Several years ago, Mark Kleiman wrote a long, well-researched article on drug policy which was so overflowing with being sensible that it has no chance of being paid any attention to in legislative circles. Most of the article was focused on street drugs, but here’s what he wrote about pain medication:
Get drug enforcement out of the way of pain relief. Physicians and their regulators are naturally concerned about the risk of iatrogenic (treatment-induced) drug dependency. Consequently, they have tended to be sparing in their use of opiate and opioid pain relievers, even when the pain involved is extreme and the patient’s short life expectancy, as in the case of terminal cancer patients, makes addiction a largely notional problem. Better professional education has made more recent cohorts of physicians less afraid of over-prescribing painkillers than their older colleagues, but the upsurge of prescription-analgesic abuse (especially of hydrocodone [Vicodin] and oxycodone [Percodan, Oxycontin]) has generated a backlash.
Tight controls and cautious prescribing can reduce medical misuse and recreational use of prescribed drugs and the diversion of pharmaceuticals into illicit markets. A crackdown on Internet pharmacies offering on-line “prescriptions” is fully justified. But the tighter the regulation, the greater the cost and inconvenience imposed on manufacturers, physicians, pharmacists and patients. Cost and inconvenience will not only annoy those groups, it will also increase the amount of untreated pain.
Current policies are scaring physicians away from treating pain aggressively. Many doctors and medical groups now simply refuse to write prescriptions for any substance in Schedule II, the most tightly regulated group of prescription drugs, including the most potent opiate and opioid pain-relievers and the potent amphetamine stimulants. The opiate-and-stimulant combination the textbooks recommend for treating chronic pain is almost never given in practice for fear (a fear well in excess of the actual risk) of disciplinary action and criminal investigation for a physician prescribing “uppers and downers” together. It’s time to loosen up.
In Reason Magazine, Jacob Sullum describes one patient preparing to commit suicide because he couldn’t get treatment:
Hurwitz may not be the only physician in the country who is willing to prescribe narcotics for chronic pain, but there are few enough that patients travel hundreds of miles to see them. “I call it the Painful Underground Railroad,” says Dr. Harvey L. Rose, a Carmichael, California, family practitioner who, like Hurwitz, once battled state regulators who accused him of excessive prescribing. “These are people who are hurting, who have to go out of state in order to find a doctor. We still get calls from all over the country: ‘My doctor won’t give me any pain medicine.’ Or, ‘My doctor died, and the new doctor won’t touch me.’ These people are desperate.”
So desperate that, like Covillion, many contemplate or attempt suicide. In an unpublished paper, Rose tells the stories of several such patients. A 28-year-old man who underwent lumbar disk surgery after an accident at work was left with persistent pain in one leg. His doctor refused to prescribe a strong painkiller, giving him an antidepressant instead. After seeking relief from alcohol and street drugs, the man hanged himself in his garage. A 37-year-old woman who suffered from severe migraines and muscle pain unsuccessfully sought Percocet, the only drug that seemed to work, from several physicians. At one point the pain was so bad that she put a gun to her head and pulled the trigger, unaware that her husband had recently removed the bullets. A 78- year-old woman with degenerative cervical disk disease suffered from chronic back pain after undergoing surgery. A series of physicians gave her small amounts of narcotics, but not enough to relieve her pain. She tried to kill herself four times–slashing her wrists, taking overdoses of Valium and heart medication, and getting into a bathtub with an electric mixer–before she became one of Rose’s patients and started getting sufficient doses of painkiller.
Patients who cannot manage suicide on their own often turn to others for help. “We frequently see patients referred to our Pain Clinic who have considered suicide as an option, or who request physician-assisted suicide because of uncontrolled pain,” writes Dr. Kathleen M. Foley, chief of the pain service at Memorial Sloan-Kettering Cancer Center, in the Journal of Pain and Symptom Management. But as she recently told The New York Times Magazine, “those asking for assisted suicide almost always change their mind once we have their pain under control.”
One thing that supporters and opponents of assisted suicide seem to agree on is the need for better pain management. Concern about pain was an important motivation for two 1996 decisions by federal appeals courts that overturned laws against assisted suicide in New York and Washington. In the New York case, the U.S. Court of Appeals for the Second Circuit asked, “What business is it of the state to require the continuation of agony when the result is imminent and inevitable?” With the U.S. Supreme Court scheduled to hear a combined appeal of those decisions during its current term, the persistent problem of inadequate pain treatment is sure to be cited once again.
In medical journals and textbooks, the cause of this misery has a name: opiophobia. Doctors are leery of the drugs derived from opium and the synthetics that resemble them, substances like morphine and codeine, hydromorphone (Dilaudid) and meperidine (Demerol). They are leery despite the fact that, compared to other pharmaceuticals, opioids are remarkably safe: The most serious side effect of long-term use is usually constipation, whereas over-the-counter analgesics can cause stomach, kidney, and liver damage. They are leery because opioids have a double identity: They can be used to get relief or to get high, to ease physical pain or to soothe emotional distress.
Doctors are afraid of the drugs themselves, of their potency and addictiveness. And they are afraid of what might happen if they prescribe opioids to the wrong people, for the wrong reasons, or in the wrong quantities. Attracting the attention of state regulators or the Drug Enforcement Administration could mean anything from inconvenience and embarrassment to loss of their licenses and livelihoods. In the legal and cultural climate created by the eight-decade war on drugs, these two fears reinforce each other: Beliefs about the hazards of narcotics justify efforts to prevent diversion of opioids, while those efforts help sustain the beliefs. The result is untold suffering. Dr. Sidney Schnoll, a pain and addiction specialist who chairs the Division of Substance Abuse Medicine at the Medical College of Virginia, observes: “We will go to great lengths to stop addiction–which, though certainly a problem, is dwarfed by the number of people who do not get adequate pain relief. So we will cause countless people to suffer in an effort to stop a few cases of addiction. I find that appalling.”
One of the most interesting findings from the happiness research literature is that human beings are remarkably good at adapting to all kinds of misfortunes. Chronic pain, however, is an exception. People either get effective treatment for their pain, or else they’re miserable. Adaptation is fairly minimum. The upshot is that from a real human welfare perspective, we ought to put a lot of weight on making sure that people with chronic pain get the best treatment possible. Minimizing addiction is a fine public policy goal, but the priority should be on making sure that people with legitimate needs can get medicine.
Unfortunately, this seems to be one of those issues that’s untouchable in Congress; it’s not a partisan issue, because majorities of both parties consist of drug war moralists who prefer to keep Americans in pain. Both parties think the DEA is better qualified than your doctor to decide how your pain need to be treated; both parties would rather have Americans in treatable but not treated agony than risk some addict somewhere getting high (which that addict probably will anyway). The brainless cruelty of our political system is one of the things that makes me rip my hair out.
Further reading: The vindictive grand jury investigation of pain-relief advocate Siobhan Reynolds, and Another Pain Doctor Raided, both by Radley Balko. And the archives of the now-defunct (because of government harassment) Pain Relief Network.
(P.S. I went back and forth about the image. But I finally decided that it means “we’re inflicting needless agony on ourselves.” And if you take “ourselves” to mean Americans, collectively, then it’s true.)
(P.P.S. One person in Congress who has decent views on pain management: Ron Paul. So there is something good about him.)