Book Notes: Pain Free 1-2-3
Appendix E: Why Physicians Do Not Focus on Pain Medicine
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by Jacob Teitelbaum, M.D.
Clearly, if pain management is to be adequate, it is necessary for medical schools to do a better job training physicians and/or to recognize that it may be necessary for non M.D.s to be given the legal rights to prescribe, so that they may appropriately take a lead in this role.
With pain being such a common problem, one would wonder why more physicians don’t specialize in its treatment. As is often the case in medicine, it boils down to dollars and cents.
Insurance companies pay very poorly for a doctor’s time unless they are doing a procedure. For example, if a doctor is performing surgery, a heart catheterization, or even setting a broken bone, he or she will be paid handsomely. If, on the other hand, the doctor is predominantly spending time listening, data-gathering, or conducting an examination so that he or she can make a proper diagnosis, the insurance company will often pay less than the physician’s overhead! Basically, the insurance companies pay for the average eight-minute doctor visit. If a doctor spends more than eight minutes on your case, without performing other procedures or tests, the doctor is likely going to lose money. Doctors can afford to do this once in awhile, but they will go bankrupt if they do it on a regular basis.
To give you an idea of the severity of the problem, Ohio has only 335 physicians who designate themselves as pain specialists, with 74 percent of these being anesthesiologists, who often, though not always, are more interested in doing procedures that tend to be invasive. It is estimated that 2.3 million people in Ohio have chronic pain. This means that there is one pain specialists for every 6,865 people suffering with chronic pain. Treating chronic pain is fairly time intensive, and seeing 20 patients a day is a very full day. If the chronic pain patient is only seen every three months, doing the math shows that we need 25 times more pain specialists that we currently have.1
The evaluation of pain is a complex and time-consuming process. For reasons that escape me, insurance companies by and large will also not pay for time spent doing simple yet highly effective pain management procedures such as trigger point injections or stretch and spray. In fact, insurance companies are shooting both themselves and you in the foot by this approach. By not paying adequately for safe and effective procedures, more and more patients are forced into surgery, medications, or nerve blocks, which are often far more expensive, riskier, and less effective than other pain reduction treatments. If your physician spends the necessary time to take a proper history, do a proper examination, and learn and use trigger point injections and/or the stretch and spray procedure, it is unlikely that your doctor will be able to stay in business if he or she accepts what your insurance company considers payment in full.
In addition to being poorly reimbursed by insurance companies (unless they perform procedures, testing, or surgery), pain specialists are often faced with patients who require narcotics for severe and chronic pain. Because of the current political climate, pain specialists often are threatened with loss of their medical license, and sometimes are even arrested for the very appropriate prescribing of these medications. After over a decade of training, would you be willing to lose your license, be driven into bankruptcy, and even be thrown in jail? This is the risk pain specialists face every time they prescribe a narcotic medication—no matter how appropriate it is to give it. Although there are a few doctors who unscrupulously maintain narcotic “pill mills,” even pain specialists who are simply providing excellent patient care are being arrested and treated like drug kingpins in the government’s “war against drugs.” This causes major problems for pain doctors, pharmacists, and suffering patients. In a front-page article in the Washington Post, Attorney General John Ashcroft was quoted as saying that arrests of pain specialists who prescribe Oxycontin show “our commitment to bring to justice all those who traffic in this very dangerous drug.” The doctor is presumed guilty until proven innocent, and is often judged by people who are hostile to the use of narcotics in chronic pain patients. In the same article, Russell Portenoy, a pain specialist at Beth Israel Medical Center in New York, who is considered one of the fathers of modern pain management, notes that “15 years of progress in treating patients in chronic pain could really be wiped away if these prosecutions continue…treating people in pain isn’t easy and there aren’t black-and-white answers…but what’s happening now is that the medical ambiguity is being turned into allegations of criminal behavior. We have to draw a line in the sand here, or else the treatment will be lost, and millions of patients will suffer.” In the same article, Rebecca Patchin, a pain specialist who is a board member of the AMA, notes that an estimated 50 million Americans live with chronic pain. She says that almost half of all Americans will seek care for persistent pain sometime during their lives, but that many will not receive the treatment they need. She notes that “Doctors hear what’s happening to other physicians… and that makes them very reluctant to prescribe opiates that patients might well need.2
Unfortunately, it will not be doctors who get these misguided laws changed. Doctors attempting to get the laws changed can make themselves targets for those who would take away their medical licenses. The change will come when patients make it clear to their senators and representatives (and the president) that they demand the right to proper care without being treated like drug addicts. Otherwise, government officials will continue to live by the adage, “all pain is tolerable as long as it is somebody else’s!” We live in a democracy; be heard, be clear, and make your vote count! The article in the Washington Post mentions a group called the “Pain Relief Network” (see www.PainReliefNetwork.org) that is fighting for your right to be pain-free.
The good news is that the large majority of patients with pain can become pain-free without narcotics using the principles in this book. Although I recommend that you make your voice heard, I would direct most of your energy into getting your life back. You can do this now, without waiting for the government to act!
More good news is that things are already starting to change. Doctors are interested in learning more about pain management, and many are aware of their own ignorance in this area. For example, a survey of 247 physicians from various specialties showed that 96 percent were dissatisfied with the training they received in medical school about opiates, and 84 percent were dissatisfied with such training during residencies and fellowships. For patients with persistent pain, 82 percent of providers were uncomfortable prescribing opiates for more than 3 months; 42 percent said they were not prescribing opiates properly, and 34 percent weren’t sure whether they were properly prescribing them. Nearly all (94 percent) said that further courses in opioid management would help them in their practices.3
The Relationship Between Prescription and Natural Medicine
Standard allopathic medicine, which focuses predominantly on prescriptions and surgery, offers powerful new techniques that fall outside of what’s found in nature. Because they are tailored to specifically suppress certain reactions in the body, they can at times be more powerful than natural medicines. Experience shows, however, that they are also far more likely to be toxic. As the pharmaceutical industry is driven largely by financial motivations (this is not necessarily a bad thing—it’s simply how our capitalist system is structured), the ability of a prescription to make money is usually the predominant driving force for its creation. Sadly, this financial influence has resulted in “modern” medicine being more closed minded than scientific. Although physicians are well-meaning, they sometimes attempt to make sure that anyone who is of a different religion than “scientism,” is legally prevented from practicing. They also ignore any scientific data that does not fit their belief system!
Can We Rely on the Results of Scientific Studies?
I wish we could. Unfortunately, both clinical experience and research has shown that “troubling financial links between pharmaceutical firms and academic scientists are pervasive and may impact research process.” In recent study published in the Journal of the American Medical Association, researchers led by Yale’s Cary Gross found that industry funding makes it 3.6 times more likely that a study result will be favorable to the sponsor! What makes this interesting is that many doctors and academics would not dream of publishing or relying on a study that is not placebo-controlled, because this increases the chance of a positive outcome by 30 percent. On the other hand, that fact that a drug company paying for a study increases the chance of a positive outcome by 360 percent, does not seem to affect whether they will rely on or publish that study. The Yale study also showed that one quarter of medical researchers have financial ties to companies whose products they’re studying, and approximately two thirds of research schools have financial ties these companies as well.
A drug company paying for a study can affect results in a number of ways. As a physician, I have often seen study designs that markedly favor the sponsor’s drug. For example, a study would use the proper dose of the sponsor’s drug, but too low a dose of the competitor’s drugs. In addition, if the study did not give a favorable outcome, the company would not allow the data to be published. Adding to the bias is the fact that research journals are less likely to publish studies showing a negative outcome because this is considered boring or less important. The exception to this, however, is that the journals are happy to publish studies that reflect negatively on natural remedies, no matter how poorly the study was done. Yet they are often unwilling to publish studies that show a positive effect from natural therapies.
The Center for Science in the Public Interest notes, “there is a lot of idealism about how science is isolated and objective. Unfortunately, that’s not the case. Money can absolutely influence scientists.” In addition, despite the heavy biases of studies that are paid for by the drug companies, the FDA still uses that data in assessing whether drug will be approved. As drug companies funded nearly 60 percent of medical research in United States (spending over $30 billion last year), in addition to spending an enormous amount on television and other advertising, they have enormous clout with both the medical and media establishments. Basically, upsetting them by saying anything bad about them and their products can be a very expensive mistake. A medical journal editor tries very hard to maintain objectivity. But, when given a choice between publishing a study that will result in the journal getting hundreds of thousands of dollars of advertising versus losing this money, the editor may be biased toward publishing the study—people are human.4 This is one reason for my policy of not taking money from any company whose products I recommend (or for that matter, from any company period).
Why Is There a conflict Between the Two Systems?
Medicine is evolving. When I was in medical school in the early 1970s, the focus of treatment was on how to poison one body system to bring about balance in another. For example, Prozac® poisons the system that brings serotonin back into the cell, thus raising serotonin levels outside of the cell. This can work well to raise serotonin and treat depression, but poisoning one system to bring balance often throws other systems out of balance. For example, Prozac causes sexual dysfunction and other side effects in upwards of one-third of people who use it. Nonetheless, in a society based on economics and quick fixes, the use of prescription medications such as Prozac moved forward quickly, and squeezed out other branches of the healing arts. This had certain benefits, but often these benefits came at great cost to you, the patient.
It is worth looking at how things came to be the way they are. This gives us both understanding and the ability to choose where we want to go. In the 1800s, there was little research and regulation in the healing arts. The healers and wise women in the tribe would learn what worked from experience and pass on the information to their apprentices in a tribal chain that dated back thousands of years. As world wars and the expansion of Western civilization began to destroy long-standing social structures on the planet, much of this ancient information and experience was lost. Natural medicine declined. In areas where there were not enough well-trained healers/herbalists, accountability was also lost, and we began to see the rise of the “snake oil salesmen.”
It was in this context that science began to come to the forefront. People longed for something more valid, from groups in which there was accountability. Scientists provided this, using techniques that allowed ideas to be tested, reproduced, and validated. Because of the natural competition among scientists, their ideas had to make it through much skepticism before being accepted. Testing and validation began to take hold in the healing arts.
As in any system that generates a large amount of money and power, however, financial influences began to have their say. In the early 1900s, research focused on both biophysics (i.e. treatments that affected the body’s energy systems) and biochemistry. Politics being what it is, the biochemists gained the upper hand, and research and treatment using biophysics was marginalized and suppressed. Seeing which way the political winds of change were blowing, many of the greatest names in modern medicine switched from biophysics to biochemistry. Medical schools were established (which initially focused on using natural therapies). Standardized curriculums and tests were developed, and it became possible to develop reliable conditions for licensing doctors. To counteract “snake oil salesman,” who were preying on the public, state governments developed licensing requirements for the practice of the healing arts, bringing more credibility, power, and respect to the field. Medicine was therefore able to attract those people who were compassionate healers. The fields of allopathic medicine and biochemistry blossomed.
As our understanding of chemistry evolved, it began to change the face of our country. We went from almost no foreign chemicals in our environment, to tens of thousands of new chemicals that our bodies had to detoxify. These chemicals are added to our food, water supply, building materials, clothing, and not surprisingly, to our medications. In addition, where a natural substance could not be patented, new chemicals could be. As a patent prevents competition, more money can be made from a patented chemical (e.g. for indigestion, patentable acid blockers can cost over $2 a pill, where non patentable calcium carbonate may cost a nickel). People realized that there was a lot of money to be made in medicine and in patentable medications. This money was used to influence legislation and people’s perceptions in an attempt to eliminate the competition.
Language was added to legislation to consolidate allopathic medicine’s power. As the FDA was (appropriately) developed to protect public safety in the face of creating thousands of new chemical medications, language was added saying that a manufacturer could not claim that something was effective for treating an illness unless it went through the FDA approval process. As this process costs $400 to $800 million per treatment, only things that are patentable (i.e. not natural) can recoup these enormous costs. Vitamin B6 used for carpal tunnel syndrome is an excellent example. Treating carpal tunnel syndrome with 250 mg of Vitamin B6 daily for six weeks costs about $9 per patient. Vitamin B6 manufacturers would therefore find it impossible to recoup the cost of getting FDA approval for this treatment, and cannot advertise the vitamin for the treatment of carpal tunnel syndrome. Because of this, most patients instead spend between $2,000 and $4,000 to have surgery. This situation is the same for hundreds of other non patentable, effective, inexpensive, and relatively safe treatments. The FDA has even been fighting to make it illegal for stores that sell supplements to hand out copies of well-conducted scientific studies showing the effects of the supplements!
In one legislative stroke, it became illegal for the manufacturer of natural medicines/products to advertise or even to give you information about how these natural products can help you get well, regardless of how good the scientific data supporting the claim was. Legislation was also pushed through saying that anyone who was not an M.D. or an osteopathic physician could not diagnose or treat you. In addition, it was illegal for manufacturers of natural products to give the patient the research studies and information needed to make an informed decision. At the same time, we were (mistakenly) taught in medical school that nutritional and natural therapies had no scientific basis and were only use by “quacks.” We were told that only “old-fashioned” (i.e. uneducated and stupid) doctors would use these treatments. Thus, despite large amounts of scientific data supporting natural medicine, you’ll find that your doctor will usually not know about this data, may be hostile to it, and will sometimes even refuse to look at the studies. Modern medicine went from using the wonderful tool of science to becoming the “religion” of Scientism.
Fortunately, as always, life moves forward seeking balance and growth. Although it had its strengths, people also began to recognize allopathic medicine’s weaknesses. Research continued on natural and energy (e.g. acupuncture) therapies despite lack of funding and acceptance by mainstream journals. Many practitioners, seeing how effective natural therapies were, explored this expanding body of research. As medicine was hostile to and turned a blind eye to this research, those who were M.D.s (like myself) were often introduced to this information by our patients.
I came out of medical school with the impression that if an important treatment existed for an illness, I would know about it. If someone claimed he or she could effectively treat a non treatable disease, that person was a quack. If such a treatment existed, I would surely have been taught about it.
I was wrong.
When I first started my practice, patients would ask me if I knew about certain herbal or nutritional treatments for illnesses. For example, one patient asked me if I had ever heard about using coenzyme Q10 for congestive heart failure. “That’s nonsense,” I answered. “If coenzyme Q10 helped congestive heart failure, don’t you think I would have been taught to use that instead of doing heart transplants?” I said that I would look into it, however.
Joyce Miller, the Anne Arundel Medical Center librarian, has always been happy to obtain studies for me (and she has obtained many thousands over the years). When she did a literature search on coenzyme Q10, she found a number of studies showing it could be very beneficial in treating congestive heart failure. I thought that was curious. Over the next few months, this scenario was played out again and again. I decided to keep notes on these rare “pearls” in a thirty-page spiral notebook. My notes are now over a thousand pages long.
The area of natural medicine has been growing tremendously in the last few decades and is now able to help give you your life back! As an example, combining natural and prescription therapies has allowed us to research and develop highly effective treatments for people with chronic fatigue syndrome and fibromyalgia. These syndromes are characterized by exhaustion, widespread pain, brain fog, and insomnia—crippling over 6 million Americans. Most doctors tell patients that nothing can be done and they simply have to live with the illness. Natural practitioners, however, know that this is not the case. “Gold standard” placebo-controlled research demonstrates that over 91 percent of patients can now get marked improvement using an Integrative Medicine approach (the full text of the studies can be seen at www.vitality101.com). In fact, natural medicine is now able to markedly improve the treatment of most illnesses!
Please recognize that because most physicians were trained in university hospitals, over ninety-five percent of the clinical training that your M.D. received was in treating severe, life-threatening illnesses. I was taught more about how to tell whether fluid coming from the patient’s nose was from a skull fracture than I was taught about how to treat a common cold! It was somehow presumed that if we could save your life in acute life-threatening emergencies, we would also magically know how to treat common non-emergency problems. As most of you with pain, fatigue, hormonal, or other day-to-day problems have learned, this is sadly not the case.
The good news is that as more and more doctors familiarize themselves with the scientific literature, many are becoming more open minded to therapies that can help you. They are trying to do the best they can, and progress is occurring. Comprehensive Medicine, which combines the best of natural and prescription therapies, is well on its way to becoming the medicine of the future!
