Bar News - May 17, 2017
Book Review: Concord Physician’s Book a Compelling Read on Chronic Pain
By: Review by Francis G. Murphy
Needless Suffering: How Society Fails Those with Chronic Pain
By Dr. David Nagel
Paperback, 320 pages
The author of Needless Suffering, Dr. David Nagel, is a Concord, NH, physician, whose stated goal for his book is to be provocative and to change the way people in society perceive and treat those who suffer from chronic pain. He describes his book as a “critique of society as a whole.”
He approaches his subject with an unapologetic, religious fervor. He tells the reader his role model in his practice is Mother Teresa, who helped raise awareness of the plight of the “poorest of the poor.” “I see parallels between the poor and those in chronic pain, and I have worked hard to help raise awareness of the plight of these individuals –the ‘poorest of the poor’ of the medical world,” he writes.
Nagel explains how chronic pain develops, how life-altering it can be for the patient, and how challenging it can be for the physician to attempt to manage it. He tells us how he came to understand that pain was not mere “cause and effect.” Each person’s experience of pain is unique and so must be the treatments.
We learn that chronic pain and acute pain are not the same and that chronic pain results from the complex restructuring of how the nervous system interprets pain. Chronic pain is a moving target because of neural plasticity (the central nervous system’s proclivity to adapt and change in response to stimulus from its environment).
Pain has both a structural and a neurological aspect. Structural injury may incite the pain, but neurological adaption or maladaption maintains or amplifies it. This is why those treatments that attend only to the structural element are bound to fail the chronic pain sufferer.
Nagel explains that pain starts with a stimulus to a nerve ending, or nociceptor. When nociceptors are excited, local or peripheral sensitization of the nerves takes place. If the central nervous system gets flooded with peripheral sensory information, it can maintain or amplify those signals – a process referred to as central sensitization. The result is a centrally maintained pain state (CMPS). CMPS may spread sensitivity up and down the spinal cord to adjacent levels, thus enlarging the receptive fields.
Each person brings different intrinsic and extrinsic factors to the pain experience. Psychological dysfunction in those who suffer is most often the result of chronic pain, not the reverse. Nagel writes about the stress-pain cycle, where pain creates stress and stress aggravates pain. Therefore, in managing pain, the physician must learn to examine the whole patient.
But the business of the medical system fails to do so. Physicians benefit by providing expensive, fragmented care that maximizes their revenue and minimizes their responsibility for the individual patient. Nagel is blunt: “In my observation, more often than not the system is destructive (to the pain patient).”
He describes how the “bottom-line mentality” in medicine, the legal system, insurance companies, and businesses harm pain patients unnecessarily. He relates “horror stories” of inhumane treatment by the worker’s compensation system and the civil justice system. All such encounters can contribute to a chronic pain state by altering the neurophysiology of pain.
He speaks from experience. “The day I testified, any faith that I had in the American court system evaporated. Both lawyers spent their energies trying to manipulate both the medical record and my thoughts. Each strove to alter the truth to satisfy the goals of the person they represented.”
We lawyers are told that out of the cauldron of cross-examination, truth will emerge. All Nagel sees is the patient being burnt by process.
Nagel levels his most severe criticism at medical “experts” hired by insurance companies to hurt the injured patient’s interests. Some of his colleagues “align themselves with insurance companies as experts to deny pain patients care, enriching themselves in the process.”
In the middle of the civil claim is the patient, who has been hurt and is suffering. Confusion about the process triggers a domino effect of fear, anxiety and amplified pain. All this directly contravenes the therapeutic goals for the patient.
The computerization and corporatization of medicine can be useful but “only when it rests on a base of compassion, empathy, understanding, listening, and touching – in other words, a base of love, which implores us to acknowledge our limits and, above all, put the needs of our patient above our own.”
By following some of Nagel’s suggestions for further reading, I came to understand that, when he uses a word such as compassion, he is not just invoking religious precepts. Pain is processed using the brain’s limbic system, which is primarily responsible for our emotional life. Science knows that loving emotions can help soothe the pain.
Needless Suffering is a compelling read. Those involved with chronic pain sufferers in the legal system should read it.
Francis G. Murphy is a shareholder/director at Shaheen & Gordon whose practice primarily deals with plaintiff’s personal injury and employment discrimination.