 Good afternoon, everybody. I'm delighted to welcome you to this year's annual lecture series, which is, believe it or not, the 40th annual lecture series that the McLean Center has coordinated and run. This year's series is called Medical History and Ethics. It was planned largely by Dr. Mindy Schwartz. I assisted her a bit. Mindy is a medical historian and a great professor of medicine here at the university. This year's seminar will bring together clinicians and historians and other scholars from throughout the US. And through their lectures, we hope to explore how understanding the past may help us to understand the present and indeed even plan for a more just future. We hope to show that history can contribute essential insights to physicians' understanding of disease, therapeutics, ethics, and of the doctor-patient relationship, and that the institutions that we work and practice in can learn that also. So let me begin by introducing our first speaker in the series of 28 talks this year. Our speaker is Professor Keith Weilu, who is the Henry Putnam University Professor of History and Public Affairs at Princeton University. Professor Weilu is former vice dean of the School of Public and International Affairs, former chair of the History Department, and currently is president of the American Association for the History of Medicine. His research covers history and health policy while dealing with drugs and drug policy, the politics of race and health, the interplay of identity, ethnicity, gender, and medicine, and also controversies in genetics. Before joining the Princeton faculty, Professor Weilu taught in history and in social medicine at the University of North Carolina in Chapel Hill and at Rutgers University in New Jersey, where he was the Martin Luther King Professor of History. In 2021, Professor Weilu received the Dan David Prize for, quote, his influential body of historical scholarship focused on race science and health equity and was also elected to the American Academy of Arts and Sciences. Professor Weilu's writings have advanced historical and public understanding on a wide range of topics, racial disparities in health care, cultural politics of pain and opioids, how pandemics change society, and on. His newest book is entitled, Pushing Cool, Big Tobacco, Racial Marketing and the Untold Story of the Menthol Cigarette, which was published, I should tell you, by the University of Chicago Press this year. We're so happy to welcome Professor Keith Weilu here to the University of Chicago. His talk today is entitled, The Politics of Pain, Opioids, Race, and Relief in America. Professor Weilu, lovely to have you. Wonderful to be here and thank you, Dr. Siegler for the introduction and Dr. Schwartz for both of you for the invitation to talk today about the politics of pain, the history of opioids, which history that ends with opioids but does not start necessarily with opioids, intersecting with questions of race and the broader politics of relief. I look forward to hearing your thoughts and much of what I'm saying is drawn from two books that I've written, Dying in the City of the Blues, which is a history of sickle cell disease in which the issue of pain and pain care is a central clinical as well as social concern. And then the book, Pain, A Political History. And just to launch in, when I was writing my book on the history of sickle cell disease, this is where I first became both concerned and interested in the question of the tangled history of pain care because in of course, sickle cell disease as many of you clinicians know, it's a disease that brings with it many clinical challenges, the challenge of managing infections, early mortality historically, but also still today and these recurring painful crises which are really one of the most disturbing features of the patient experience. And the history of sickle cell disease is one in which what you have is the history of this experience being given meaning depending on the social dynamics of the time. So in the book, I traced how a disease went from being largely invisible and unknown in the clinical world to acquiring a measure of clinical awareness and scientific meaning but also acquiring social meaning in the 1960s as a quote, new disease. It wasn't new, but it became new in a social sense characterized by pain and suffering among African-Americans that has been long ignored. And you could see how that framing of what sickle cell disease is and was resonated with the political and cultural currents of the time, a time of civil rights, activism and rising awareness of the African-American condition. So the awareness of the disease and the awareness of African-Americans in the broader social and political climate speaking to one another. And it's also in the course of writing that book that I began to understand that the history of pain, that is whether pain is recognized or not and the history of relief, how to treat pain and is also that the history of pain is not just defined by the time and the context but also by the place. If pain, you might say, has a history and a geography. The setting for my book was Memphis, Tennessee. And there I encountered physicians who talked about the, you might say, political complexities of recognizing and treating pain in the Mid-South. A Memphis researcher whose words you could find in the book pointed to the geographical variations in relief noting that the people in Oakland and Chicago disagree with us because they feel that we undertreat people in sickle cell crisis whereas we feel that they overtreat people in sickle cell crisis. Moving forward in time, this book also chronicled how a changing social and cultural context created new challenges for patients experiencing sickle cell crises. Patients confronting especially beginning in the 1980s but also in 1990s increasing skepticism when they brought their crises, when they brought their experience to a nurse or an emergency room worker. An increasing concern about whether this was authentic pain was it as severe as patients said it was were patients perhaps faking pain in order to acquire drugs. That is to say whether this was not a form of drug seeking rather than authentic disease. And in fact, the image on the cover of my book is taken from a 1990s article. The caption underneath the image, this image of a patient contorted in pain with thorns sticking out of their arms and their legs, the caption underneath it said before you can get past the agony you have to convince a doctor that it's real. And so what I wanna start by pointing out is that sickle cell disease introduced me to the history of pain, the cultural complexities of recognizing pain but also the politics of relief. And what I wanna do today is to spend a little bit more time talking about how the history of sickle cell disease is part of a much larger story of how racial attitudes, racial awareness are translated into clinical practice and social policy and that the politics of pain isn't just a story of racial experience but it is the story in some ways of an American political conversation that has been unfolding over the last 50, 60, 70 years in which medicine is often caught up. You might say the story of sickle cell pain introduces us to the idea that there is a micro politics of pain. That is the question of what to make of painful crises in the clinic. Is it real? How aggressively should pain be treated with what mix of narcotics? And then there's a broader macro politics of pain. Whose pain matters? Who is to judge? Whose pain matters? A question in clinical care but also a question in public policy. And doctors, nurses and caregivers are often sitting at the intersection of this micro and macro politics as gatekeepers, decision makers deciding on whose pain matters and what measure of relief should be granted. And pain is one of those topics that defies easy measurement and judgment. Before you can get past the agony a patient knows you have to convince a doctor that it's real and shadowing the doctor or the nurses considerations are often concerns about the financial costs of caring for patients or the clinical frustration of seeing expensive chronic pain patients return over and over again where their pain complaints are never fully resolved. There is this underlying anxiety that you find in the history of chronic pain which is a concern about whether the relief you're providing can feed other problems such as addiction and dependence. So pain care is a kind of a flash point for a wide range of other concerns. And as I mentioned that underpinning this are issues of whose pain matters. Back in 2003, it's really starting in the 1980s, 1990s but more prominently in the 2000s. You find articles like this in the American Journal of Public Health documenting that pain is not measured equally in different parts of the country or in different patients. This pointing to racial and ethnic disparities in emergency room analgesic prescription or articles like this from April of 2016 on the disturbing reason why some African-American patients may be under treated for pain which is based on a study that came out from the proceedings of the National Academy of Sciences and I'll get back to that at the very end of my talk, this particular study. But this article points out it's one of the most vexing problems in pain treatment today that whites are more likely than blacks to be prescribed strong pain medicines for equivalent ailments. So this is a broader context in which I'd like to kind of say that one of the prominent issues today in our discussions about pain isn't just opioids and prescription and addiction but it is this broader question about whose pain matters and how pain is portrayed in newspapers. The pain of the young white woman, the pain of the elderly black man and to what extent, you know, the issue of opioids is gained increasing traction because it's understood as a white disease as a white problem. So these are the kinds of issues that you might say shape the broader macro conversation of pain and they filter into decisions at the patient's bedside. What I'd like to do is to do a historical study of historical presentation about how this story plays out. Why has pain been so controversial for so long in medicine and US society? In some ways it's captured by this New Yorker cartoon from 2000, the doctor is standing over the patient's bedside along with presumably the spouse and he says, we can give you enough medication to alleviate the pain but not enough to make it fun. And there is the kind of macro politics of pain right there. Of course, who is to decide where the line between pain relief and pleasure happens and who is to decide who is to know whether the actual alleviation of pain is not itself pleasurable. Pain is one of those problems, especially chronic pain that defies the physician and scientists a custom desire for objective knowledge driving clinical decision making. Pain defies reliable measurement. It's subjective, the expert depends on individual patients or secondary indices to decide what measure of pain someone is experiencing. It's not truly a vital sign. It's not like temperature and blood pressure in the same sense that it can be measured. Its levels can be chronicled. It can be monitored systematically over the course of a patient's stay in the hospital. And then shadowing that patient's that physician's determination about, you know the alleviation of pain but not producing fun is the fear of dependence. The fear not just the pleasure but addiction to opioids and other medications which of course varies dramatically from one individual to the next. So one of the challenges in the history of pain is deciding on legitimate or illegitimate relief and I'll give you a good example which comes not out of the product pain world but out of end-of-life pain to show you the blurry lines between relief and some other goal. In end-of-life pain, we know that morphine can provide exceptional pain relief but it also suppresses blood pressure, inhibits respiration. It provides relief to be sure but it can also hasten death in the chronically you know, terminally ill. Who is to decide where the line is between not pain and pleasure but in this case, the alleviation of pain and the hastening of death. For instance, in euthanasia. This is the blurry line in which pain relief exists. When is pain truly disabling? Another conundrum that physicians as gatekeepers to disability relief have to weigh and who is to judge? And how should a patient behave when they are in chronic pain? Who is to judge? Now, this issue of subjectivity and pain is as I said, a really confounding one is pain a sign like pulse, blood pressure, respiration and temperature? Is it necessarily related to pathology or is it a symptom subjective and therefore undependable? And how should we judge complaints? The history of pain is the history of the challenge of intrasubjective understanding. Another cartoon from the New Yorker. No, they're not like us. They don't feel pain. The main character in my book, Pain, A Political History is John Bonica who is often called the father of pain medicine, pain physician at University of Washington, the founder of the first kind of multidisciplinary pain, one of the first multidisciplinary pain centers in the country who was asked in 1974, Dr. Bonica, what is pain? Can science actually define the sensation? And at the time he said, if you ask a hundred different authorities that question, you would get a hundred different answers. Pain, I wanna suggest exposes a problem of weighing objective and subjective evidence. And what I learned in doing the book, Pain, A Political History is that those evaluations of whose pain matter is not just an issue that has defined medicine over the last 70 years. It's been a central concern of law and politics and society more broadly. And in fact, it's the legal debate about whose pain matters that has informed the medical debate. And so what I discovered, and I'll give you a quick overview of, is that pain is really a fundamental legal problem, a question of patients and people's rights that ends up trickling into clinical decision-making. Just very briefly, what I wanna do is to focus not just on John Bonica, but the history of pain that starts with World War II in the birth of pain medicine, opens into a period of liberal social welfare, but the recognition of chronic pain as a topic that physicians need to deal with, a backlash that ensues in the 1980s and the kind of more recent debate about how to appropriately deal with people in pain if you're the gatekeepers of relief. So when John Bonica was coming into the field, it was not at all clear in the 1950s that pain was the proper topic of clinical expertise. In fact, there's many like a Boston psychiatrist in 1959 who wrote that the relief of pain is obviously one of the main functions of physicians, but ironically it's one of the things we do released well, partly because we don't understand it. And a lot of the focus in the 1950s was not on pain itself, but on the complainant, the person complaining of pain. For instance, a psychiatrist on the West Coast at a symposium on pain in California, Henry Albronda noted that in his presentation that the patient in chronic pain is certainly worthy of study, but not necessarily worthy of sympathy. He wrote that the complaints of chronic pain may develop in the child brought up to repress feelings of hatred who then may use complaints of pain to cover his hostile feelings towards an associate. For people like Albronda trained in psychiatry, the pain complainant was someone to be studied skeptically because malingering or masochistic self punishment underlies the chronic painful condition. So physicians really, especially psychiatrists weren't sure that if they were dealing with somebody who was in pain or simply profoundly maladjusted. Now these issues of malingering and deception or playing sick are certainly still part of the clinical conversation today or in recent times, but in the 1950s it figured really prominently much more so than today and shaped the question of, sorry, the question of how physicians should deal with the pain, the chronic pain. I also should point out that, what was Albronda so upset about? Well, in the 1950s there was a dramatic stage, the dramatic change of foot, not in pain care, but in disability politics. A year earlier, just before the California pain symposium, President Eisenhower, the Republican president had signed into law a new disability benefit, establishing social security disability benefits for the very first time that disability should be covered within the social security system. But this immediately raised the question and California had passed similar legislation. And this immediately raised the question of what evidence established a compensable disability and whether chronic pain belonged in the disability system. So this is what I mean by the fact that the question of who judges pain doesn't start in the clinic, it actually starts in a political development in 1956 that physicians are pulled into. And the first patient who became a test case for the question of whether chronic pain belongs in the disability compensation system is a Texas housewife named Rosie Page in the case Page v. Zellabrizi. She petitioned for disability benefits in the mid, well, just after the disability program was set up, she was denied by her, by the secretary of health and education and welfare and she went to the courts to appeal the case. And it is her case of, she was a woman who was, who had what her physician called arthritis with a marked psychogenic overlay of her symptoms. And once she was rejected, once again, it's the courts that had to make the determination of whether this rejection was legitimate. And here you see in the Page v. Zellabrizi case in 1963, the beginning of my story, of the opening of the doors of relief and the role of the courts in these disability rulings. The author of the Page v. Zellabrizi ruling was this gentleman, Eisenhower Appointee, a member of the, quote, Fifth Circuit Four, a Republican appointee of Eisenhower who ruled John Brown in a landmark case that hinged on the fact that subjective pain was real pain. He wrote that if pain is real to the patient, the disability entitles the person to the statutory benefits. And the fact that the pain complained of by the claimant is not shown by objective clinical and laboratory findings does not mean that the secretary or health, education and welfare must give little weight to allegations thereof. Subjective pain was real pain warranting these disability benefits. Now, if there was a public sector debate about pain in the 1950s, there was also a private sector discussion that hinged in a much more recognizable way around drugs. In fact, around the very same drugs that we talk about today, oxycodone, coming in the form of Percodan in the 1950s. Percodan had been quickly integrated into pain care in the 1950s because it was seen as acting fast, lasting long and providing thorough relief, providing exceptional clinical utility. Physiological observations at the time suggested that it was as good as morphine, but does not produce respiratory depression. Once again, looking for an alternative to morphine because of the depression of respiration. And here you see a model also of what addiction was seen as how addiction was defined in the 1950s. As one scientist wrote, Percodan was well tolerated and it was broken down extremely slowly. And the slow breaking down of the substance was seen as very important because it would produce very little euphoric effect. And as a result, the theory went, addiction should not be a problem. And on the basis of this, Percodan was really taken up and this is Dr. Bonica again. This is the culture in which he began practice. Now there's a kind of a history repeating itself feature to this story about Percodan oxycodone in the 1950s and 1960s. Very shortly thereafter, regulatory concerns begin to grow about the widening use of Percodan. In California, the attorney general Stanley Moss criticizes what he calls the high powered campaign waged by the Endo company, the makers of Percodan among doctors and pharmacists. Of course, if you swapped out Purdue Pharma for Endo you'd have the same story playing out itself out today or he bemoaned the drug company's apparent influence on the California Medical Association which had found that Percodan did not require prescription controls. And articles like this on, sorry, I'm just blocked from, articles like this on the addiction potential, give one insight into the way in which the past if not repeats itself, it certainly rhymes as Mark Twain once wrote. Then as now there were concerns about Percodan, false marketing promises and also addiction. As Edward Bloomquist in the California Medical Association wrote, the drug has acquired the unenviable status of being the principal choice of a, as a substitute for heroin by California-based heroin addict. So this is actually a flip of how we think about Oxycontin today, not Oxycontin as a substitute for heroin but people moving from Oxycontin to heroin. He also write that this is a moment in time in a kind of humorous aside or what to us as humorous. He says it may seem odd that California has become the center of Percodan misuse. Two factors however may contribute to this. California he writes has an undue share of unstable personalities who welcome bizarre methods of escaping reality. And this is true circa 1963. This is an image of course, a social portrait of California in changing times. And it's on the basis of this that US senators and others are calling for stricter controls on the prescription of Percodan. What the 1950s and 1960s represent however is a kind of continuation and expansion of John Brown's idea that we need to think more broadly about pain and what pain is and whose pain matters. And a new theory of pain in some ways endorses this broader vision. It's a theory that emerges out of the 1960s. The fathers are the architects of this new model of pain are Ronald Melzak, a psychologist in Patrick Wall, a physiologist and it's known as the gate control theory of pain. And they argue in one of their books that the surgical view of pain as being purely kind of neurological anatomical is all wrong. The concept of a pain center in the brain, a single pain center is totally inadequate to account for the sequence of behavior and experience. Indeed, the concept they write is pure fiction because there's so many parts of the brain, the thalamus, the limbic system, the hypothalamus, the pirated cortex, so the frontal cortex are all implicated in pain perception. And so they come up with this kind of metaphor of the gate control as if what really is the experience of pain is shaped by small fibers and large fibers. And the question of which gates are closed and opened to transmit pain to the brain is determined by a multiplicity of other factors, individual psychology, neurophysiology, one's past, the context in which one is experienced being pain, personal traits. So the gate control theory is kind of a metaphor that suggests that while there might be straightforward neurological neural pathways, the opening and closing of the gates is shaped by a wide range of factors. The psychologist, Ronald Melzak, sees this theory of pain as really opening the new doors to thinking about relief as well. In fact, he himself was astonished at how quickly this theory was embraced. He wrote that gate control theory wrote it on a zeitgeist. But he said it did do one thing, was it endorsed the liberalization of pain care because what it meant was that you could try, you could think about relaxants, tranquilizers, sedatives, suggestion, placebo, hypnosis as all influencing pain. They all deserve more attention than they receive. Another hallmark of how pain was being, the approach to pain was being liberalized in the 1960s is in, well, you can find a multiplicity, you can find the emergence of, you can find a new theories of doctor-patient relationships. A book comes out in late 60s, Mark Zabrowski's People in Pain, which in retrospect is either recognition of the cultural phenomenon of pain that different cultural groups experience and think about pain differently or the crudest form, it's either cultural sensitivity in medicine or the crudest form of ethnic stereotyping. In fact, it's both. He writes about Jews in the clinic that he studies in a VA clinic who are vocal and suspicious of doctors and concerned about their pain, Italians vocal but trusting and very present oriented. That is to say if the pain is present, they complain about it, but if it's just past, it's as if it didn't happen. And he characterizes the Irish patients as in some ways pathologically stoic. That is to say ignoring pain even when it's there, as if it doesn't exist, as well as being highly suspicious of physicians. And not surprisingly, he writes about what he calls the old Americans, that is the Anglo-Americans who in some, as if magically know precisely how to communicate about pain, how to rationalize it to Anglo-American physicians in a language that they understand and respond to. So this is a book that really talks about and stands in for kind of the recognition that pain is also culturally complicated. It's also in the 1970s that you see the emergence of the multidisciplinary pain clinic of the kind that Dr. Bonica is creating in Seattle. And it's also in the early 1970s that one begins to see a shift in the doctor-patient relationship around pain with the rise of a phenomenon called patient-controlled analgesia. That is to say, rather than subject the patient to the kind of skepticism that Henry Albronda voiced in the 1950s, by the 1970s, the idea is put the morphine drip into a patient's hand and have them determine how much analgesia they need in a controlled clinical environment. Or something that we still do today. This is the opening of what pain means, the McGill pain questionnaire, authored by Ronald Melzak himself in its first iteration, which essentially says, ask the patient how much pain they're experiencing on a scale of one to 10, 10 being the worst, at first they didn't say self-referentially, 10 being the worst pain you've ever had, how would you rate the pain that you're experiencing right now? There are other indices that show the rise of pain medicine as a field, new professional journals, and also new skepticism about whether doctors should be rethinking the stigmatized use of marijuana, LSD, heroin, right? These controlled substances, should they be brought back into pain medicine? So there are many ways of thinking about the liberalization era in pain medicine. I wanna highlight that global politics also plays a role in the liberalization of pain medicine. So the Republican president Richard Nixon goes to China and Americans discover in its wake, the needle pain killer coming to the United States. The theory also helped explain as this article in the New York Times said, and legitimate acupuncture, but the gate control theory ended up explaining and legitimating acupuncture, which up until then had been dismissed as a clever trick of auto suggestion. So these are the indices, one might say, of how pain medicine is diversifying and changing. And that is why in 1974, when John Bonica is asked by US News and World Report, can science actually define the sensation of pain? He says, if you ask a hundred different authorities, you would get a hundred different answers. Because what he is describing is the flowering of pain medicine as a field, but also the flowering of a multiplicity of approaches to pain medicine, like the TENS unit, the Transcutaneous Electrical Nerve Stimulation, which actually is the brainchild of Patrick Wall, one of the architects of the gate control theory of pain. You have acupuncture. You have John Brown. And you have patient control analgesia. All of these are byproducts of this transformation. But as with much that happens in the 60s and early 70s, there is backlash over questions of whether this liberalization in medicine and society had gone too far, and how to judge and distinguish between those who are worthy and those who are not, and how pain intersected with the broader politics of welfare. Even as early as 1972, you have reports like this in New York, the NBC News on the dilemma of pain care, pain, where does it hurt, in which a new term emerges that becomes increasingly important in pain care. The Lucy Jarvis, the producer, refers to those who are burn victims, who are obviously in legitimate pain, and then people who are experiencing what they call lured pain. Or there's even a phrase that's thrown out in this broadcast of low back losers. That is people whose chronic pain costs the state of California extraordinary amounts of money. $100 million a year in compensation for low back losers. People whose low back pain explains the emergence of a welfare society. In fact, pain ends up being a really linchpin concern that helps us understand the tensions between liberal commitments and conservative commitments. Looking back from 1984, one political and social scientist notes, over the last 20 years, a significant number of federal cases of disability were decided in which the alleged disability was wholly or substantially related to pain. And so the history of pain that I tell in my book, Pain of Political History, is the history, you might say, of the liberal trans I've just described, how relief in the name of compassion, social justice, recognizing individuality, and anointing subjective pain experience as real in the name of intersector subjective understanding is transforming medicine and society. And how it confronts these conservative impulses, which you saw from the very beginning when Henry Albronda said, aren't we just feeding and indulging people by acknowledging their pain? Well, these kinds of concerns about the social consequences of indulging subjective complaints, feeding addiction, feeding dependency, malingering, learned helplessness, and also the economic and social costs of liberal relief are also part of the politics of pain and they become resurgent in the 70s, but most dramatically in the 1980s. So my book took me into the archives of the Ronald Reagan administration and to the Reagan presidential archives in Loma Linda, California, in which you could see how pain was at the center of the, one of the centerpieces of the Reagan revolution. After all, Reagan is known as a major critique of the welfare state, a major critique of government, as he said in his inaugural address, government isn't the solution to your problem, government is the problem. When he ran for president for the nomination in 76, he singled out a black woman in Chicago as the welfare queen image. And in the White House, those who worked in his office of policy development, like Peter Ferrara, would write and take aim at disability benefits, writing that over the years, the disability benefit provisions were significantly over-liberalized as compared with the original concept of paying for such benefits only for truly permanent and total disability. The administration's proposal to roll back these benefits would change back the definition of disability so that it would rest solely on medical grounds and would not take into account vague factors which are so difficult to determine in a consistent manner. And pain was one of those centrally concerning diagnoses, chronic pain. Now it's not that Reagan was alone. All the way, even before he became president through the 1970s, courts were growing increasingly skeptical of the idea that subjective pain was real pain that warranted disability benefits. In 75 and ruling Miranda V. Richardson, one of the court's rules, pain is not easily diagnosed but the secretary of health education and welfare is not at the mercy of every claimant's subjective assertions of pain when determining eligibility for benefits. And even in pain medicine, you have the writings of people like SF Brenna, who's a pain specialist who worked with Don Bonica for a while and set up his interdisciplinary pain clinic in Atlanta writing a new book in 1978 on chronic pain in which he says in the introduction that there is such a thing as learned pain. And he writes, and like I said, this is an example of the backlash. Chronic pain is often a conditioned socioeconomic disease, he writes, majority of patients show pain behavior in excess of biomedical findings. And he says, the rise of chronic pain is really evidence of a society that had gone too far in granting monetary compensation for escape from work via pain complaints. So this is the story of the Reagan Revolution. I'll try to skip past this to get towards the end very quickly of disability benefits rising, rules broadening allegedly, disability tests to police the line between malingering. And what Reagan would do in the first years of office is purge the disability rules by almost a half a million people, many of whom were claiming intense back pain or chronic pain as the basis of their disability. Of course, this resulted in lawsuits. It resulted in a class action lawsuit where once again, who should decide who was in pain and not, well, the courts. So following the purging of the rules, as it was called, you have class action cases and the signature one is the Pulaski v. Heckler case which results in a victory for patients in which the courts, you can see them trying to reconcile the liberal commitments of the early era with these new conservative skepticisms. So I'll just read you this paragraph because it's fascinating to see how the court is trying to reconcile subjective pain with the adjudicator's responsibility. While the claimant has the burden of proving that the disability results from a medically determinable physical or mental impairment, direct medical evidence of the cause and effect relationship between the impairment and the degree of the claimant's subjective complaints need not be produced. The adjudicator may not disregard a claimant's subjective complaints solely because the objective medical evidence does not support them. So this is really about trying to thread that line. Since the 1980s, there have been a number of kind of battles between this liberal commitment and this conservative ideology and concern. In fact, there are articles in the 1980s that show how multiple concerns about pain can coexist. The undertreatment of pain, sorry, just lost my... At the same time that we have... One of the interesting things in the American history of pain is thinking that either an era is responsible for undertreatment or overtreatment, under recognition or too much care. Articles like this highlight that these two things can actually happen at the same time. That is to say in 1986, an article says, it's an irony of our age, millions of Americans in hospitals, the late-stage cancer patients, burn victims suffering unnecessary, sometimes agonizing pain with doses of narcotic analgesic too low. While at the same time, millions more are unhospitalized, dangerously overdosing on painkillers, often inappropriately prescribed for their chronic pain. This is not a story from 2021, this is a story from 1986. So the intersections of undermedication and overmedication. I'll end with that theme, but a number of themes, maybe five themes to highlight where the politics of pain goes from the 1980s onwards. When John Bonica, this pioneer in anesthesia and pain medicine dies in 1994, a new politics of pain is unfolding. And it's unfolding in different states that are trying to grapple with where you draw this line. And it's unfolding around a new development, which is end-of-life pain care. In mid-1990s, the state of Oregon passes its Death with Dignity Act and it's revisited again in the 1997. And opponents of the Oregon law like Henry Hyde, the Republican Senator from Illinois, proposed what he calls the Pain Relief Promotion Act of 1999. And here you see this new moment in the politics of pain in which the state of Oregon is trying to decide that the liberal model of using pain medicines, using medicines to maybe even facilitate death at the end of life under controlled circumstances is one direction to go in. And this congressman is proposing a Pain Medicine Promotion Act that says that permitting the DEA to prosecute physicians who dispense control substances for the purpose of hastening death is a crime. So it's an attempt to empower the DEA to determine the physician's intent and whether the drug is dispensed for a legitimate medical reason. The bill fails. But here you see a kind of politics of not only who's pain matters, but who should be judging and setting the rules for how pain medicine should be carried out. In the 1980s and 1990s, there's another flashpoint which is a question of who's pain matters. On the religious right, there's a new phenomenon that emerges, not the focus on end of life pain, but actually what they endorse as fetal pain. Now, of course, neurologists will tell you that early neurological development in fetuses is not sufficient for early stage fetuses to feel pain, but that does not stop abortion rights activists from creating movies or endowing the fetus with the ability to feel pain, as in the film, The Silent Scream, to mobilize a particular concern about whose pain should matter. And at the other end of the life course, one might say in places like Oregon, the focal point is on ending life without pain and with dignity. Even if it means blurring the line between compassionate relief and aid in dying through euthanasia. And when my book is reviewed in Science Magazine, it's this image that they choose to kind of illustrate the book, the donkey and the elephant, the left and the right, who feels your pain and whose pain matters. This is one direction in which the politics of pain emerges. And as in both instances, having enormous significance, this macro politics of pain playing out in clinical decision-making at the bedside. Just to sort of say a few more words by way of conclusion, this question of whether aggressive pain relief at the end of life is legally sanctioned, makes its way ultimately to the US Supreme Court. In the case Washington v. Glucksburg. In this case, the Supreme Court is being asked, is do people have a right to die? Is there such a constitutional right? The what the court decides, well, before I get to what the court decides, in its filing, the American Medical Association must speak to this question. And here again, the pain question is at the center. What the EMA does, like many, is they just try to find a point at which you can find a kind of a compromised position on the question of physician-assisted suicide. And what they write is, we reject the notion of physician-assisted suicide. However, we support pain relief even if it hastens death. And they invoke, they reach all the way back to Thomas Aquinas, right? This Catholic theologian who speaks about the principle of double effect, in noting that the recognition that the physicians should provide patients pain medication sufficient to ease their pain, even where that may serve to heathen death is vital to ensuring that no patient suffer from physical pain. Justice Sandra O'Connor agrees, and she writes a really influential opinion that basically agrees with this position, that there is no such thing as the right to die, but there is a right to relief, even if it hastens death. There is no dispute she writes that dying patients in Washington, New York can obtain palliative care, even when doing so would hasten their deaths. And that is where the courts have come down and where that issue had stayed. And in response to that, Henry Hyde promotes the Pain Relief Promotion Act, Marsha Angel at the New England Journal of Medicine writes, the title of his proposed law is misleading if the bill becomes law, it will almost certainly discourage doctors from prescribing and administering enough doses. Just wanna end by bringing back the story of race and pain and the gatekeepers of relief. Throughout the story, the question of why is it that African-Americans, why is it that ethnic minorities, Latinos in Los Angeles, African-Americans in Atlanta are routinely face the likelihood of lower analgesic prescription, even if they have equivalent, let's say, long bone fractures. And some scholars really take issue, try to understand this, but they try to dissect whether it is the question of physicians assessing pain differently or whether patients express pain differently or because physicians interpret those expressions differently or is it at the level of recognition? That is, is it possible that physicians assess pain in whites and blacks or whites and Hispanics similarly, but simply choose to address pain less aggressively in one group over another? The politics of pain took an interesting turn for me in 2016, when a new, the article that I mentioned from the PNAS came out, it's a psychological, a study by psychologists of the attitudes of medical students and residents at the University of Virginia about issues that are immediately germane to pain care. Based on this survey, students exhibited a wide range of really specious, biologically unfounded and highly suspicious views about the differences between black people and white people, believing that black people's blood coagulates more quickly than whites, that their skins are thicker, et cetera. And the argument of the article was unquestionably believing that there was thinner skin would translate into perceptions of pain. Of course, the major story in our era has been the opioid crisis and the way in which the politics of pain has been transformed by the unleashing of OxyContin. This is the last chapter in my book on pain. And what I wanna point out is that there are three developments that one of which really stems from the Reagan administration that explains the rising prescription, the appearance of OxyContin and the rising prescription. And one has to do with deregulation that emerges out of the Reagan era and the rise of more aggressive direct-to-consumer advertising. The second is the decline of the rural economy. OxyContin emerges as a problem in American society. First, not because of over-prescription but because of what's called Hill-Billy heroin. The appellation economy tied to the increasing abuse of this painkiller. And one could also argue that it's the decline of the very kinds of clinic that John Bonica inaugurated, the multi-disciplinary pain clinic in an era of cost containment and medical reimbursement that turns physicians more towards the quick fix for dealing with chronic pain. That is to say, the pill rather than, you know the more costly labor intensive and arguably frustrating approaches to dealing with chronic pain. With the rise of the opioid epidemic, I found myself having done this book a, you know on the receiving end of phone calls from journalists who would ask me some rather perverse questions or exhibiting some perverse theories about race. One once told me, you know well, if it's true that whites were harmed by the over-prescription of opioids, doesn't this mean then that blacks in being denied access to pain relief were somehow protected from the opioid crisis? And, you know, I thought about this as not only a perverse theory but a strange new theory of like beneficial discrimination. That is to say, we can only judge, you know the pain of black people through the lens of white distress and over-prescription. It also is an example of how, you know we tend to move, excuse me, whiplash from the question of whether we're over-prescribing or under-prescribing without understanding that both of these two things happen at the same time. I'll skip past this because it highlights that, you know the opioid crisis isn't one crisis, it's many and point out that, you know I've written about this for those who wanna read more not just in the book on pain and political history but also thinking through pain, an essay that came out in the prescriptions, perspectives in biology and medicine and also in this daily beast piece entitled The Pain Gap Why Doctors Offer Less Relief to Black Patients. So I wanna end by just sort of revisiting the broader politics of pain. I've tried to kind of illustrate why it is that pain has been so controversial for so long in American society. What I've tried to do is on a certain level illustrate the idea that we have 70 years of ongoing cultural debate and social transformation on this question of pain that a lot of it stems from the familiar stories of the lack of measurement, the lack of objectivity, the intersection between objectivity, subjectivity and ideology in how we measure pain and how we relieve it. Much of it but not all of it relates to drugs like Percodan and Oxycontin. And a great deal of it revolves around the liberal and conservative commitments and the debate over liberal care, conservative care, liberal governance and conservative governments, not only in pain but also in the area of disability. And I wanna leave you with the point that I started with which is the discovery that I made which is that when it comes down to make a final decision over whose pain matters, I've been just stunned at the way in which it's the courts. It's judges who have had to make that liberal and conservative determination over what pains matter and what degree of relief is warranted. And often people in chronic pain are the ones caught in the middle of these pitched clinical, scientific, political and legal battles. Which is why back about what, 15 years ago, then Institute of Medicine, now National Academy of Medicine, did a study on pain. And its final conclusion was this, that we need a cultural transformation in the way pain is viewed and treated. And I would argue understood. And that's partly the reason why I wrote the book that I did and why I've enjoyed chatting with you about the politics of pain as it intersects with questions of race and social policy and clinical medicine today. So I will end there, stop sharing and look forward to your questions and conversation. Thank you. Thank you so much. That was extraordinary. I think we'll just open it up for questions from the audience. Mindy, would you have one to start? I don't have a question. I just think that the most interesting thing clinically is the, so on the wards, and we see a lot of patients with sickle solenemia, is this phenomena and the anesthesiologist identified it that increasing narcotic medications cause a decreased efficacy of it. And it comes to a point that people have the same amount of pain on or off it. And it's just such an, it was such an unanticipated finding that narcotics would become less effective the more you use it. Who to thunk, you know? But we learned a lot about clinical medicine through a life with narcotics. You didn't mention the thing about pain is the fifth vital sign. And I think that's another, I mean, I know you know that, but I just thought that was another way pain crept into the clinical practice. So I don't think that's a question but just more food for thought. Well, I do have one thing to say about, I mean, it's true, I didn't mention the fifth vital sign, but it's a good example of how the effort to make pain matter by calling it a vital sign was very much part of what the, you know, Jacob and the American Pain Society were advocating. And yet the conundrum is, I mean, it can seem like a small semantic issue, but pain isn't a vital sign in the same sense that blood pressure, temperature, right, are. And so it tries to make pain into something that it's very, very difficult because it's not subject to the same kind of clinical assessment. Now, I'm not saying that it can't be somehow, but it's because it's not measured in the same way and not subject to sort of integrated thinking about how it's related to pathology. It's very difficult to integrate it. And so one of the problems with the pain making it a vital sign is the unevenness with which that has been actually implemented in the clinical world. I think when they did that, the point was out of sight, out of mind, they just want to make the pain more visible. They never meant it to take it literally. That's right. So that was the difference. My question would be, I know you spoke with many physicians. In my mind, the problem is, we don't have a gold standard, what a well-controlled pain look like. So when we don't have a gold standard, what a good, well-controlled pain look like in a person, then everyone becomes an expert. And when everyone is an expert, then everyone has an opinion and then we don't know how to do anything. So it's like basically a death of an expert. Now everyone has an opinion. That's a good comment. One of the things that you're highlighting also, the difficulty of doing the thing that we call kind of replicable science experiments around pain. So one of the interesting developments around patient control analgesia is that those who advocated for it, it's one of those kind of multiple discoveries. People in Menlo Park, people in New York, I think London and somewhere in Canada, they were all doing patient control analgesia studies in the early 70s. And there they thought, well, this would be the place where you can begin to set a gold standard. Because if you could actually correlate patient experience with how different patients are medicating themselves, you might be able to understand where the line is between effective relief over medication, et cetera. But of course that runs right into the problem of highly individualized patient experiences, right? That pain is not pain in the same way in everyone. So anyway. Thank you, Peggy Mason. Yeah, I just, thank you for that. It's so interesting because I spent the 80s, 90s, and knots in pain research with Howard Fields who you may have come across that name in the Melzac tradition. But the other big group that I was aware of in the 80s that was really not getting any recognition for their pain was pediatric burn patients. Which was such a travesty. When I started graduate school, it was an argument to get them some pain relief for their dressing changes. And the other is just a comment. I just wonder what your thoughts are about how this intersects with something that's very much talked about in the neuro enhancement field which is authenticity. And to what extent is it preferable to be more authentic as in to take care of your own pain? I have a friend who grew up in Harlem who used to say, I don't take no tea for fever. And so, to what extent is that coming from various segments of the population? Yeah, those are two great observations. I mean, I did skip past the, so in an effort to kind of show you the pivot from, you might say the liberal view of pain at the end of life and the conservative view of pain as fetal pain, I skipped past the fact that pediatric pain in some ways was the thing that connected the two. So in the 70s and 80s, there is this sense that the next front for understanding people in pain who are being under-treated are infants and pediatric patients, right? That there was this kind of sense that they didn't need analgesia as much or we couldn't afford to do analgesia. I don't mean to afford in the financial sense that there were too many downsides. And there was a reform movement to sort of think more broadly about pain care. You can see how this can slip into fetal pain, right? Because if you're suddenly embracing the notion that infants pain matters, you can easily see how on the, just on the other end of the political spectrum, you can say, well, fetal pain matters. And if fetal pain matters, you can see it's, I didn't mention it, but it's really about anti-abortion politics, right? So you're right that the pediatric pain for burns and for others in sickle cell disease too, comes to figure very prominently. Your observations on neuro enhancement and authenticity is fascinating. I don't know very much about it. And it's an interesting way in which the neurology is changes the conversation about pain. I haven't really followed it very closely, except those who had this kind of ideal that, you know, FMRIs could somehow, you know, in this field where it's all a mess and it's all subjective, maybe there's a way to anchor our scientific understanding of pain using technologies like FMRI, which of course is not, you know, at all reasonable. But it's interesting to see how new scientific fields emerge and how they change the character of the conversation about what pain is, how you measure it and whose perspective on it matters. That's all I'd say, but I'd have to look into more what you've described. Thank you. Bob Chung, Bob please. Thank you for a very stimulating presentation. I had a couple of reactions. One is that I see a power authority struggle. Physicians are used to having authority, pain being quote subjective, challenges that by giving patients authority. Second, in Japan once I went to a workshop on quote Zen therapy, close quote. The message I took home was in the West, we try to treat and defeat symptoms. In the East, they try to adapt to and live with symptoms like pain. Yeah. So these are two, I'll take these as observations because I do agree fundamentally with you that underpinning what I've described are issues of power and authority. And what I was kind of describing, part of the liberal trends of the 1960s is what you might say is a shift in the power and authority of the doctor-patient relationship, right? So which we as historians know happened, right? Patients' rights, movements, et cetera. But what you do, you see in the history of how pain is being treated, evaluated, that shift of power and authority happening. But at the same time, you know, so one of the interesting stories, for instance, is that after, and this maybe segues into not so much Japan, but the East, after Nixon goes to China, the next person in my book who goes to China is John Bonica because he is being confronted by patients who are saying, how do I get access to this acupuncture? And he is, and you see this flow of correspondence where everybody's trying to figure out. So he goes to China. In fact, he has a great journal where he collects lots of information. And then when he gets back, he's asked by the state, both the legislature, how do we regulate acupuncture? And how do we, and he's in this zone where it's a mode of medicine that he understands as being kind of a political outgrowth of Chinese society. The kind of re-embrace of acupuncture is really a Maoist kind of political development. And so it's this kind of like the physician seeing the politics of acupuncture as political, but also responding to it here. So power and authority very, very much part of, how do you incorporate this? Is this a challenge to medical authority? I don't have much of a response to the Zen therapy, but I should think more about it. But I like the notion that in the West, there is a kind of a acute care model that is focused on defeating, subduing a health problem and pain doesn't comply, especially chronic pain. And as a result produces the kind of frustrations that you find both in clinical settings, but also in political settings. So much so that when people in pain become more and more, and of course people in pain are becoming more and more prevalent because aging and increasing longevity. And like I've been sitting here for a long time, we have a sedentary society that produces more back pain. So it's kind of a natural outgrowth. And yet you have a frustration when those people are disabled and you want to kind of fix it, rather than as you say, kind of adjust. And maybe that's the underlying story in this story. How much should society adjust and accommodate? And how much should we just demand that this gets fixed? Great comments, thanks. Thank you. Steve server, Steve, please. I'm a javad. I wanted to make a comment, if I may. Yes, fine. Yes, first of all, I first of all say this is one of the best talk I ever heard on the subject of the pain. And I wanted to tell you about observations some 40 years ago, my mentor developed a stereotactic cordonomy. Malin and I and him saw thousands of a patient with pain and did 700 cordonomy. I came with the impression that the more you're trying to understand pain, you understand it less. It's such a complicated issues that once you wanted to say you are expert, you miss it. If you go too far toward the objective one, you miss the emotional part. If you go too far to emotional part, you go to the other. But the other thing that I wanna tell you recently, I wrote an article about chronic pain. And one of my issues that I wanted to argue about that I never believed that there was anything called psychogenic pain, that there is no evolutionary issue in creating pain. We cannot create sight. We cannot hear noise and less hallucination. And so evolutionary, there is no reason that it would be psychogenic. Of course, you could have pain of cancer and you'd be more concerned about it that you have top pain and this one. But several places didn't accept it because they did, yes, according to Dr. Sarno's that there are a lot of people who have psychogenic TMJ and that has become a major issue for some psychologists to help. I wanted to know what is your opinion about presence or absence of psychogenic pain? That's a great question. I tend to agree with you, although as a historian, I tend not to weigh in directly on the relative value of these concepts or not, but I have followed the history of this theory of psychogenic pain. In fact, it shows up very prominently in the very first case of Rosie Page. And the question for many is whether psychogenic pain is legitimate pain warranting compensation or not. I don't have much more to say, but your observations on cardotomy are fascinating because one of the themes in the book, which I skipped past in this talk is at the same time you have people like Henry Albronda saying pain is illegitimate and you have the sort of drug world, the percadine as a solution, you also have the world of neurosurgery. And chordotomy, but also it's a fascinating moment in the history of pain and neurosurgery where lobotomy for end-of-life cancer pain was quite, if not the norm, then more widely practiced. And the fascinating feature of it is the way the surgeons do talk about the fact that this is alternative to morphine, but it is also, they will come out and say, actually patients still complain about pain, but they just don't worry about it. Well, they don't complain, they tell you they have pain, but it's as if you've removed the worry center of the brain. So it's a kind of fascinating moment in which surgery also has something to say and it's almost as if what they're saying is, well, if the concern is the pain complainant, we know how to fix that. We don't know so how to fix pain, but if people stop complaining about it, you've fixed the problem that you've identified. Anyway, great questions. I'm not able to answer the one on psychogenic pain, but I certainly will think about it. Dr. Heckman, by the way, is a neurosurgeon. But you know, this issue of whether it is ethnic or it has anything to do with race, I seldom see it among physician. Physician don't differentiate those that I have experienced between what races, what other. It seems to be mostly among the politician who trying to fix something. Thank you, Heckman, Shavad, Steve, please. Thanks, Dr. Siegler, and thanks to you, Dr. Weber for a really stimulating talk. You talked a little bit about sort of what you see as sort of the court's role, and I guess mediating some of these macro politics of pain and sort of, you know, as courts come and go careening between these kind of liberal and conservative visions of sort of pain management and who's worthy of pain. And I'm curious, what you think about like the ways in which sort of non courts, non clinicians sort of enact some of these politics in terms of sort of the rank and file average American in the pharmacy. So that's sort of one element of my question. And the other part is, you know, thinking about the pharmacy and thinking not necessarily about opiates as prescribed, but thinking about, you know, what many sort of, again, rank and file everyday Americans think about in terms of pain management, think about NSAIDs and the role in which you think NSAIDs play in this sort of broader sort of, I guess, micro politics of pain. Yeah, so see, I could talk forever on some of this. So I'll pick maybe one, which is the rank and file and the, so, you know, because I do have at least in this project a kind of micro, macro dynamic. I really do see that the macro questions about, let's say, social policy are really reflections of smaller conversations. And those smaller conversations are the kinds of conversations that happen around issues like parenting. So many, and so when psychiatrists in the 50s are talking about the proper approach to pain, it's not hard to see that what they're saying is, is the kind of society we want, one where when someone falls down and begins to cry, we coddle them and we nurse them and we indulge them, or is the kind of society we want, the one where we say, just get up and get back to whatever you're doing and forget about your pain, you'll get over it. And for all of the sophistication about theories of pain and governance, and sometimes it reduces to like that dynamic which is either grin and bear it or people need compassion. In my book, I do kind of bring in religion in one particular way, which is that in the American society, there's kind of, there's an argument in the, in Christian tradition for both of these possessions. Either you're embracing a vision of Jesus Christ as he who suffered for others and who had extraordinary compassion to the poor and those who were suffering, who recognized pain and sought to relieve it, or you are embracing a certain tradition that says, the more you suffer, the more you are aligned with the experience of Jesus Christ, that suffering has some redemptive significance. And in the religious Christian theology, both of these are kind of part of how we think about pain. Pain as redemptive, right? Pain as transformative in a positive sense or pain as something that one should be committed to eradicating. And years ago in a medical school at Chapel Hill, I taught a course on pain and I tried to find like the equivalent writings on pain among Jewish scholars. And it's actually hard to find writings in the Jewish tradition that sees pain as redemptive at all, or that endows pain with this kind of grand sort of personal significance. Pain for the most part is, you should just try to get rid of it. There's nothing redeemingly positive, right? So it's interesting to see how a lot of the discussion that I've traced today is a kind of a refraction of a broader American kind of Christian question of how should one be in the world if one is sick and what are the responsibilities of care? And you see it manifesting as parents and really in society. Thanks so much. Thank you. Jay and Caroline, you know what I'm thinking? I'm thinking we should break for about 10 minutes.