Why is it so hard to get good help for pain? Part 2 (Member Post)

6. The opioid war is catastrophic for pain patients

Opioid phobia has been cyclical throughout history, the pendulum of medical opinion swinging from reckless overuse to paranoid prohibition. There has never been a sensible, sustained compromise between the medical power of opioids and the responsibility of mitigating its hazards — it’s just a perpetually unsolved problem. But now we are in a phase of hysterical overreaction to a social crisis, the all-too-real addiction destroying communities around the world. The impulsive reaction has solved exactly nothing, but has created a major new crisis for pain patients.

The root of this new problem is the demonization of any usage of opioids: “We’ve swallowed the lie that anyone who uses opioids is just one step away from the gutter,” writes David Manny in “The Forgotten Casualties of the Opioid War.” And so patients in obvious and serious need (example) are now treated like criminals and drug-seekers, humiliated and denied treatment, with shockingly cruel and Kafkaesque consequences for millions. It is one of the worst things that has ever happened in healthcare.

7. Professional pride, tribalism, investment, and the corrupting power of profit

People invest deeply in their educations and careers, and that’s the only way to get expertise and competence. But that sword has two edges! Those large investments also trigger that great glitch of human nature, the trouble with getting someone “to understand something when their job depends on not understanding it” (messy attribution).

It’s bad to have armies of professionals convinced their Excellent Method™ works when no one really knows how to treat most kinds of pain. What could possibly go wrong?

In healthcare, earnest good intentions are a perfect disguise for “greed.” But many healthcare professionals make good money from their credentials and reputations, and you can draw a straight line from their bottom lines to their denial of any evidence that threatens them. Consider the vivid recent example of the surgeons who blustered dramatically when challenged by science.

Importantly, the money doesn’t even have to be good to be corrupting: it just has to be enough to pay the rent. Struggling freelance professionals are strongly biased towards whatever inspires their clients to come back for more. They invest in post-grad training and certifications, professional upgrades that they hope will increase their value to patients. They lean into their affiliations and associations for moral and marketing support, and it makes them thin-skinned about criticism — which is why I have gotten truckloads of hate mail in the genre of “how dare you criticize my profession/methods/beliefs.” Most people don’t even know that attitude problem exists, but in fact it’s extremely common and serious.

All of this is toxic to intellectual honesty, and drags clinicians towards inflexible faith in their expensive methods and beliefs — rather than basing their work on good science, curiosity, humility, and clinical reasoning.

8. Academic and intellectual weakness

There is a full range of quality in the education of professionals who try to help with pain, from the decade-long training for medical specialists all the way down to “barely detectable” for some professions. But no matter how much or how good the initial education, it must continue, because you truly cannot learn enough in school. Lifelong book learning isn’t optional. A professional that isn't interested in the science isn’t really interested in healthcare. And yet there is a serious shortage of nerdy enthusiasm for physiology and pathology in healthcare professionals.

In all cases, their education wasn't enough … and then many just stop, or only continue for a while, or in the wrong direction.

Continuing “education” should mostly be about increasing knowledge to the point where you understand how much you still don’t know, but instead it’s mainly dedicated to learning dubious skills, marketable treatment methods and techniques, and certifications. There’s far too much “practical” content, rather than the all-important nerdy stuff. And so many professionals fail to ever dig into the messier, harder, and more obscure topics that are essential for tackling tough pain problems … and also for building that all-important bullshit detector.

Pure clinicians tend not to know how much they don’t know. Operating only within the confines of unknown limitations, health care professionals will not see the options that they didn’t even know they could look for, and won’t look for more because they don’t even know there’s more to look for.

Nassim Taleb, Fooled By Randomness

The result is insidious and serious: we end up with pros that are even more vulnerable to bad ideas than their patients, because they are much more motivated to pursue and promote bad ideas. They are intellectually disabled by ignorance of the history of science, critical thinking and clinical reasoning skills, and the cognitive distortions and limitations that afflict us all — like emotional reasoning, confirmation bias, being suckers for oversimplification and “common sense,” and looking only where the light is (the potent streetlight effect).

This general poverty of knowledge and respect for book learnin’ is a major basic reason why the field is so amateurish in tone, but it also explains much worse …

9. Rank quackery, icky snake oil, and flaky bullshit

There are many embarrassingly bad ideas in the industry, truly archaic alt-med stuff that shames the field and holds it back: true superstition, spiritualism and vitalism, magnet and crystal cures, detox scams, homeopathy, psychic/faith healing, germ theory denialism, anti-vax and plandemic zealotry, quantum quackery, fear-mongering about Wi-Fi and 5G, and supplement-selling pyramid schemes. To name many of the worst.

Most of the obviously alternative professions are on thin scientific ice even at their most sober, but there are lots of especially rotten apples that promote truly malodorous malarkey:

• My guide to chiropractic focuses on that profession’s major ongoing controversies, a few of them horrifying. You just don’t see physical therapists trying to sell pre-paid treatment packages, or treating infants, or poisoning patients against vaccines, and so on.
• Massage therapy is also rife with silly myths and New Age mysticism — mostly getting literal about having “magic hands,” like trying to cure the Karate Kid’s messed up knee with “life energy.” Lots of reflexologists and self-proclaimed empaths and Tarot card readers in that population. It’s hard to explain just how weird it can get, so I have a large collection of examples.
• The darling of alt-med, acupuncture, was once given a pass by many skeptics, but no longer, because it’s really no different than the magic hands thing — pure magical thinking, as silly as believing in the The Force from Star Wars, and yet acupuncturists believe far stranger than that.
• There is a big industry of pain cream and lotions of dubious value, but the category is ruled by one of the most dubious of them all: homeopathic arnica, probably the most profitable pain snake oil in history. Why is this noteworthy? Because homeopathy is far stranger than most people realize.

The point of all this is that a lot of seriously silly ideas have been normalized and pulled the average quality of care way down. Like a bar that tolerates Nazis, before you know it they take over the place and the good ideas stop coming.

Even much more seemingly “mainstream” care indulges in plenty of equally egregious twaddle. For instance, doctors also sell treatments recklessly “ahead” of the science: regenerative therapy, knee lube jobs, ozone therapy, hyperbaric oxygen, chronic Lyme overtreatment, hormone “optimization,” and so on.

And physical therapy is never called “alternative medicine,” but there are days when I think it should be, because many common physio practices really aren't any more plausible or evidence-based than homeopathy or magnet healing, just better disguised. There are many examples, but one category stands out: quackery disguised with technology, and that’s such an important one that it’s got the whole next section to itself.

10. Tech as sneaky quackery

Help for chronic pain is rotten with gadgets, gadgets, gadgets. I once got a hard sales pitch from an allegedly progressive chiropractor for an “infrared spinal scan” that promised to spot the exact location of my problems — causing my bullshit detector to overheat like it was at a Deepak Chopra talk. Alternative medicine has plenty of obvious pseudo-tech: quantum harmonizers, foot scanners, vibration belts, detox patches! Sheesh.

But many more are not so obvious. We are suckers for supposedly advanced medical technologies for every kind of tough health problem, powering demand for vast amounts of pseudo-quackery in physical and pain medicine: snake oils effectively masquearding as modern medicine with… dials and LED lights? We’re an easily impressed species! From the tickle-you-with-electricity devices on the shelves of every drugstore on Earth to laser therapy to shockwaves to massage guns and spine stretchers, many of these products are commercially successful and don’t trigger the skepticism of the average person, even though many of them are not much better than faith healing.

Even mainstream medical tech with real value gets snake-oily when abused. For instance, X-ray and MRI are obviously valuable medical technologies, genuine modern miracles … but for patients with, say, back pain, they are also notoriously and harmfully overused, so much so that they can be no better than quackery. Another example: innovations in orthopaedic surgery, like new kinds of implants, have dazzled patients for decades, obscuring their weirdly weak scientific foundations. Surgery has been extremely slow to embrace evidence-based medicine, and it remains mostly based on authority, tradition, and “common sense” — often with disastrous results. But ooh, joint replacements that look like Terminator parts!

Pain patients have wasted staggering sums of time and money on ridiculous or just excessive technological treatment options, and yet most of them continue to be perceived as “promising” and “advanced.”

to be continued in part 3