Judy Foreman has written a remarkable book about pain. Although aimed at an educated and curious non-professional readership it contains information and perspective that will be of great value to patients, scientists and clinicians as well as those interested in policy. It is a broad based survey of the ‘problem’ covering its prevalence, psychosocial and economic dimensions and perhaps more impressively, a broad survey of current animal, human and clinical research. Despite the breadth and scholarly analysis reflected in the material, the author’s journalistic style and efficient prose make for easy reading. By artful interview and through her own suffering she has captured the predicament and frustration of patients facing both their own pain and the ignorance and rejection of health care professionals. In contrast, she conveys the scientists’ excitement and enthusiasm about their discoveries, all the while remaining objective and open about the limits of their findings. Her chapter on gender and pain is particularly informative. As with most of her chapters it is amply but not exhaustively referenced, providing a guide to deeper inquiry for the reader. In fact, this is one of the reasons the book is so good; Foreman has mastered the skill of providing sufficient information to give the reader a reasonable level of understanding without the burden of detail typical of a scientific paper. Best of all, the text is spiced with direct quotes from leading experts in the field. This was not only enjoyable for me because I know most the individuals personally but, in addition, it gives the reader confidence that the author’s conclusions have been scrutinized and informed by those in the know. The acknowledgements section reads like a who’s who of pain research.
The chapter on opioid use, misuse, efficacy and treatment solutions is the most informed, even handed and useful review of the subject that I have read to date. Her chapter on exercise is quite refreshing and probably one of most valuable for patients, not least because it is outside the realm of traditional health care approaches and is probably one of the best things people with musculoskeletal pain can do for themselves. On the other hand, a couple of the chapters are one-sided almost to the point of hype. For example, she totally advocates the use of cannabis for the treatment of pain, even to the point of suggesting it be sold as a dietary supplement and suggests that it is as effective as opioids for the treatment of pain. In contrast, some important therapeutic advances, such as the mixed amine reuptake inhibitors like duloxetine and venlafaxine are mentioned largely in passing and the mixed action drugs tramadol and tapentadol are not mentioned at all. Her chapter on the immunological contribution to chronic pain is also decidedly one sided and credulous. There is elegant rodent work on the subject; however, the failed clinical trial illustrates how little we understand about most chronically painful human conditions. However, these are minor quibbles and I highly recommend the book, it is thorough, informative and a pleasure to read.
Howard Fields is the Director of the Wheeler Center for the Neurobiology of Addiction and a professor of neurology at the University of California San Francisco School of Medicine, US, and a PRF Science Advisor.
Comments
Kathleen Foley, Memorial Sloan-Kettering Cancer Center
I am pleased to add to Howard
I am pleased to add to Howard's remarks.
Judy Foreman’s new book A Nation in Pain is a tour de force. Full of important facts about the public health crisis in chronic pain, this comprehensive text uniquely presents the challenges of America’s pain epidemic.
As a skilled and accomplished health and science writer, and a person experienced in chronic pain, Ms. Foreman takes on the topic with the perspective of both a sleuth investigator and enthralled observer trying to make sense of what we know and what we need to know to move the science of pain and the care of patients in pain forward.
The book begins with her startling observation as she began research on the topic of pain, “I found that there is an appalling mismatch between what people in pain need and what doctors know.”
How true this is and her book’s publication follows the 2011 Institute of Medicine ‘s Report Relieving Pain in America. Commissioned by Congress, this first ever review of the state of pain care in the United States provides the evidence base for Foreman’s call to action. More than 40 percent of the American population (over 100,000,000 Americans) live with chronic pain, and pain costs between $560 to $650 billion a year in direct medical costs and lost wages.
This encyclopedic review focuses on educating the public, health care professionals and policymakers on the science of pain and the barriers facing patients in pain as they seek medical advice and care.
Through the 14 chapters, which are referenced in detail, the reader is taken on a journey that begins with clarifying what pain is and how it is transmitted from the site of injury to the brain, and how transmitters, receptors and neurons in multiple sites and along anatomically-defined pathways contribute to this hard wiring of pain sensation.
This section needs to be read by every healthcare professional, especially medical students, to help teach themselves and patients about pain sensation and perception. It makes complex pain anatomy and molecular pharmacology understandable, providing a useful framework to grasp the potential for new scientific advances that might inform treatment approaches.
Details about the genetics of pain, imaging pain in the brain, and the mind–body connection and pain are skillfully described and referenced, again serving to emphasize the complexity, variability and plasticity in the nervous system as it responds to painful events in a complex emotional and social environment.
In describing how we perceive and respond to pain, Foreman cites the relevant scientific literature by leading pain neuroscientists, to exemplify the sophistication and specificity of pain sensory processing as it assesses and expresses this complex human behavior.
At times, the reader can almost experience a David and Goliath feel to the book as one witnesses how this writer is trying to review and describe pain, and make it understandable to an audience who may have experienced the phenomenon, and have their own perspectives and questions on what pain is. But she succeeds in making the topic of pain intelligible, clear and fascinating.
Three chapters focused on the “opioid wars” and marijuana are excellent summaries of the current controversies in the use of opioid drugs and marijuana in chronic pain. They provide not only the evidence base for these agents in selected patients, but also describe in a balanced fashion, the political, ethical, and social controversies associated with drug use and the potential for addiction.
Foreman’s last chapter offers “A Way Forward” and provides a suggested roadmap for the cultural transformation called for in the IOM Report. She strongly endorses the need for more education of healthcare professionals and for more research, but she also calls on chronic pain patients to consider approaches that might enable them to better live with their pain and to learn self management approaches, to facilitate their adaptation.
For both patients in pain and for professionals trying to care for such patients, the book is optimistic and hopeful, emphasizing the innovative research opportunities for new approaches to better understand the human experience of pain. The pain community is indebted to Ms. Foreman’s leadership on mastering this complex field and bringing attention to the possibilities and potential, while also calling out the challenges and barriers. This is a landmark publication that helps to make pain accessible and understandable and needs to be read widely by the public, policy makers and the profession.
Neil Andrews, Pain Research Forum
I think it is worth a mention
I think it is worth a mention here that Judy Foreman recently received the 2014 Kathleen Foley Journalist Award from the American Pain Society. The honor, presented at the APS annual meeting in Tampa earlier this month, recognizes excellence in reporting pain-related topics. See more about the award at the APS website.