The Agitator is essential reading, one of the best political blogs anywhere. Still, Radley Balko sometimes uncritically parrots libertarian tropes. Government Evil! Liberals Stupid!
For instance, today he posted this libertarian boilerplate:
Alternet publishes article calling for government monitoring of doctors and their pain patients, a crackdown on prescription painkillers, and generally expanding the drug war, all because . . . corporations are evil. And Florida’s governor loves the Tea Party. Or something.
So I followed the link, and the reason the Alternet writer, Kevin Gray, gave ad nauseum for wanting stronger government regulations of pain pills is to prevent accidental deaths. Not because corporations are evil (corporate power is mentioned once). Not because Florida’s governor loves the tea party (again, one mention). This is an article that is clearly and overwhelmingly about deaths caused by prescription drugs. Here, for example, is Gray’s first paragraph:
For the first time in nearly a century, automobile accidents are no longer the nation’s leading cause of accidental deaths, according to a major report released Tuesday by the National Center for Health Statistics. The new number one killer is drugs—not smack, crystal meth or any other stepped-on menace sold in urban alleyways or trailer parks, but bright, shiny pills prescribed by doctors, approved by the government, manufactured by pharmaceutical companies and sold to the consumer as “medicine.” Yet of the billions of legit pills Americans pop every year for medical conditions serious and otherwise, the vast majority of lives are claimed by only a select few classes—painkillers, sedatives and stimulants—that all share a common characteristic: they promote abuse, dependence and addiction.
Gray goes on that for paragraph after trite, overwritten paragraph (“pill mills and doctor shoppers are not just creating a land of bathroom-cabinet addicts—their bodies are packing morgues.”) Balko is either the least competent reader of English in the world, or he just flatly lied to his readers about what Gray’s article was about.
That said, I hated Gray’s article. For one thing, the factoid that he builds his article around — his claim that “The new number one killer is… pills prescribed by doctors” — is wrong. According to the CDC data brief Gray cites (pdf link), in 2008 there were over 41,000 deaths by poisoning, compared to 38,000 auto accident deaths. But “deaths by poisoning,” although mostly pill-related, includes some other deaths; the CDC says that in 2008 there were about 36,500 pill-related deaths, about 1,500 fewer than auto-related deaths.
That’s not a big deal – given the trendlines, pill deaths will soon overtake auto deaths, if they haven’t done so already – but it’s still annoying that Gray couldn’t be bothered to correctly understand the leading statistic in his article, which he wrongly hypes again and again.
What does bother me most about Gray’s article is that he never acknowledges that untreated pain is a serious problem in the United States and worldwide, even while he endorses policies that could make matters worse. For instance, the Florida “pill mill” law:
…mandates the creation of a statewide prescription drug monitoring program (PDMP), delineates narrow conditions to establish a pain management clinic, limits the amount of controlled substances physicians can prescribe, imposes harsh penalties on physicians who violate the law ($10,000 minimum fines, six-month suspensions) and restricts advertisement of pain treatment centers, among other measures.
Gray’s article favors this law, and certainly saving lives is important. But the life-saving aspects of restrictive laws (if they really save lives — I’d like to see some research on that) should be balanced against the loss of freedom involved when the government decides for me how much medicine my doctor can prescribe me; and it should be balanced against the truly incredible suffering caused when people can’t get pain medication they genuinely need.
But you’d never know that reading Gray’s article. Is he even aware that there are millions of people with chronic pain? Does he consider providing them with relief worth even a moment’s consideration? I assume so, but he doesn’t allow any such compassion to come through in his article. And that’s unfortunately typical of how this issue is discussed.
***
Couple of side notes:
First, I should acknowledge that libertarian writers are a zillion times better than progressive writers when it comes to pain management. If I could put our country’s pain management restrictions under either liberal or libertarian management, I’d opt for the libertarian in a heartbeat.
Of course, the same libertarian whose heart is broken if Lucy is suffering because badly-written laws keep Lucy’s chronic pain untreated, might not care if Lucy’s pain is untreated because Lucy is poor. So although I’d put a libertarian in charge of the restrictions, I’d put a liberal in charge of guaranteeing access.
Second, I’d really like to see those pain-pill-related deaths broken down by cause. Specifically, I want to know what percentage of pain-pill-related deaths are related to liver failure caused by acetaminophen in prescription opiates. Acetaminophen — which is not hard to accidentally take deadly amounts of, and is available without a prescription as Tylenol — should be banned from prescription opiates altogether. No one’s freedom is substantively reduced if they have to take a Tylenol with their prescription pain med rather than having the acetaminophen built-in, and it’s much safer for consumers to be aware of how much Tylenol they’re taking.
Third point: Off-topic, but I was amused by this paragraph of Gray’s article:
“This is just the tip of the iceberg of the prescription drug abuse problem,” says Dr. Margaret Warner, the federal report’s lead author. “The take-home here is, this should be a wake-up call.”
Dr. Warner reportedly went on to say, “if we keep our nose to the grindstone and take the bull by the horns, then when the dust settles there’ll be a light at the end of the tunnel.”
I don’t think a lot of people who aren’t in chronic pain really understand the severity of it, or the hoops people have to jump through to get their meds. As an example of that, one of my Facebook friends posted some doctor’s Craigslist rant about pill-seekers, and was going on about healthier methods of managing pain, like “exercise and physical therapy.” One of the comments said, “Pills are not the answer, except for palliative end-of-life care.” Really? Physical therapy is great for addressing injury damage and strengthening muscles, but I’m pretty sure it doesn’t magically fix nerve damage. Or fibromyalgia. Or cluster headaches. Or cancer.
Also, in addition to treating all poisoning deaths as pill deaths, the statistic doesn’t distinguish addiction-related deaths from accidental overdose. If a five-year-old dies from swallowing a bottle of pain medication, that’s a tragedy, but it shouldn’t be counted toward an argument about “pill mills” and “doctor shopping.”
Keith Wailoo has written about this problem specifically with regard to people with sickle cell disease, who started being slandered as addicts and potential addicts in (I believe) the 80s or 90s. People with sickle cell disease can experience pain crises that can be disabling, but the awareness shifted to paternalistic discussion among experts (and op-ed busybodies) of how much medication certain patients should be allowed to have, if any, how to sniff out “drug-seeking behavior,” and generally how to avoid the possibility of addiction as if that were really the most pressing problem faced by someone with a disease that causes severe pain.
Addiction and overdose are real health threats, but so is the severe chronic pain some people live with, which the writers posturing like this have obviously never experienced. Disregarding the autonomy and well-being of people who need those medications is ableist for sure. In the treatment of some health problems, it is racist as well.
Thank something that the black market exists, huh? Sure, you don’t know for sure what you’re getting, but you can get something. It’s comforting to know it’s there as a last resort.
some doctor’s Craigslist rant about pill-seekers, and was going on about healthier methods of managing pain, like “exercise and physical therapy.”
Doctors aren’t any better at their job than other groups are at their jobs. You know how there are loads of incompetent auto mechanics, plummers, programmers and managers? The same ratio applies to the medical field. The difference is in the impact doctors can have on your life.
For 15 years after a drunk driver wrecked my back and my car running a red light, I didn’t take any pain medications, because I worried about addiction.
Then a very wise friend pointed out that addiction is only a problem when you a) can’t get the addicted thing, and b) don’t need it for some other reason.
For instance, she pointed out, you’re addicted to air and water too, which is only an issue if you can’t get one or both, because you will always need it for another reason (e.g., sustaining life). So I started taking the pills my doctor prescribed for me: largely oxycontin, but also muscle relaxants and anti-inflammatories (I have advanced degenerative disc disease – 10 vertebrae so far are disintegrating, I’ve gotten an inch shorter so far).
Because I live in Canada, which has (relative to the US) a hugely liberal prescribing milieu, I have no problems with access: after a few months, even new pharmacists become pretty easygoing about the amounts I use. My doctor writes me two three-month prescriptions at a time, one post-dated to the end of the other.
In the ten years that I’ve been taking the meds, I’ve had only two dosage increases – by 10mg each time.
The effect on my life? Quite simply, the difference between disability payments and working for a living. If I didn’t have the meds, I’d be on disability. I’d rarely leave the apartment, would probably be in a wheelchair by now (I use a cane), and certainly would not be earning any money. The pain is bad enough that I’m rendered nauseous, and have to use appetite stimulants to be able to eat, and that’s with the pills.
I’m also still, at 45, able to lumber around a soccer field once a week with a bunch of other over-40 women, which means I stay fitter, which means I stay healthier.
So, with no pills, I’m on disability, a shut-in, gradually growing weaker and more of a burden on the state. I would not only pay very little taxes, but I’d be entirely reliant on public support to live.
With the pills, I run a small business, work a part-time day job, “play soccer” (this is exaggerating the level of intensity), and have a social life. I pay taxes of all sorts, and contribute to the productivity of society.
There’s no comparison. Those who focus on the potential for addiction are costing their nations hundreds of millions of $CURRENCY, I’m quite certain, in people whose pain goes under- or untreated, and whose productivity changes from making a contribution to society to requiring society’s aid to keep living. It’s stupid, short-sighted and damaging public policy, grown from the idiotic War on Drugs.
“If we just hit that bullseye, the rest of the dominos will fall like a house of cards … checkmate.”
@CaitieCat (#4):
I agree with
addiction is only a problem when you a) can’t get the addicted thing, and b) don’t need it for some other reason.
However I would add that a problem is also when the addiction itself impacts your life negatively – i.e. if you spend all your money on the desired thing, if you neglect other things or even people, and so on.
Also, would you say that “some other reason” can be having fun/feeling pleasure? And where would one draw a line there? After all the relief one feels when satisfying an addiction need is also a kind of pleasure, isn’t it? (I am not being polemic, I really want to know.)
Another, more general question regarding the article – aren’t suicides by legal drugs also considered overdoses? I think everybody should have the right to take their own life in a relatively painless way, and lumping these deaths together with accidental overdoses only serves to skew the numbers more.
To be fair to Dr. Rantypants, the “pain meds are evil and PT magically fixes pain” comments came from a couple Facebook comments *about* his Craigslist rant, not the post itself. One commenter works in a pharmacy, I think, and the other I have no idea.
Though you’re right that there are really incompetent doctors out there.
The post is here: http://www.craigslist.org/about/best/sfo/301345524.html He does at least say that he’d rather “give that [a vicodin script] to ten [addicts] than make one person in real pain (unrelated to withdrawal) suffer” which I think is the right attitude. If you have to err on one side or the other, err on the side of helping people who are hurting.
Of course the counterargument to that is that some of the people getting lax pain pill rxes in the name of helping those who hurt, will themselves be hurt. I have an acquaintance who became addicted to benzodiazepine. Her life went from hard but promising to total train wreck. Would she have been better off if the doc who yielded to her initial, slightly-but-not-really justified initial request had said “try aspirin for a couple weeks first”? Yep, big time.
It’s a hard balance to strike. Some of the puritanism is undoubtedly coming from a “pleasurable drugs are bad” moralism, but some is rooted in concern for bulnerable
Robert, that’s a valid point. I think personal decision-making and informed consent play a big role, though. Was the doctor up front with her about the risks of addiction and other less addictive options, and what the potential trade-offs of those are?
I think there might be a very different decision-making process between “this person has been on pain meds forever and is probably addicted to them and lying to get more” and “this person has never been on pain meds, let’s take the risk of addiction into account.” That is, the difference between deciding whether to take someone at their word or not, versus avoiding a future risk.
I’d pay a lot to see a doctor who said that. IME, it’s never that. It’s either a pain clinic willing to prescribe narcotics or, “You just need to learn how to live with the pain.” Your hypothetical quote is a fantastic dream about a seemingly non-existent middle ground.
I’ve been to dentists and doctors both about pains real and psychosomatic, and on a number of occasions have heard “if the aspirin or tylenol don’t get it done, call back and we’ll see if you need something more”. I don’t doubt that there are heartless villains and free-love pain clinics, but I do doubt that those two extremes are all that exist, in the face of my personal experience with many providers in the middle.
Kelly, I meant to finish that post with something along the lines of “what we need are telepathic doctors”. Perils of the Kindle Fire interface in the (thick, clumsy) hands of a noob.
Then a very wise friend pointed out that addiction is only a problem when you a) can’t get the addicted thing, and b) don’t need it for some other reason.
Or, you know, c), when the addicting thing has all kinds of other horrible effects on you, but you can’t stop taking it because you’re addicted.
I assume pretty much everyone hear shares the view that it’s inhumane to deny people genuinely-needed pain medication out of “well, some people get addicted” or “you have to suffer for a while first to prove you really need it”. But it’s not a simple matter of medications that have only two effects, pain relief and addiction. And, as Robert points out, it’s also not as simply binary as aspirin vs. oxycodone.
I don’t think a doctor even has to be a “heartless villain” to fall on the “no pain relief for you” side of the spectrum–they just have to be more concerned about the risk of addiction, or their liability if someone does become addicted, than they are about the pain that someone’s in.
But, then again, if OTC meds are addressing a problem to the point where I find it tolerable, I usually don’t go to the doctor (unless it’s been ongoing and, yeah, OTC meds are helping, but I’d like to see about getting the underlying issue identified and corrected). So I would usually hear “Try aspirin first,” and be tempted to reply, “If I could fix this problem myself, why the frak would I be here?”
yeah…addiction doesn’t just cause death or physical harm. Some of these drugs are very powerful and very addictive. I wrote on an ex-cop doing 15 to life for the crimes he did while strung out and unable to get his pain meds which he needed for a debilitating cervical injury arising from fracturing two vertebrae. At the time I wrote it, the cop was in jail on armed robbery and kidnapping charges and still denying his addiction despite I suspect being popped for it in drug testing. It wasn’t being admitted or discussed publicly certainly, but I had enough info to know what was going on and when he plead out, his lawyer finally made a statement about what a lot of people knew, his severe addiction. I thought about him while I’m working on my draft on addressing his department’s Early Warning System. He was one of six officers including a chief prosecuted within a 12 month period and about 10 arrested. But he was the one known one where addiction to drugs likely factored into his situation although alcohol, another legal drug, was involved in at least two others.
He had problems anyway I suspect before this and that can’t be ignored but somehow while trying to take measures to ease his chronic pain from his injuries he went down this path and one of the questions would be, what was his doctor doing or thinking or did he even know the guy was an addict? That can be hard if the person denies it certainly and believes everyone’s out to get him on something.
Pain medications are very important but they should never be underestimated. People do talk a lot about the illegal drugs when it’s the legal controlled substances that can be the most worrisome in some regards because people believe since they’re legal and prescribed, they’re “safe”. People sometimes have a flippant attitude about them I have noticed and I think that’s a mistake.
“At the time I wrote it, the cop was in jail on armed robbery and kidnapping charges and still denying his addiction despite I suspect being popped for it in drug testing.”
Was he trying to get money for drugs he could have afforded if they were legal?
Some of this is also a consequences-for-doctors thing.
It’s very very hard to successfully sue a doctor for refusing to prescribe pain medication. That’s especially true if you can get it somewhere else, but is true even if you don’t: pain damages are hard to prove, and it’s simple to find a reason for refusing the meds.
It’s far easier to sue a doctor for prescribing pain meds which lead to addiction, injury, or death.
So a doc who gets asked for pain meds has to balance two things. There’s the risk of harm to the patient (through pain) against the risk of harm through addiction. That’s a “fair” balance, relatively speaking. The laws of liability, however, only weight one side, creating an “unfair” balance towards refusing to prescribe.
Also, Amp said:
I suspect that is partly to deter abuse. They probably don’t want people popping 5 percocets–which they may be less likely to do if they contain Tylenol. But it’s probably also linked to realistic pain management: Tylenol is actually pretty effective, patients are notoriously noncompliance, and a lot of patients wouldn’t take the other pills.
AFAIK, almost all unmixed opiates are limited to IV form (designed for hospital use) or suppository form (presumably difficult to abuse for obvious reasons.)
I suspect the drugs were legal and had been legally prescribed but he had lost his ability to access them legally. But that’s just a guess. He had been compelled by his Internal Affairs Division to submit a sample and had filed a suit before his arrest challenging that action. The department had given him the option of rehab which it makes available for drug addiction but he hadn’t admitted he was addicted and thought the department was just out to get him.
But his drug addiction had been brought to my attention before that. At the time he was arrested, he had been put on admin leave.
But the chief at the time had been likely an alcoholic and had numerous incidents reported of being pulled over and driven home while intoxicated and being picked up in bars while intoxicated right up to the incident that led to his prosecution on DUI (and he had apparently been mixing prescribed pain meds with his drinking) and his medical retirement after I guess people who knew about it decided they’d had enough of it and leaked the incident out to get it out.
Prescription drug addiction is a major problem in LE since so many officers are working with injuries and take them. I did know a guy who was a personal trainer with officers as clients looking to rehab and look into alternatives to addressing chronic pain than prescription meds. They serve a critical purpose and do help a lot of people with pain management but they have to be administered carefully and any followup done including liver and kidney function tests if necessary.
The laws of liability, however, only weight one side, creating an “unfair” balance towards refusing to prescribe.
Let’s also take into account that doctors have a wildly unrealistic view of how likely they are to get sued.
There are quite a few unmixed opiates available. For example. Or fentanyl.
I’m not saying that the majority of unmixed opiates are available in non-IV/suppository forms, just that there are a fair number that are.
I dislike the libertarian approach to medication for several reasons.
1. Pain is a signal. It means something is wrong. If you have persistent pain that is worse than can be covered by an aspirin or maybe some ibuprofen, you probably should see a professional about it. There might be something wrong that’s causing the pain. Possibly something fixable. Frankly, if people could take narcotics and forget about it, they probably wouldn’t spend the time and money to go to the doctor and find out what’s wrong. If what’s wrong is something like cancer or a subarachnoid hemorrhage, that could mean death decades before necessary.
2. Direct to consumer advertizing. It’s the invention of Satan in the best of circumstances, but at least as things stand, patients at least have to go to a professional to find out if the latest, greatest, most expensive product of Big Pharma really is right for them or not. The idea of direct to consumer marketing of, say, fentanyl or ativan, without any second line of control (however imperfect-and it is VERY imperfect) is terrifying.
3. Related problem: Most people don’t have the knowledge to choose pain the right pain medication for their situation without advice. This has nothing to do with the person’s intelligence or common sense, but rather to do with their education in a very specific, narrow field. It takes a lot of time and energy to learn what is needed and the average person really should be able to expect to simply leave a lot of that work to the professionals. Of course, the patient’s needs and wishes ultimately dictate what choices are made, but a patient should be able to say, “I have to keep working and can tolerate some pain” or “I simply can’t live with the pain any longer: I’ll tolerate any side effect to get rid of it” or “The nausea from that last pill you gave me was worse than the pain–think of something else” and have their doctor give them some reasonable recommendations rather than having to decide on their own whether to take high dose ibuprofen, oxycodone, or gabapentin as their first choice.
4. Drugs kill. Yes, acetaminophen can be deadly. Without much effort even. This to me is an argument for making it prescription rather than making percocet or fentanyl available on the free market. Even if one is willing to go with the libertarian “buyer beware” view and not worry about overdoses, consider the increase in accidents that would likely result if people had unlimited access to mind altering drugs. As it is, I’d like to see penalties for driving and performing potentially deadly tasks while under the influence drastically increased. Like, say, prosecuting drunk driving as attempted murder: there’s not a person out there who doesn’t understand that they can kill someone if they drive drunk-take the crime seriously. But that’s a different issue, I suppose.
I entirely agree that doctors often undertreat pain, sometimes criminally. However, I don’t think that simply making drugs freely available is likely to solve the problem.
If I may tease out a distinction that I think is important in these conversations, it can be irksome when threads about pain management go straight to language about addiction without stopping to make the crucial differentiation between addiction and dependency. If we restricted insulin the way we restrict pain meds, there would be a lot of sick desperate diabetics doing possibly-harmful things in order to get access to the meds that they *need in order to live* (especially with a certain quality of life). We know better (I hope) than to be moralistic about insulin, or other meds for chronic conditions– if you have the access to the health care system and the money (big ifs, of course), you can often access the meds without also having to endure too many restrictions from the docs or pharmacists. The same is not always true of psych meds, or BCPs, and is absolutely fucked up when it comes to pain meds, where the specter of our addiction-obsessed culture leaves no room for “yes, it’s a crutch– in that it *helps me get around and live my life rather than not be able to move*.” As people like CaitieCat have said, pain meds can be the difference between being functional and being in torment. In those circumstances, one is dependent on pain meds like I am dependent on psych meds, and the language and framing of addiction is entirely irrelevant.
So useful a comment! So my daughter-in-law, a Type I diabetic, is never subjected to “moralistic” battering over insulin. Why then should people in chronic, intractable pain be the target of criticism, or be denied the medications which make near-normal life possible?
If we restricted insulin the way we restrict pain meds, there would be a lot of sick desperate diabetics doing possibly-harmful things in order to get access to the meds that they *need in order to live* (especially with a certain quality of life).
Thank you, Sam, I was starting to wonder if I was speaking Old High Gallifreyan by mistake, as no one seemed to get that point. For some reason, it’s okay to moralize about my meds, and speculate about their danger in addiction, but it’s not okay to moralize about other meds, and speculate about their danger in addiction. People DO use insulin in an addictive way (research insulin-based weight control, and prepare to shudder), but we recognize that diabetics simply must have it, to have any shot at a life, so we cope with the addictive types: we still allow insulin users to have needles with relatively little distrust, but try asking for your pain meds as injectables sometime.
The problem is that my meds happen to be chemically similar to ones which, for historical and often racist reasons, happen to be considered “dangerous narcotics” – where I’d argue that both nicotine and alcohol, as currently constituted, pose a greater inherent danger to society than opioids or opiates. The trap we’ve fallen into is that we’ve taken as read that the governments’ lists of what are and are not “dangerous narcotics” actually are comprehensive and accurate, and they simply aren’t: they’re based on opinion and racism from the early 20th century, not science.
And then we apply the moral judgements from the neocon bullshit that was the “War on Drugs” (i.e., a way to unite the country by finding someone to hate, since the communists were fading away as a viable threat to keep people hating in the same direction), and someone like me but with less privilege – like not having white skin and blue eyes, say – finds that getting the meds they need to function requires being willing to be treated as a drug addict and junkie, with all the opprobrium of 30 years of Nancy Reagan’s moral lofty equestrianism thrown on top of the usual stew of race and class.
All opiates like darvon, morphine, demerol, hydromorphone, lorcet, lortab, tylox, hydrocodone and others are all narcotic in nature and so have the potential for abuse. These are prescription medicines and are prescribed only when needed by the patients however drug abusers often acquire it and abuse such medicines. These recreational drugs are not easily available over the counter and market but can be availed online. They have many side effects which include impairment of thinking and reasoning ability, insomnia, sedation, drowsiness, lack of coordination of movements, seizures or convulsions, nausea, vomiting and many more. These often lead to respiratory depression.
These drugs are prescribed by the doctors only when need arises as these causes addiction. Some prescription medicines are used for chronic pain but often recommended for short term treatment. Information about such recreational drugs is available online in different websites like FindRxOnline which provides information about such medicines and its side effects along with the vendors and pharmacies list where it is available. These sites often help users and guide them about the uses of such medicines and warn them about the associated risk. So it is advisable for users to visit the doctor or these sites before using such recreational drugs.