wailoo. how do you write a political history of pain? >> guest: that's a wonderful question. so my background is as a historian of medicine and i've always been perplexed by the fact that we have such a hard time treating people in chronic pain in america. that is to say, debates about whether too much medication promotes drugging addiction how to -- drug addiction, how to measure pain is something that's not easy. but what i realized when i started to do the research on why this medicine has been controversial is how it intersects with deep and divisive issues in american society. about how you measure pain. how do you decide who's in pain and who's not. the story really becomes high hi politicized -- highly politicized way before today, it becomes politicized in the '50s when we establish b a disability provision in social security 1956 eisenhower era.

and the question before physicians is, okay, we know what a disability looks like, but is pain a disability? is chronic pain something that's not easy to measure a disability that should be compensated by the federal government? and immediately the question when physicians are asked this question, they see it as a political question about the size of government. they see it as a political question having to do with welfare. they see it as a political question having to do with liberalism, what it means to build a society that treats pain -- this immeasurable quantity quality -- as real. you see it politicized when reagan comes into office as president in early 1981. one of the first things he does is he turns to his secretary for health and human services, and he says we need to start

reducing the social security disability rolls. and the first group of people they begin to identify as illegitimate welfare claimants are people who are claiming pain as the source of their disability. so there you have the problem of how pain is political from the outset and becomes even more politicized in the context of this battle that's waged between liberals about how you build a compassionate, caring society and how government programs should be there to provide compassionate relief and conservatives who are suspicious that by creating that society you are catering to dependence you are building a welfare society that's unsustainable, that costs too much, and it turns out that the linchpin the key question at the heart of so many of the liberal and conservative battles over the last 70 years is the question of

who's in pain, are they really in pain what degree of relief do they deserve and if we create too much relief are we building a society of dependents or are we building a compassionate society? so it turns out that's how you write a story, a history of pain as a political history. it's a history that i didn't set out to write it's a he'sly that as i started -- it's a history that as i started to do the research about this topic in medicine took me into politics. and then ultimately, took me -- surprisingly -- into the law. that is to say, when there are pushed battles between liberals and conservatives over whether disability should be extended to people in pain when those people, hundreds of thousands of them are removed from the disability rolls, they sue. in this issue ends up in court.

and it's the courts that ultimately have to decide how to measure pain who's in pain and who deserves relief. and that's the story really at the core of the book. how it is that pain is at once a medical concern and at the same time an intensely debated political concern and also a legal issue that ultimately it's the judges who decide. not the doctors and not the scientists, it's the judges who decide who's in pain. >> host: how many people are currently on social security disability generally and of that what percentage are there because of pain? >> guest: well, that is, that's a very difficult question to answer for the reasons that have to do with comorbidities; that is, pain is only one feature of a variety of ailments. so pain is a feature of disability, but pain is not a necessary component of disability. so if i were to say 400,000

people another person might say, well, that's that's 400,000 that only encompasses pain as a significant feature of disability. but many other people are on disability who experience pain but they're not deemed to be disabled because of their pain. do you see what i mean? so the question is really a difficult one to answer specifically. the question of whether people are there because of illegitimate reasons is also difficult because, and this cults to the heart pain is -- this cuts to the heart pain is not something that is ultimately measured. pain is not like blood pressure it's not like temperature. i can't tell -- i can tell if you have a fever i can tell if you have low blood pressure or high blood pressure. they're vital signs that are easily detected. pain is not one of them. the degree of pain you're experiencing is highly

subjective, it's very personal. you and i may be experiencing the same pain but you may tolerate it differently than i do. and it's these questions of intersubjective understanding, trust, believability that inevitably intersect with the broader judgments about who's in pain and how much we should believe them and how much relief they deserve. so the numbers of people on disability vary across time. unquestionably, it is rising dramatically in the 1950s, since the establishment of social security disability benefits. pain does become a reason why people seek disability in the 1960s. in some ways, pain is seen as one of the, one of ways in which disability system grows in the 1960s and 1970s. it's a vexed question that you just asked. it's historically vexed and it's sill vexed today -- it's

still vexed; how many people are in pain, what degree of pain and how present are they within the disability system? >> host: how controversial in 1956 was the disability program? >> guest: it was hugely controversial. and in a way it has its own political origins. in the late '40s, '50s, harry truman proposes national health insurance. he says, you know, we shouldn't be dating whether soldiers have insurance, we should be dating whether americans have insurance. eisenhower comes into office k and eisenhower's an old soldier, and one of the key questions before him is whether the veterans benefits provisions have grown too expansive or whether they're not, pansive enough. expansive enough. the ama sees the veterans administration, they identify the v.a. as the thin end of the wedge of developing socialized

medicine. and so the ama looks at all of these questions of government medicine disability, pain as legitimate disability, and they -- physicians in general but the ama in particular -- see this as a trojan horse. the first chapter of my book is called "the trojan horse of pain." they see this as a political question. and when eisenhower is compelled really by a crafty senate leader named lyndon johnson, aided by another crafty legislator named john f. kennedy who's in the senate to consider this provision, he himself is looking at re-election. he knows this is a very powerful and -- it's an issue that much of american public supports. this is pre-medicare, of course. and he also sees the ama on

other side who sees this as the thin end of the wedge of socialism. now, one of the interesting things about eisenhower is that he wasn't, he wasn't an idealogue. and he really understood that in signing in this legislation, he was really helping to insure his re-election. it was never really in doubt, but he was in some ways boxed in by a very crafty legislator and a crafty senate leader. and it's he who reluctantly signed this legislation in 1956 establishing this disability benefit. the ama thought of this as heresy. they thought that this was a terrible decision. and physicians abhorred it not only because they abhorred socialized medicine as they called it but because they thought -- and rightly so i think -- that it put physicians in a new role of being gatekeepers to relief. it's the physician who would

have to determine what true pain was, what extent of pain meant relief, and they were the ones whose opinions on topic -- which they rightly are understood was not conducive to sign terrific analysis -- scientific analysis it's their opinions that would be constantly called upon in determining whether this patient or that patient was deserving of relief. so it really was a controversial topic from the outset. and it only continued to be so as the disability system grew from the 1950s through the '60s into the 1970. >> host: what about the affordable care act? has it affected how we look at pain? >> guest: well, that's another fascinating story. buried deep deep in the affordable care act is a provision on pain relief which has its own history which i

touch on in the conclusion of the book. and the way i would tell the story of this is that in -- after many, many years of controversy not only about disability benefits the growth of the welfare society, but debates about pain relief at the end of life that pushed oregon to establish death with dignity legislation and new debates emerging around fetal pain. so you might say pain becomes part of the cultural battles between left and right over whose pain matters and whose pain deserves relief in the 1990s. after a long time of these kinds of politicized discussions, in the early 2000s there are politicians on the left and right -- orrin hatch on the right, others on the left -- who say, you know, one of the hinges that is not being -- one of the

things that is not being addressed is proper end-of-life care that's not politicized. and so in the course of the period leading up to obama's election, there is actually an attempt to write what you might call bipartisan legislation dealing with the fact that we don't do a good job of taking care of people at the end of life in pain. that so much of pain medicine has been politicized both at the bedside and broadly in politics that we're not doing a good enough job. and in the early years of the affordable care act, in the crafting of the legislation, there's a desire to enfold this pain relief provision into the affordable care act. and in the early years in early stages of the affordable care act, there was a lot of funds set aside for public education, a lot of funds set aside for physicians' education on these issues that physicians themselves aren't adequately

educated on. and in the course of crafting the aca -- because, of course the extent of the new legislation was the source of much debate -- many of the, many of the appropriations set aside for this or were stripped out. and what was left in the affordable care act is a call to the institute of medicine, iom, to do a study. as if we needed another study to look close arely at why we don't -- closely at why we don't deliver pain medicine in the way we ought to, pain relief in the way we ought to in this country. so the aca the affordable care act has a pain provision but it's a weak example of what can what congress can do to address this issue in terms of physician education, in terms of public education about the pros and cons of aggressive pain relief. and in some ways i think we're back to where we were previous

to the aca which is their interests now in returning to this question of how we adequately deal with this issue that's a source of enormous contentious debate both in politics, in disability, in law and in government. >> host: professor wailoo, how much pain medication is out there? >> guest: the rate of rise of prescriptions and use of oxycontin is skyrocketing. it's hard to actually say how much quantifiably but if you look at a graph -- which i have in this book -- of the rise of pain relief drugs in the 1990s through 2000s, it really outstrips all other class of drugs. and oxycontin, which is the topic of my last chapter called oxycontin unleashed, is, you might say, an example of where

we are today in the pain debate. to put it really in a nutshell i would say that there are those in american society who are undermedicated undertreated because of the anxieties about drugs like oxycontin, and there are those who are overmedicated. we have a society today where you have two faces of the pain problem; people in urban america without access to pain relief drugs because their pharmacies don't carry them because of concerns about drug diversion and too liberal access to main medicationment so in some ways -- medication. so in some ways one of the problems we have in the management of pain in american society is that we tend to go from one extreme to the other. either we think the problem in american society is too little

relief too little medication, not paying attention to people in pain as in not treating people with end-will have of life --of-life pain adequately, or those who feel there's too much oxycontin there's too much relief there's too much liberal access to medicines. and we go back and forth in our society without -- and we kind of just go from one extreme to the next. and one of the main challenges going forward is how we figure out a way to deal with drug diversion and oxycontin as the major problem in pain medicine abuse today while not subjecting people who really need ox to city con tin because of -- oxycontin because of chronic arthritis and other infirmities access to the medicines they need. and that's not a challenge we have really grappled with at one time. what we've done is we've tended to look at one problem or other problem without looking at both together.

and that's going to be a real challenge in terms of public policy and in terms of really adequately dealing with people who need relief. >> host: is there any estimate on how much pain fraud costs? >> guest: it's very difficult for me to tackle a question like that because the issue has been so highly politicized over the course of the last 80 years. there are no good estimates. so even in the era of the passage of the 1956 disability act, this is a question that physicians said they tackled. physicians would say, you know, the real problem with establishing a disability benefit is that it will promote you're monetizing relief -- pain, and you're promising some form of monetary compensation for pain. be regardless of whether -- and

regardless of whether we believe that pain is minor chronic, severe or truly debilitating, we are creating a monetary compensationing system. and there's -- compensation system. and there's some physicians who would say even if pain is real, it's in some ways fraudulent to provide relief, because it caters to people. i mean there's a kind of heavy moralistic overlay to anxieties about pain. so your question, how much pain fraud is there well imagine how -- can how would one decide to argue to answer that question? how really can you answer that question in a context where, i mean certainly there's pain fraud, right? there's certainly people who claim to be in pain when they're not in order to collect disability benefits. the question is, where does minor pain fall? where does sporadic pain fall? where does chronic pain that's at a low level fall on one's

estimate of what constitutes fraud? and where does pain that is tolerable for me but intolerable for me fall on our measure of fraud? i mean, these are the kinds of tricky cultural, social, ethical, moral and political questions that physicians and disability judges have had to answer since the establishment of this system. and i am reluctant to give you an answer because i know that the answer is filtered through the lens of politics, cultural bias and you might -- and also economic concerns. a lot of the concerns about this question about how much fraud there is, isn't a question about truly measuring fraud, it's a question about the cost of our disability system. as it grew, the argument for fraud grew as well. it's hard to argue that, you

know, in a society where were aging, we are living longer, we're dealing with chronic debilitating diseases, the rise of caron ec pain is a -- chronic pain is a by-product of an epidemiological and demographic transformation in developed countries. so to say that pain fraud has grown is a blurring, it's a question that's hard to answer in the context of an aging society. we're very proud of the fact that we have people who live into their 80s and 90s. we're not surprised that people who live into their 80s and 90s experience more pain. arthritis grew chronic arthritis grew as a new phenomenon in the wake of an aging society. to start the to have ask -- to start to ask the question how much arthritic pain is fraudulent and how much of it is true pain is to ask a highly

political question that is about really the cost of care and not necessarily about, you know whether we can truly evaluate when arthritis rheumatoid arthritis is a true problem, how painful it is and whether disability benefits are required for the relief of such people. >> host: professor wailoo, whats' your job here at princeton? >> guest: at princeton i have several jobs. i'm a faculty member in history where i teach on drugs race and drug policy. i teach on the history of medicine. i teach about these fraught discussions between science technology and medical innovation and their social and cultural and political implications. i teach about those issues historically, through the 19th century, through the rise of fda and until today so that the

debate about how we should regulate oxycontin is part of what i teach as history. i also teach in the woodrow wilson school of public and international affairs, and there i teach on a wide range of public policy questions. you might say looking from the present back into recent history. i teach about the role of the courts in health care reform s so that's something that we're living with literally right now. but it's also part of the history of how courts have modified legislation, maybe extending it or sometimes reduce canning its scope in service of broader kinds of concerns. so i teach about the role of the courts and the role of legislatures and the role of executives in shaping health care policy. i've brought together -- so those are the kinds of things that i do here both in for public policy education but also history. >> host: how'd you get here?

>> guest: how'd i get here to princeton? i moved here from princeton about five or six years ago -- >> host: from where? >> guest: well, i was at rutgers. >> host: rutgers. >> guest: and before that i taught at the university of north carolina at chapel hill. at chapel hill i've always, you know, my background as a scholar is in the history and sociology of science. so it's inherently multidisciplinary. it's a field which is historically grounded. it says that you have to be able to see contemporary issues from a long perspective, put them in perspective. my first job was in a medical school as well as the history department at chapel hill. so teaching professionals how to think about health care and health care reform. when i landed in chapel hill bill clinton was just elected president, and we were thrown into a discussion about the role of government in health care reform. when the health care reform died in the clinton administration

the next concern students had was the role of the private sector hmos in tying the hands of clinical clinicians from making medical decision making. so i've worked at the intersection, you might say, of history and policy for a long time. at rutgers i worked in an institute for health care policy and history, and here i straddle once again history and public affairs. so i came here about three, about four -- five or six years ago really recruited to do what i do. and i also play a role in the history of science program as well. so i like to think that i do finish i in about three different places here at princeton. ..