The Devil Effect and Patients with Pain

This article, in a slightly edited form, first appeared on Pain News Network on October 24, 2019.

Treating pain has often triggered controversy, and society’s response to chronic pain management has shifted over the years.

During the Civil War, a soldier who was in agony was often given “enough chloroform to render him insensible to pain.” Afterwards, patients may not have recalled the pain they felt, even if they remembered having surgery. But we, as a society, were concerned enough for our soldiers to ease their suffering with the most effective medication we had available.

At other periods in our history, society has seemed to worry more about the risks of treating pain than the debilitating (and sometimes lethal) effects of the pain itself. At times, we have even questioned whether pain was real, or whether people were just inventing symptoms to receive attention or drugs.

People with pain have often been stigmatized. They have been expected to just tough it out, and those who couldn’t were accused of being weak.

The Pendulum Swings Toward Empathy for Patients With Pain

In the 1990s, professionals throughout the country understood the need to help people with severe chronic pain. Most people dying of cancer experienced excruciating pain, despite the fact that doctors had the means to help them.

Opioids could ease their suffering. There was a consensus in the medical profession that prescribing opioids for cancer-related pain was the right thing to do. Then doctors began prescribing opioids for non-cancer pain, such as arthritis. The number of prescriptions increased.

Treating pain with opioids became acceptable—even expected—when the alternative was to let people continue to suffer. It seemed reasonable at the time. There was little evidence then that opioids would cause serious harm if people used the pain medication as directed.

We always acknowledged that a subset of the patient population was at risk for abuse or addiction. Pain doctors like me did the best we could for patients with the research that was available to us at the time. Perhaps, in some cases, we would do things differently now.

Casting Blame for the Opioid Crisis

Ultimately, overprescribing was one of the contributors to America’s drug crisis. Looking back, it is easy to cast blame. We now have better information about the risks of using opioids than we did, but the efforts to control pain and mitigate suffering were laudable. We had few effective tools to manage pain at the time, and prescribing opioids seemed like a valid alternative to letting patients suffer unnecessarily.

However, with more opioids’ being prescribed, there was a corresponding increase in all drug overdoses. That set off alarms. We know now that the causes of drug overdoses were myriad and complicated, and there wasn’t a simple correlation between rising opioid prescriptions and increased overdose-related deaths.

But societal attitudes began to shift again in the first decade of the 21st century. Families who had lost loved ones to overdoses were looking for someone to blame. There were public and private demands to hold someone accountable for the deaths. The initial target of their anger was the pharmaceutical industry.

This wasn’t anything new. The American public has expressed greater hostility toward Pharma than they have directed at any other industry. A 2019 Gallop poll reported that the public felt more distrust of Pharma than they did of the federal government!

The news media covered the tragedies of teenagers and young adults who were dying from overdoses. Often, those deaths involved opioids. The media also covered stories of families torn apart by addiction. Then the media’s narrative shifted to allegations of deceit, greed, and cover-ups by the pharmaceutical industry.

At first, they focused on Purdue Pharma. The company was making billions of dollars from OxyContin, and they were accused of irresponsibly promoting its use. The government filed a lawsuit against Purdue Pharma and this week announced a $8.3 billion settlement with the company. 

I recall the primary initial complaints about OxyContin were unrelated to the increased number of opioid related overdoses. Instead, Workers Compensation groups were complaining about the skyrocketing cost of the drug. In the late 1990’s, I recall hearing the medical director of Utah’s workers’ compensation program speak to the local pain society. He was angrily insisting that the cost of OxyContin was exploding and must be stopped.

A new Opium War had begun. This time, it was not between the Chinese and British. Instead, it involved U.S. health insurance payers and opioid manufacturers.

Chasing a Pot of Gold

The need to blame someone for the overdoses and make them pay for the harm opioids caused accelerated. Opioid manufacturers and physicians were in the crosshairs of regulatory bodies and the U.S. Department of Justice. Opioid distributors and patient advocacy groups were also accused of contributing to the drug crisis. It was alleged that distributors knowingly and irresponsibly supplied communities with large amounts of pills that far exceeded the amount needed for medical purposes. Advocacy groups were accused of being front organizations for opioid manufacturers, because they allegedly promoted opioids for the treatment of pain. Whether or not distributors were irresponsible depends on one’s perspective, but the latter accusation was certainly baseless and malicious.

Of course, the bandwagon of accusers grew as the potential pot of gold increased. Plaintiff lawsuits filed by government agencies could result in a golden egg if they could convince a sympathetic jury or judge that they had been wronged. The sympathies of the public turned more and more against the drugs used in pain treatment.

Cognitive Bias Harms Us All

Greed and the harm it causes is a well-known story. However, what is not as well appreciated is how this saga in our history causes a cognitive bias called the devil effect, in which one bad quality creates the impression that there must be only negative qualities associated with the person or entity.

The belief that Big Pharma is inherently bad makes it difficult to appreciate the good things (such as vaccines and cures for diseases) that come from Pharma and separate them from the bad things (such as the negative consequences of some drugs and apparent greed). When doctors consult with or accept any funding from Pharma, particularly the companies that make opioids, it is commonly referred to as “being in bed with the devil.”

Society’s current perception that Big Pharma is evil helps explain why people in pain are struggling today. The truth is, Big Pharma is not intrinsically bad (although there are some bad actors within the industry), and drugs used to manage pain are essential partners in healing when used appropriately. Our tendency toward “black or white” blanket perceptions—and our choice to not learn about the complexities which would allow us to take a more balanced approach in our reasoning—has consequences for every aspect of society. Regarding the issue of pain management, the devil effect has yielded the terrible unintended cost of suffering by innocent people.

The pendulum eventually may swing back toward more empathy for people who are suffering—but not until more people recognize the influence of the devil effect on society’s attitudes towards Pharma, opioids, and people in pain.


Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, The Painful Truth,” and co-producer of the documentary,It Hurts Until You Die.” Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.

You can find him on Twitter: @LynnRWebsterMD.



  1. mary wille on October 25, 2020 at 12:06 am

    ”group think,” is another contributor to this torture upon the medically ill in physical pain from their medical condition…What also truly saddens me is our deaths’; of course,but also thee non-ability for society as a whole to evolve..As u mentioned during the civil war,,1000’s of truly physically ill soldiers truly in physical pain from their war injuries’ were labelled addicts,,just as we are now..Here comes’ the field of psychiatry opening up Pennhurstr,Waverly’s ,warehouses all over the country ,deeming these truly injured soldiers addicts,,WRONGLY of course,,we learn now,1,000 were inflicted with lead poisonings from bullets left in their bodies,,but once again psychiatry saw a way to make $$$$$and the prejudice of addiction was derived,.ie your ,”devil,”,,KOLODNY has used the same blueprints’ fast forward to 2020,,and making millions MANUFACTURING ADDICTION,,, yet again,doctors,society does NOT evolve,,to recognize that the medically ill in physical pain from their medical condition are thee true,honest definition of thee appropriate use of opiates medicines..Why,,why can’t society evolve past thee addiction prejudice card???With soo many getting willfully medically tortured,why can’t they see the truth and evolve to a humane society where the medically ill in physical pain is the definition of appropriate medical use of opiates medicines??

  2. roxan on November 4, 2020 at 2:29 am

    Have to consider–what sort of society has the ability to treat pain but instead puts patients and doctors in jail?

  3. Gina on November 4, 2020 at 7:05 am

    I will miss your blogs, but if anyone deserves a break, it’s certainly you. Sometimes we all have to step back and assess what the next steps should be. God bless you for all of your efforts and in educating all of us along the way, too. Education is always the key. Hopefully we’ll all lift up the banner and continue to share your blogs and keep trying to educate the public. Thank you, Doctor Webster.

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