Why is it so hard to get good help for pain? Part 1 (Member Post)

• Jul 21, 2025 • by Paul Ingraham
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A weekly nugget or two of pain science news and ideas for patients and pros, usually 400–1000 words. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

This series was inspired by a reader who was justifiably outraged by a string of examples of egregiously incompetent care she’d gotten for a stubborn injury. It was all routine nonsense from my perspective — I hear about stories like this daily — but she was in a state of disbelief, gobsmacked: How can medical help for such a simple problem be so amateurish? What is wrong?!

The main problem, of course, is that pain is rarely as “simple” as it seems. It’s not rocket science … it’s much harder than rocket science.

There’s so much more to say about it, though. Healthcare lets people down in many ways, of course, but it’s especially bad for patients with puzzling and/or persistent pain and injury. They bounce around the medical system — and its alternative shadow — like they are in an evil pinball machine of disappointment and frustration. Patients are …

Serially misdiagnosed, patronized and dismissed, blamed and gaslit, and demonized as drug-seekers.
Referred to specialists who never seem to be the right specialists.
Irradiated (scanned) to find copious red herrings that routinely have nothing to do with their pain.
Indoctrinated in endless examples of fashionable ideology to “explain” their pain, from “your glutes aren’t activating” to “you’re just sensitized.”
Inundated with dubious treatment options: expensive, distracting, counterproductive, and (surprisingly often) even dangerous.

The whole business of helping people with pain and injury is a shambolic parody of good healthcare. In this three-part series, I will explore fifteen reasons (at least) why it’s such a mess — starting with five today. See also Part 2, Part 3, and a follow-up: Ideas for improving pain care. Most of the series — the details, the nuances, the grim realities — is for members only. But the next section is a free summary, and so is the constructive follow-up post, because I never want to put important basics behind my paywall.

This has been years in the making, a careful compilation of most of what I’ve gotten cynical about over the last quarter century of reporting on this messed up industry. It was easy to write in a way, barely an inconvenience: I could hardly keep up with the exasperated ideas that came tumbling out of me! Plus I’ve already written about plenty of them for other reasons, and I kept stumbling across them, lots of “oh, right, and that too.” But it was also a nightmarish challenge to update everything, and corral and cram it all into something shorter than a book.

And now I will also try to fit as many key points as possible into a highly polished 300-word overview…

Photo of a classy statue doing a “facepalm” of disbelief.

What image is suitable for a wide-ranging rant about the poor state of healthcare for chronic pain? The classiest facepalm, of course. No, this is not a classical statue of a “facepalm”: it’s a depiction of “Cain After Killing His Brother Abel,” by Henri Vidal, found in the Tuileries Garden in Paris. In this framing, however, it is perfectly suited to the more modern interpretation!

What’s wrong with pain care generally?

Medicine has always had bigger fish to fry. Chronic pain is relatively invisible, mysterious, and “minor” compared to medical heavyweights like diabetes, cancer, or HIV/AIDS. But pain turns out to be a harder, stranger medical nut to crack than anyone would have guessed fifty years ago. Even seemingly simple problems like tendinitis and arthritis have turned out to be the tips of mighty icebergs of pathophysiology and psychosocial factors. For instance, inflammation is immunology, but that subject is “where intuition goes to die” (science journalist Ed Yong).

Treatments that work well for pain tend to be extremely specific (like migraine drugs) or they involve major side effects and complications, like the opioids. The opioid war has pointlessly and cruelly deprived countless pain patients of badly needed medication — and yet opioids are also mostly useless for many kinds of chronic pain.

We just don’t have enough science, and the huge knowledge gaps are filled with pseudoscience, snake oil, and human prejudices. Simplistic nonsense dominates, and not just in alternative medicine: much of it is well-disguised as mainstream and evidence-based medicine, things like — and this is a carefully chosen shortlist of the worst offenders — shockwave therapy, platelet-rich plasma, spinal fusions, cognitive behavioural therapy, and much more. Also thanks to the science shortage, education has not just been inadequate but generally misdirected, mostly training professionals to think like “body mechanics” of various kinds, leading to an awful lot of barking up the wrong trees, paving the road to Hell with good intentions and bad ideas that won’t die

I am referring to the average here — “not all professionals,” of course. But the average is disturbingly poor, and it shows in the half-arsed help that patients get for their pain from every kind of healthcare professional.

What’s wrong specifically? The first five problems

MEMBERS-ONLY AREA

A tiny table of contents (green links will jump you to that spot on the page):

Pain is an extremely hard problem
There’s not enough good science about pain
Pain is too easy to ignore, trivialize, and blame on the mind (especially in a world full of prejudice)
Lack of medical leadership
Specialists aren’t very special if you aren’t their kind of patient

1. Pain is an extremely hard problem

Fifty years ago, we just didn’t have a clue how tough a nut to crack pain would turn out to be — even when it’s coming from seemingly “simple” things like tendinitis or arthritis. Decades later, we mostly cannot fix what we still often don’t understand, but it might not even be possible in principle to separate pain from consciousness and other critical physiology. Pain is so integrated into our plumbing and wiring that, so far, we mostly can’t suppress it without impairing the person at the same time (disassociation, detachment, sedation, anaesthesia).

When pain gets more chronic, it also gets weirder, often behaving in ways no one can explain, let alone fix. It could be failure of the pain system itself, dysfunctional pain (primary pain, or “nociplastic” pain). But plenty of it probably is functional (secondary), and probably does have an explanation (a source of nociception) — it’s just extremely tricky to diagnose, because of the dizzying array of causes and variables: countless insults and pathologies, multiplied by several layers of neurological and sensory processing, from nerve endings in our toes to the neurology and messy psychology going on in our skulls, and even the genetics that affect how we process sensation.

Good pain troubleshooting requires exceptional expertise — both broad and deep — but even that would fall short, because there’s so much that no one knows, no matter how expert they are.

2. There’s not enough good science about pain

The only way we’re ever going to solve the hard problem of pain is with a lot of research, probably especially neuroimmunology. No one’s getting this done with intuition. The need for more pain science is great, but physical and pain medicine have always been relatively slow-moving areas of research, and in some ways it’s actually getting worse. Although the quantity has greatly increased, the quality of the output of the scientific publishing industry has plunged in the 21^st Century. Science is saddled with a number of serious new modern problems, like predatory journals (the lousy consequence of publish-or-perish pressure), good journals chasing prestige instead of rigor, fraudulent conferences, and broken peer review, “advanced” p-hacking and data dredging, escalating conflicts of interest caused by industry funding, rampant publication bias that skews the literature toward false optimism … and AI is now an accelerant for many of these.

And so we get reams of junky little studies that are mostly only good for padding resumés and selling products and services. The data are often used to justify dubious gadgets and methods as “evidence-based,” including much of what goes on in mainstream pain clinics. One major example is cognitive behavioural therapy, which is widely touted as being good evidence-based medicine for chronic pain … but the evidence is such weak sauce it might as well not even exist. That one surprises a lot of people (hence the link to an article with a bunch of sources), but that’s what makes it a great example: everyone thinks it’s evidence-based, but it really isn’t.

It’s not all bad news — some progress has been made — but it has been a trickle compared to what it should have been, and the science of pain has mostly been a big disappointment ever since I first chose to dedicate my career to reporting it.

3. Pain is too easy to ignore, trivialize, and blame on the mind (especially in a world full of prejudice)

“No one would listen to me” comes standard with pain stories; “dismissiveness” is the sad rule. It’s shocking how much healthcare professionals ignore and minimize pain and other subjective symptoms — especially in women, who do get more chronic pain (though not so disproportionately as widely believed). Obviously this has a lot to do with the invisible, subjective nature of pain … but that alone shouldn’t be stopping anyone from taking patients and their symptoms seriously.

There’s more going on here, and I think it’s the common, tempting suspicion that pain can be psychosomatic — which is mostly or entirely wrong. No other symptom seems to be such a magnet for mind-blaming.

That bias combines disastrously with systemic racism and sexism. Overwhelmed clinicians unconsciously warm to any seemingly legit reason to de-prioritize a challenging patient. If you’re going to avoid taking some patients seriously, who gets chosen? Why, the “difficult” and “weird” ones, of course! The queers and the freaks and the hysterical ladies! The folks you can’t personally relate to, with symptoms you can’t relate to either. Inequality corrodes care for pain patients in many ways, but I suspect this is the main one.

4. Lack of medical leadership

Alternative medicine is going to take it on the chin later on in this process. To soften that blow — for many of my readers and members — I want start by making it clear that mainstream medicine isn't getting off the hook. While it is often criticized harshly for the wrong reasons, it is easy and necessary to constructively criticize medicine for the right reasons, and without just bashing science itself (see Stegenga).

The medical professions (and their institutions) have mostly failed patients with puzzling chronic pain, and there is a conspicuous lack of leadership from doctors collectively. The issues are plentiful: neglect and distraction with more dire and obvious problems; widespread profound ignorance (education in physical and pain medicine is notoriously token); the systemic prejudices (and sexism especially pollutes pain care); the buck-passing of tough cases between specialists (more on this in a moment); dramatic overuse of imaging and surgery (especially for back pain and arthritis, all based on eminence and convention and “common sense” rather than evidence); extensive pharmaceutical malfeasance (most notably the unmitigated disaster of the opioid crisis, but there’s much more, like anticonvulsants).

And finally, and worst of all, many doctors are actually following rather than leading. For lack of good science-based options, they have carelessly ceded the pain problem to alternative medicine (“well, you could try acupuncture I guess”) — or just gone over the dark side themselves, becoming quacks with credentials — and there are a lot more of those since the polarizing power of the pandemic and the rise of MAHA.

Medical pain clinics are the only place where most patients can find physicians (among others) who actually do specialize in chronic pain. They should be leading, and yet they do not have a great reputation, and some of the most famous are even the most notorious. At best, they can only help people so much because, despite their expertise and focus, no one has any good answer to many kinds of chronic pain. At worst they just make the same mistakes everyone else is making, but with maximal authority and credibility.

Because of all this, hardly anyone thinks doctors are leading the charge to better healthcare for pain.

5. Specialists aren’t very special if you aren’t their kind of patient

People expect specialists like neurologists and rheumatologists to be savvy diagnosticians in their field — like more focused versions of Dr. Greg House. This is wishful thinking that causes much confusion, frustration, and disappointment.

No matter how lovely it would be if every neurologist was a great troubleshooter of possibly-neurological problems, they just aren’t. What they are is busy helping the patients they can actually understand: the ones with major, distinct pathologies like Parkinson’s or rheumatoid arthritis. Not the strange cases.

And there are a lot of possibly-neurological problems. A neurologist I once saw for my strange symptoms explained to me that at least half of his new patients had symptoms that were vaguely neurological in character, without coming close to fitting a diagnosis, and that it’s common for neurologists to have to shrug and pick other clinical battles. Rheumatology is similar.

It’s ethically and legally safer for any specialist to just assume that a strange case is out of their scope of practice than to take on the hassles and risks of trying to figure you out. They will refer you on, and they’ll sleep well at night doing it! Because problems they don’t understand actually are arguably beyond their scope of practice — and there are plenty of problems like that, thanks to our persistently inadequate science.

Continued in Part 2