Chronic Pain and COVID-19: Why Is Treating One Disease More Noble Than the Other?

By Dr. Lynn Webster, PNN Columnist

During the coronavirus pandemic, our frontline healthcare providers have put their lives on the line, and many have paid a price. Their sacrifice is quintessentially noble, and we feel boundless respect and gratitude for their work.

Similar compassion is felt for COVID-19 patients. We are moved by the tireless efforts made to provide them with proper care, medication and life-supporting equipment.

This outpouring has led me, as a pain and addiction medicine physician, to reflect: When is healthcare noble? And why is some healthcare noble and other healthcare suspect?

There is a stark, bittersweet disparity between the esteem and appreciation we rightly bestow on COVID-19 frontline providers and the suspicion we direct toward chronic pain physicians.

Our frontline heroes in the coronavirus crisis -- regardless of patient outcomes -- are viewed as inherently noble and courageous. Conversely, those who treat people with chronic pain -- especially in cases with an adverse outcomes -- are often threatened with harsh judgment, loss of medical licenses and even incarceration.

Recently passed federal legislation provides “broad immunity” from legal liability to providers treating COVID-19 patients. Pain physicians have no such immunity.

This disparity is also mirrored in patient treatment, sometimes involving the same drug. There is a shortage of injectable fentanyl and other painkillers ventilated coronavirus patients need. The Drug Enforcement Administration recently increased the production quota for those drugs so manufacturers could produce more of them. But DEA-ordered cutbacks in the production of other opioids remain in place.

People in pain -- whether they have the coronavirus or not -- deserve the same effective and humane treatment.

As a pain physician, I have watched people with chronic conditions who are forced to live with undertreated pain for years. I have seen them fight to get through each day as the medications they need are tapered due to governmental regulations and cultural biases, rather than their physicians' decisions. I have observed their struggles with desperate options, including suicide, in the face of daily, oppressive and almost unimaginable pain.

Even as I recognize the heroism of the frontline practitioners caring for people with COVID-19, I have to wonder: How did patients with chronic pain end up on the wrong side of the empathy divide?

Pain patients feel this empathy inequity. It's not uncommon for some healthcare providers to treat them like exiles from society, as drug-seekers, malingerers or even criminals. But these "criminals" are people who have a disease that saddles them with long-term pain. Does their suffering matter less than coronavirus patients’ pain?

How must they feel about society’s outpouring of love for COVID-19 fighters and victims compared to the suspicion, derision and slander they receive?

An Opportunity for Reflection

I submit that the heroic and selfless medical response to those afflicted with COVID-19 should prompt valuable reflection by all providers on empathy and equitable treatment for all patients.

What is it about certain medical conditions that results in unprecedented concern, a willingness to muster all resources, and an outpouring of selflessness from practitioners and the public alike? Why are healthcare professionals willing to risk their lives for coronavirus patients, but not their reputations to treat chronic pain?

Some may argue that it is the immediacy of the threat and risk of death that makes the difference. But that’s a false argument. All pain is immediate and, despite what is commonly thought, people with severe chronic pain have dramatically shortened life expectancy. 

Providers on the frontlines of the lengthier, more widespread and complex pain crisis are as noble as those fighting the current pandemic. They often take on patients that others don’t want to treat. They show open-mindedness, concern and great courage in risking the respect of their peers, running afoul of misinformed authorities, or being persecuted by misguided legislation. They put aside their professional well-being to serve a seriously oppressed and underserved population.

We need to find a way to professionally restore belief in the nobility of those providers who may not cure patients, but who do offer comfort and relief. These are professionals who are willing -- often for months and years -- to fight wearying and risky battles for their patients.

If such battles received the respect they deserved, there would be nothing bittersweet about watching all members of the same profession going above and beyond the call of duty for all.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD.

The opinions expressed in this column are those of the author alone and do not inherently reflect the views, opinions and/or positions of Pain News Network.

This Film Is Far from a Joke

By Dr. Lynn Webster, PNN Columnist

Good films entertain. Great films inspire. Sometimes, they even galvanize people to create a social movement against injustice.

I recently saw one of those rare movies that fall into the category of movies that can inspire: Joker.

The film moved me, and I think it has the capacity to raise the consciousness of other viewers, too. This is why I was surprised to read extremely negative critical reviews about Joker.

The Guardian dismissed the movie as being “shallow,” while the The New Yorker described the film as “numbing emptiness.” The New York Times labeled it as an “empty, foggy exercise in second-hand style and second-rate philosophizing.”

These reviewers all missed the point.

To me, Joker contains substance and in-depth messages about the shortcomings of our health care system, and the part that society's cruelty plays in the development of a psychopath. The gravity of the film caught me off guard.

I was expecting to see just another comic book/adventure movie, but this was far more than that. The film clearly shows a pattern of childhood trauma, repeated shame, income disparity, lack of health care, discrimination, corruption, and rebellion. In other words, Joker reflects real life through excellent and Oscar-nominated acting and production.

Joker demonstrates what happens if you take two people and put them in two different environments. You shower one person with money, love and other advantages, while you deprive the other of all those things.

WARNER BROS.

The movie shows that the result is the creation of one hero and one anti-hero.

Batman's nemesis, the Joker, didn't start off as a bad person. He once was a child named Arthur Fleck.

Fleck’s story begins with the physical abuse he suffered as a child at the hands of a harsh, rigid father and an enabling mother with serious mental health problems. She alleges that she had an affair with the wealthy businessman and politician Thomas Wayne (father of Bruce Wayne, who eventually becomes Batman).

Fleck believes his mother had the affair and, therefore, he is owed respect and support from Thomas Wayne. However, a callous and cruel man causes Fleck to doubt his parentage. Fleck learns from this man that he may not be Wayne’s child, and that his mother may have adopted him and kept the truth hidden from him. This deceit causes him unbearable shame.

In a startling contrast of good vs. evil, Bruce Wayne is blessed with a happy childhood, while Fleck suffers layer upon layer of abuse. His rage builds throughout the movie with recurring episodes of humiliation.

Fleck develops a neurologic disorder called Pseudobulbar Affect, a condition of involuntary, uncontrollable laughter and crying. The condition sets him up to be repeatedly isolated and ridiculed.

Fleck comes to see the inequity of his upbringing. Because the man he still believes may be his father withholds economic and emotional support from him, he experiences escalating anger and mistrust of politicians and the wealthy.

Fleck holds it together until his health care benefits are cut off and he can no longer see his therapist or receive medication. Then he snaps and becomes society's worst nightmare: the Joker.

Batman fans know the rest of the plot. So does anyone who follows the news.

What the Joker experiences, and the consequences of those misfortunes, happen all too frequently in real life.

Society's failure to provide treatment for people with mental illness, and the cruelty with which we shun them, create the seeds of school shootings, terrorism, mass murders and other horrible crimes.

People aren't necessarily born with a greater capacity for hatred than others, nor are they necessarily destined to become criminals. They may be born with mental illness, but it is often environmental factors — including society's lack of empathy, and its failure to treat them humanely and compassionately — that put them over the edge.

My hope is that audiences will see that a "joker" is made, not born. Some of the same ingredients that create a psychopath may also sow the seeds for drug abuse and many other societal pathologies.

Joker is not shallow or empty. It is a reflection of what society experiences when people receive too little empathy, too little love and too little support.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.

Do Selfless People Feel Less Pain?

By Pat Anson, PNN Editor

Are you selfless? Do you show concern for other people and take an interest in their well-being?

If the answer is yes, then your brain may be hardwired to feel less pain than people who tend to act more selfishly.

That’s the conclusion of a novel study conducted at China’s Peking University, where researchers performed MRI brain scans on nearly 300 people to learn about the biological reasons for altruistic behavior. They wanted to know why “performers” act selflessly in a crisis – such as food shortages or a natural disaster – even when there may not be a direct or indirect benefit from helping others.  

Their findings, published in the journal Proceedings of the National Academy of Sciences, showed that selfless behavior reduced activity in regions of the brain that process pain signals.  

“Our research has revealed that in adverse situations, such as those that are physically threatening, acting altruistically can relieve unpleasant feelings, such as physical pain, in human performers of altruistic acts from both the behavioral and neural perspectives,” wrote lead author Yilu Wang. “Acting altruistically relieved not only acutely induced physical pain among healthy adults but also chronic pain among cancer patients.”

Altruistic behavior has long been cherished in human society because it enables group members to collectively survive earthquakes, famines, floods and other crises. However, behaving selflessly also puts people at risk because it means giving away food, shelter and other resources.  

The MRI findings shed light on this paradox – and the psychological and biological mechanisms behind selfless behavior. 

“Engaging in altruistic behaviors is costly, but it contributes to the health and well-being of the performer of such behaviors,” Wang said. “Our findings suggest that incurring personal costs to help others may buffer the performers from unpleasant conditions.

“Whereas most of the previous theories and research have emphasized the long-term and indirect benefits for altruistic individuals, the present research demonstrated that participants under conditions of pain benefited from altruistic acts instantly.”

Heroic behavior isn’t necessary to reduce pain. Sometimes all it takes is a little empathy. 

According to a small 2017 study, just holding hands can reduce pain levels. Researchers found that when a woman was exposed to mild heat pain, her pain levels dropped when she held hands with a male partner. The more empathy the man showed, the more her pain subsided.     

Why IQ Isn’t Enough for Pain Care

By Pat Akerberg, Columnist

Our once patient-centric healthcare system has been upended and turned into a profit-over-people financial equation. 

Consequently, patients feel their concerns are intentionally disregarded while medical practitioners are ham strung by compromised standards. I wonder if they are as disillusioned as we are with timed, cookie-cutter treatment approaches that reinforce unsettling disconnects.

One such disconnect involves an underrated, often missing link – empathy – considered one of the most effective aspects of an outstanding healthcare practitioner. 

Empathy is compassion for the chronic illness, pain and impairments their patients endure. 

In his 2005 groundbreaking book, “Emotional Intelligence: Why It Can Matter More Than IQ,” Daniel Goleman made the case for empathy to be recognized as an essential component for emotional intelligence.

Differing from the intellectual focus of IQ, empathy is one of the 5 essential dimensions that make up ones’ emotional quotient or emotional intelligence – “EQ” for short. 

• Emotional self-awareness: Knowing what one is feeling at any given time and understanding the impact those moods have on others
• Self-regulation: Controlling or redirecting one’s emotions; anticipating consequences before acting on impulse
• Internal Motivation: Utilizing emotional factors to achieve goals, enjoy the learning process and persevere in the face of obstacles
• Empathy: Sensing and responding effectively to the emotions of others
• Social skills: Managing relationships, inspiring others and creating connections

The key point behind EQ is that it can often matter more than IQ or technical training alone.  While IQ may typically get someone hired or gain them entry, the EQ factor is what gets them promoted, predicts excellence and professional success.

Possessing both IQ and EQ is considered a winning combination in any role or field. But not everyone acquires that golden pair without awareness and training -- unless they are uniquely and naturally skilled at both. 

Our medical practitioners (regulators and stakeholders) are no exception to this.  In fact, the widespread distortions and neglect surrounding our side of the pain care equation and story clearly demonstrate the kind of harm pervasive EQ blind spots can do.

We’ve all experienced those rare physicians and practitioners who are both competent and capable of conveying a caring approach and empathetic style.  Even if medications and various treatments fall short in addressing our chronic illnesses, their support and desire to help us never falters.

It helps immeasurably to know they’re in our corner.  Physical healing may not always be possible given our circumstances, but that’s not the only kind of healing that matters. The presence of such EQ far outweighs the deficits of an approach without it.  Numerous studies confirm that such human consideration and concern delivers a positive placebo effect that can’t be underestimated. 

Pain patients already endure more than most will ever face.  We suffer even further when our practitioners and administrators lack or devalue the human understanding EQ brings.

So how effective are our practitioners at delivering that kind of humanistic medical care in our current system?

Using the 5 factors for EQ, I did a personal rating of all of the practitioners I’ve seen since the start of my trigeminal neuralgia.  It turns out that 30% on my list are high in EQ.  Unfortunately, that means that 70% fall short.

The stand out characteristics that I look for made those 30% rank far above the 70% include:

• Being personable
• Making eye contact with me (not a computer screen)
• Showing true interest in my level of pain
• Patiently and intently listening to my answers
• Being open to my questions
• Offering tailored options
• Expressing empathy or gestures of concern
• Thinking outside the box for solutions
• Collaborating
• Treating me like an important partner and a helpful staff

The reasons that some practitioners or institutions may or may not possess or demonstrate empathy vary as much as our illnesses do.  The good news is that once a person becomes self aware and motivated, EQ and empathy can be learned thanks to plasticity, our brains’ ability to change.

There’s no formal assessment that I know of that measures the damaging, stressful effects of chronic pain and illness when coupled with the double whammy of marginalized or impersonal healthcare.

However, like an IQ test, there is a formal assessment that determines a persons’ EQ status on all five dimensions.  For a better tomorrow, there’s no reason that this assessment couldn’t be required at the start of medical training programs (doctors, nurses, physical therapists) to identify a students’ strengths and needs.

Taking it further, educational institutions can also borrow from a virtual reality learning tool developed by Embodied Labs founder Carrie Shaw, which she used to increase her understanding about her mother’s experience with dementia.    

With the intention of bridging the life experience-understanding-empathy gap for young medical students, John’s Hopkins recently experimented with this technology. The project, “We Are Alfred,” gave students hands-on experience of what it’s like to be a 74- year old dealing with impairments in sight, hearing, and memory.  The simulation demonstrated that you can develop EQ skills and foster understanding between practitioners and patients by giving students a slice of what their patients have to deal with.   

Many times I’ve wished that the severe face pain that I experience could be simulated so that practitioners (and others) could experience what it feels like. I bet you have too. 

Wouldn’t it be great, even fitting, for our government to sponsor an initiative to simulate pain?  Maybe then the reality of debilitating pain would finally trump the punitive intellectual biases blocking the balanced approach EQ brings about.

Meanwhile, I’m all for efforts that aim to reinforce the message to our medical practitioners and facilities, educational institutions, government regulators, insurance companies, Big Pharma and other stakeholders that no one cares what you might know (IQ) until they know that you care (EQ).

Pat Akerberg suffers from trigeminal neuralgia, a rare facial pain disorder. Pat is a member of the TNA Facial Pain Association and is a supporter of the Trigeminal Neuralgia Research Foundation.

Pat draws from her extensive background as an organizational effectiveness consultant who coached and developed top executives, mobilized change initiatives, and directed communications.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

The Link Between Empathy and Pain

Pat Anson, Editor

The Merriam-Webster dictionary defines the word empathy as “understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another.”

Or as former President Bill Clinton famously said, “I feel your pain.”

But new research suggests empathy may be a lot more complicated than we think – at least when it comes to feeling the pain of others.

A team of European researchers has found evidence that empathy may be strongly influenced by neurotransmitters in the brain -- and is not just a form of emotional or social bonding.

Their findings suggest that empathy is dependent – not on feeling the pain of others --- but on experiencing pain yourself.

“Empathy is of major importance for everyday social interaction. Recent neuroscientific models suggest that pain empathy relies on the activation of brain areas that are also engaged during the first-hand experience of pain,” wrote psychologist Clauss Lamm of the University of Vienna, lead author of a study published in Proceedings of the National Academy of Sciences.

Lamm and his colleagues recruited 100 participants for an experimental trick with a placebo. They divided the volunteers into two groups and gave one group a pill they thought was a painkiller but was actually a placebo. The second group received no pill at all.

Both groups were given a small electric shock and asked to rate the degree of pain they felt -- and the degree of pain they saw in others who were also shocked.

The group that received the placebo not only reported less pain than the control group, but they also felt there was less pain experienced by others. That placebo-empathy effect was confirmed by MRI’s – which found there was less activity in brain areas of the placebo group that felt less pain and empathy for others.

Researchers tested the placebo-empathy effect in a second study in which they used the drug naltrexone to block opioid receptors in some of the volunteers. Those given naltrexone reported feeling more pain when shocked and felt that others felt more pain as well.

"This result strongly suggests an involvement of the opioid system in placebo-empathy, which is an important step to a more mechanistic understanding of empathy,” said Lamm.

"The present results show that empathy is strongly and directly grounded in our own experiences – even in their bodily and neural underpinnings. This might be one reason why feelings of others can affect us so immediately – as we literally feel these feelings as if we were to experience them ourselves, at least partially. On the other hand, these findings also explain why empathy can go wrong – as we judge the feelings of others based on our own perspective,” explains Lamm.

Lamm and his colleagues are now working on a follow-up study in which they are investigating the effects of opioids on empathy.