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Even for chronic pain patients who aren’t mistaken for drug-seekers, the possibility that they might be is always lurking. It can color all of a patient’s interactions with care providers. For patients, the stakes are ludicrously high, and the fear of being seen as an addict and cut off from pain medication makes many patients’ already terrible situations worse.
From Brianna Ehley in Politico:
Last August, Jon Fowlkes told his wife he planned to kill himself.
The former law enforcement officer was in constant pain after his doctor had abruptly cut off the twice-a-day OxyContin that had helped him endure excruciating back pain from a motorcycle crash almost two decades ago that had left him nearly paralyzed despite multiple surgeries.
“I came into the office one day and he said, ‘You have to find another doctor. You can’t come here anymore,’” Fowlkes, 58, recalled. The doctor gave him one last prescription and sent him away.
Like many Americans with chronic, disabling pain, Fowlkes felt angry and betrayed as state and federal regulators, starting in the Obama years and intensifying under President Donald Trump, cracked down on opioid prescribing to reduce the toll of overdose deaths. Hundreds of patients responding to a POLITICO reader survey told similar stories of being suddenly refused prescriptions for medications they’d relied on for years — sometimes just to get out of bed in the morning — and left to suffer untreated pain on top of withdrawal symptoms like vomiting and insomnia.
The opioid crackdown was intended to cut down deaths from opioid overdoses. But legally prescribed opioids aren’t behind the vast majority of opioid deaths. Researchers in The Journal of Pain Research found that “fewer than 10% of opioid-related deaths involved prescription pain relievers without… other dangerous substances [such as heroin and fentanyl].”
It would be reasonable to expect that the increasing prevalence of heroin and illicit fentanyl in drug-related deaths would encourage policymakers to thoughtfully reconsider the relationship between opioid prescribing and deaths involving opioids. The data suggest that the overdose crisis is largely an unintended consequence of drug prohibition. Prohibition provides powerful economic incentives for illicit manufacturers, transporters, and dealers to supply banned substances. Nonmedical users appeared to prefer diverted prescription opioids, perhaps because the doses were reliable or because the fact that they could be legally prescribed for medical purposes created the illusion that they were relatively safe. But as diverted pain pills became more difficult to obtain in recent years, the black market filled the void with cheaper (and more dangerous) heroin and illicit fentanyl. …
Ending drug prohibition will not curb the growing tendency to use drugs nonmedically. However, it will potentially reduce the resulting harm…. Health care in general, and pain and addiction management in particular, are nuanced undertakings. Current public policies aimed at reducing opioid-related deaths ignore such nuance in favor of ham-handed, empirically dubious, and demonstrably harmful dictates. Americans suffering from chronic pain, and those from whom they receive their treatment, deserve medical care managed through better-informed and more even-handed policy.
Some readers will – quite reasonably – object to how this cartoon villainizes a doctor. Doctors, after all, didn’t crack down on pain medications out of nowhere. Doctors were (and are) reacting to public policy, and the fear of unreasonable regulators yanking their licenses. And I did consider incorporating that information into this cartoon.
But I couldn’t find a way to incorporate all of that without sinking the cartoon under the weight of too much exposition. And many pain patients have reported dealing with medical providers (not always doctors) who seem obsessed with finding any sign of drug-seekers, to the point of making legitimate pain patients feel like suspected criminals.
In the end, I decided this cartoon should take the perspective of pain patients, not the perspective of doctors. I wanted the cartoon to focus on the catch-22 pain patients face, where virtually any response – and in particular, any response that involves the patient standing up for themselves – could be interpreted as a sign of drug-seeking.
If I do another cartoon on this subject I might try to find an approach that looks at the systematic and regulatory pressures on doctors to deliver sub-optimal care to pain patients.
One more quote, from Amanda Votta’s essay “How The Opioid Crackdown Is Hurting Chronic Pain Patients,” which I highly recommend if you have time for a medium-long read.
Politicians and policymakers are “using us as scapegoats in the opioid crisis,” Danielle said. Lynn, another of my informants, said: “They don’t want to deal with the fact that their drug war is a failure. People are still getting high. Blaming people like us for overdoses is easy because we’re dependent on opioids. We’re captive to the system, which, right now, feels like it’s trying to kill us by refusing to treat our pain.”
Drawing this one didn’t go smoothly. I expected panel three to be the really fun panel to draw, but when the time came I had trouble making the face work. I actually ended up completely erasing the lower half of the doctor’s face and redrawing, but I’m not sure the new drawing was any better. Here’s are the two versions side by side:
I didn’t like the mouth in the first version – to me, it seemed like it was floating on the face rather than being part of it. And the mouth doesn’t seem correctly centered – it’s sort of drifting to the left side of his face. But then, the redrawn version doesn’t sit right with me either.
But eventually I had to stop redrawing and just be done. A completed “good enough” cartoon is always better than a cartoon that never gets finished because a drawing isn’t perfect.
I do like the figures in panel four – I like the way the patient is leaning way back from the doctor’s hostility, and I like the doctor’s sour expression and blank glasses for eyes.
TRANSCRIPT OF CARTOON
This cartoon has four panels. The cartoon is set in a doctor’s examining room – it has one of those tall examination tables with padding so patients can lie down, medical equipment and a degree hanging on walls, various cabinets, a sink. A tired-looking woman in a yellow tank top and black capri pants is sitting on the exam table. A doctor is standing in front of her. We can tell he’s a doctor because he’s wearing a white lab coat and has a stethoscope hanging around his neck. He’s holding a clipboard in one hand.
The doctor is speaking to the patient. The patient is slumping a little, while the doctor is stiffly upright.
DOCTOR: Some people use narcotics to get high. So when you come here and say you’re in constant pain, that tells me you’re a lying drug-seeker.
A closer shot of just the doctor as he speaks, looking stern and a bit angry, clutching the clipboard to near his chest.
DOCTOR: If you ask for pain meds, you’re a drug seeker.
DOCTOR: If you seem desperate, you’re a drug seeker.
DOCTOR: If you cry, you’re a drug-seeker.
A close-up of the doctor’s face as he lectures, one forefinger raised.
DOCTOR: If you talk back to me, you’re a drug-seeker. If you don’t like me assuming you’re a drug-seeker, you’re a drug-seeker.
A shot of the patient and doctor. The patient is now very wide-eyed, and leans back, away from the doctor. The doctor leans forward, hunching over his clipboard a bit as he makes a note.
PATIENT: Could I talk to a doctor who isn’t horrible?
DOCTOR: “Doctor-shopping.” Classic drug-seeker.
This cartoon on Patreon
I’ve been fortunate in that I got to know a physician when I worked at a hospital and engaged with him as my primary care physician. So when I tell him that I’ve got pain that Tylenol won’t work for he provides me with adequate medication. If someone does not have a long-term primary care physician – and I’m not saying that’s personal negligence, there’s lots of perfectly legitimate reasons why you would not – I can see how the above scenario would occur.
How about a cartoon that has the first panel with a patient pleading for more medication and then has 3 panels showing an empathetic doctor explaining what the hospital and/or the local/State/Federal medical authorities will do to him and his group’s practice if he signs one more prescription to the patient? I understand that some doctors are a$$holes but a lot aren’t.
You know I’ve been complaining about exactly this for more than 20 years. The biggest problem is how government has discouraged doctors from prescribing pain meds with threats of punishment. You’d be surprised how effective that’s been.
I can add another big problem to the mix… Insurance companies’ fairly recent refusal to pay for any of the time release opioids under any circumstances does a lot to keep people in pain.
Wow, the suck just keeps on coming. :-(
I was going to say exactly this, right now the buzzword in media is “opioid crisis” and some governments are trying to hold anyone from pharmacists to prescribing doctors responsible. And making them liable for addiction-related damages means that they’re going to err on the side of caution.
I don’t know what the right answer is here, because I have some sympathy for the argument for this: Opioid addiction is real, it’s serious, it drives and exacerbates poverty, and it kills people. But pain is subjective qualia. How is a doctor supposed to judge whether your pain is real or if the medications are working? What do you do for people that are in distress? And how do you hold a doctor responsible for not being a perfect human lie-detector?
The solution is to remove the socio-economic factors that drive the opiod epidemic. Opiod abuse is no different than heroin or cocaine abuse (except for the racial makeup of its sufferers, but we won’t go there). It can’t be stopped by enforcement, only by removing its causes. Then doctors would not have to be assholes, and we could hold the doctors who -choose- to be assholes to account.
But that response is a dodge in some ways. Suppose that Alice wants to end incarceration and Bob asks “What about violent criminals?” Alice says, “We should end the conditions that cause violent crime”. Alice’s response is a dodge- not because ending violent crime isn’t a noble goal but because we need to come up with a solution in the meantime.
Why do we need an “in the meantime” solution? Why can’t we end the conditions right now?
Because even if all our social-economic problems were fixed tomorrow, they might prevent NEW addicts or NEW violent criminals, but the existing addicts would still be addicted and the existing serial killers and wife beaters would keep serial killing and wife beating.
You’re assuming people’s behaviour is somehow fixed at an early age and does not respond to socio-economic contexts after that point. I don’t think that’s true.
Alcohol related deaths top opioid overdoses in the US (for now), but no one seriously proposes going back to prohibition on alcohol. Instead, the focus is on harm reduction when using alcohol (with some success – drunk driving deaths are way, way down since when I was a kid in the US). I would much rather spend money on harm reduction than on the war on drugs (even if I am not 100% convinced that legalization is a good idea for opioids), and I strongly oppose forcing doctors to be drug law enforcement by threatening their livelihood.
I read an article (that I can’t find now) discussing veterans, and the acknowledgement that tightening access to opioids would lead to more veteran suicides and overdoses (which it did). The people interviewed for the article strongly came down on the side that heavy opioid users served by the VA were drug seekers/addicts, and the suicides/overdoses could be curtailed by better access to drug addiction services and/or mental health treatments and/or never giving opioids for pain.
When I read the article, I wondered if many of the people who committed suicide or overdosed were people with chronic pain who needed large doses of opioids to function and were unable to deal with the pain/debilitation after being cut off from something that had been working for them. Or who looked for a solution on the illegal drug market once the legal one was removed as an option. We’ll never really know, since the people running the transition definitely are not considering that suicide/overdose may be the result of the best choices possible for someone with uncontrolled chronic pain.
I think the second drawing is better than the first.
Theory: the mouth looks better (so much more dramatic!) but once it’s crunched up like that, would the nose normally be affected so that it’s wrinkled at the intersection between the eyes and tilted some? I could be so totally wrong about this, obviously you know way better, but I wonder if that’s why it feels like tehre’s a disconnection between mouth and top of face.
I’m not sure I see them as disconnected, but I do think you’re right, it would have looked better with some crinkling on the bridge of the nose.
That would certainly be our strategy if Mrs. Squid were to get cut off.
A piece of advice I once gave someone on this site a long time ago, based on my experiences in biochemistry research labs working with labile chemicals:
You may have some left-over pain relief medicine that you no longer need but wish to keep on hand in case of emergency. Take a small jar whose lid seals at least water tight and that the prescription bottle fits into with a reasonable amount of room. Put a inch of calcium chloride pellets – the kind that is used to melt ice on sidewalks or driveways in the winter – into the jar. Put the prescription bottle in it. Close the lid tight. Mark the date on the jar lid or on a piece of tape with a permanent (non-water soluble) marker. Put it in the freezer. It’ll keep for a much longer time that way without losing efficacy.
If you need to access it and have the time to do so, take the bottle out of the freezer and let it warm up to room temperature before you open it, so as to avoid condensation inside when you do open it. But if you really need it right away, don’t worry. Go ahead and get what you need, just close it all up as quickly as you can.
That’s awesome advice that I still remember, RonF.