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Drug Story

On chronic pain

50 min episode · 2 min read

Episode

50 min

Read time

2 min

Topics

Design & UX, Marketing, Psychology & Behavior

AI-Generated Summary

Key Takeaways

  • Chronic Pain Neuroscience: Chronic pain is not an ongoing injury but a central nervous system malfunction where nerve receptors become permanently oversensitized, creating a neurological feedback loop. Pain and anxiety mutually amplify each other, and overlapping trauma or life stressors make both harder to manage, meaning effective treatment must address psychological factors alongside physical ones.
  • The Fifth Vital Sign Trap: In the late 1990s, the American Pain Society designated pain the fifth vital sign, requiring physicians to log patient-reported scores on a zero-to-ten scale. This created an obligation to treat the number rather than the patient, directly enabling opioid overprescription. The AMA formally reversed this policy in 2016, acknowledging physician culpability in the epidemic.
  • Opioid Crisis Scale: Purdue Pharmaceutical's OxyContin marketing relied on a single one-paragraph letter in the New England Journal of Medicine to claim addiction risk below one percent. That figure was never a controlled study. Over one million Americans have died of opioid overdoses since 1995, and 55,000 died in 2024 alone, though that figure represents a 35% decline year-over-year.
  • Journavix Access Reality: FDA-approved in January 2025, Journavix targets only the peripheral nervous system, bypassing brain reward centers and carrying no addiction potential. It costs roughly $1,000 monthly. Vertex offers a $30 savings program, but only for two months. Insurance covers only 14-day acute-pain prescriptions, leaving chronic pain patients paying full out-of-pocket costs for any extended off-label use.
  • Multidisciplinary Pain Treatment: Academic pain clinics modeled on John Bonica's 1940s military approach, combining neurology, psychiatry, physical therapy, injections, cognitive behavioral therapy, and pain reprocessing therapy, produce better outcomes than single-specialty clinics. Insurance restrictions increasingly block access to this model, with coverage often limited by diagnosis category, such as acupuncture covered for back pain but not pelvic pain.

What It Covers

Drug Story examines chronic pain, affecting 50 million Americans, through patient Paul's 15-year ordeal, the history of pain medicine from John Bonica's 1953 textbook through the opioid crisis, and the 2025 FDA approval of Journavix, the first new non-opioid pain drug in two decades.

Key Questions Answered

  • Chronic Pain Neuroscience: Chronic pain is not an ongoing injury but a central nervous system malfunction where nerve receptors become permanently oversensitized, creating a neurological feedback loop. Pain and anxiety mutually amplify each other, and overlapping trauma or life stressors make both harder to manage, meaning effective treatment must address psychological factors alongside physical ones.
  • The Fifth Vital Sign Trap: In the late 1990s, the American Pain Society designated pain the fifth vital sign, requiring physicians to log patient-reported scores on a zero-to-ten scale. This created an obligation to treat the number rather than the patient, directly enabling opioid overprescription. The AMA formally reversed this policy in 2016, acknowledging physician culpability in the epidemic.
  • Opioid Crisis Scale: Purdue Pharmaceutical's OxyContin marketing relied on a single one-paragraph letter in the New England Journal of Medicine to claim addiction risk below one percent. That figure was never a controlled study. Over one million Americans have died of opioid overdoses since 1995, and 55,000 died in 2024 alone, though that figure represents a 35% decline year-over-year.
  • Journavix Access Reality: FDA-approved in January 2025, Journavix targets only the peripheral nervous system, bypassing brain reward centers and carrying no addiction potential. It costs roughly $1,000 monthly. Vertex offers a $30 savings program, but only for two months. Insurance covers only 14-day acute-pain prescriptions, leaving chronic pain patients paying full out-of-pocket costs for any extended off-label use.
  • Multidisciplinary Pain Treatment: Academic pain clinics modeled on John Bonica's 1940s military approach, combining neurology, psychiatry, physical therapy, injections, cognitive behavioral therapy, and pain reprocessing therapy, produce better outcomes than single-specialty clinics. Insurance restrictions increasingly block access to this model, with coverage often limited by diagnosis category, such as acupuncture covered for back pain but not pelvic pain.

Notable Moment

A patient hospitalized after major spinal surgery had to plead with staff just to receive his standard pre-existing pain medication, because the surgical pain was being treated as the primary concern despite his chronic baseline pain being significantly more severe than the post-operative discomfort.

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Episode Transcript

I was laying in bed next to my wife and dog. It was just a lazy Sunday afternoon. It was a rainy day. Dog was asleep in between us. She's was only about eighteen pounds. She was a pretty small dog. Somebody slammed a car door outside. She, jumped up, and the best I can describe it is she sort of spring boarded off my left testicle. And it sort of felt like somebody had hit me in the nuts and, it just never went away. Sort of felt like I was in a vice and then a couple of times a minute, it kind of felt like I was getting hit by lightning. It would be so sharp that I couldn't breathe. Oh my god. A couple times a minute, you said? Yes. And this was going on for years. Yes. This is Paul. He lives in Connecticut and has had chronic pain for about fifteen years. Oh my god. So, I mean, I've had I've been kicked in the nuts before, and I know what that feels like. Yeah. So it was definitely that that first day that she had jumped on me. Unfortunately, we were leaving for vacation that following day. So I was in South America for two weeks, and then got back and saw a doctor. But there really wasn't much of anything anybody could do. I assume you went to you you began kind of a medical treatments and seeing doctors and stuff like that. Oh, I actually have a list written down here. Oh, I'd I'd love to hear it. I've had three spinal cord stimulators. Basically, they implant a battery under your skin, and they run leads into your spine. And the idea is it kind of overwhelms the nerve with a signal, that should kind of block the pain. Unfortunately, it didn't didn't work for me. I've had two different surgeries to sever that nerve. I've had a nerve ablation that hurts so bad I actually almost passed out on the table. I've had physical therapy, pelvic floor physical therapy, talk therapy, pain reprocessing therapy. Everybody always recommends yoga. Yes. I've tried that. Medication wise, I've tried antidepressants, anticonvulsants, gabapentin, pregabalin, opioids, muscle relaxers, THC, CBD, about a a thousand snake oils. I've got drawers full of of pills. Basically, if anybody said that some supplement helped them, I tried it. Really, the only things that have worked, opioids kind of take the edge off. THC kind of distracts me from the pain. I haven't said no to a medication or a treatment because, as you can imagine, it's it's pretty desperate for a solution. As you can hear, Paul has struggled for years with chronic pain, pain that just doesn't go away. In his case, he knows exactly when it started and how it started. This sad story about his dog. For many people with chronic pain, though, how or when it started is more ambiguous, but no less real. …

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Books, tools, and gear mentioned in this episode

SignalCast may earn commission on purchases via these links. As an Amazon Associate, SignalCast earns from qualifying purchases.

Books

Tools

  • by GoodRx

    GoodRx is listed as a podcast sponsor with URL https://www.goodrx.com/drugstory

Products

  • JournavixBy guest

    by Vertex

    FDA-approved in January 2025, Journavix targets only the peripheral nervous system, bypassing brain reward centers and carrying no addiction potential. It costs roughly $1,000 monthly. Vertex offers a $30 savings program.
  • OxyContinBy guest

    by Purdue Pharmaceutical

    Purdue Pharmaceutical's OxyContin marketing relied on a single one-paragraph letter in the New England Journal of Medicine to claim addiction risk below one percent.

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