstory Co. You can also subscribe to our substack there and be notified when new episodes come out. And if you like this episode, help us spread the word. Rate us on Apple or Spotify or wherever you get your podcasts. Next up on Drug Story, insomnia. It's the great American pastime. And then came along Ambien, the perfect sleeping pill. Until it wasn't. Listening to this episode of Drug Story may cause you to stock up on Advil, to thank God for small blessings, and to triple check that your insurance will cover that new prescription. We advise you to always bend at the knees when picking up heavy objects, never give up on finding something that works, and always, always listen to your spouse. Yeah.