Painkiller Paranoia is Over Prescribed

by nikki meredith

At least once a week there’s an article in The New York Times about the dark side of opiate use. Veterans, NFL players, pregnant women, old people — all on painkillers, all at special risk, whatever the study of the week finds.  Oxy, as in Oxycodone, is now ubiquitous in popular culture: we have Nurse Jackie lying, stealing and having sex to score oxy; the The Good Wife defending a doctor accused of prescribing oxycodone to a star high school quarterback who overdosed; and many of the Harlan County reprobates on Justify pop, sell or kill for oxycodone.

All of this attention strikes fear in the heart of those of us living with serious pain. Most pain patients will not die if they can’t get enough medication to dull the pain  (in most cases opiates don’t eliminate pain, they only ease it) but our appetite for living will certainly be diminished and, according to research, the toll unmediated chronic pain takes on our bodies will shorten our lives.  The drumbeat to restrict the prescribing of opiates is getting louder and who knows where this attention will lead.

Serious, balanced focus on prescription painkillers is warranted. Too many people are dying of overdoses and apparently too many people who are not in pain are addicted to prescription drugs. There are many theories about the cause. Many of them having to do with the profit motive: drug dealers garner big bucks selling prescription pain killers on the street as do unscrupulous doctors who operate pill mills.  Some believe that Big Pharma is a culprit. I don’t know if that’s true.  What I do know:  there is a degree of hysteria surrounding the issue that distorts the problem and makes it difficult to find solutions.  Search articles on painkillers on the NYT website and you will download one after another of dire sounding and often distorted articles. One recent example: in an article about pill mills in Florida, the Times, by its own admission in a subsequent correction, vastly overstated the extent of the problem (it claimed that Florida doctors were purchasing 87 percent of all of the oxycodone sold in the country) and it exaggerated the dangerousness of oxycodone, claiming that it was the most lethal drug —  again, a fact it subsequently corrected.  I’m not defending Florida, until recently, an unregulated mess that’s finally cleaning up its act.  But the hype makes it difficult to have an evidence-based conversation about drugs, both legal and illegal, in the country.

Why the hype?  One, it makes a better story if it looks as thought the whole country is addicted to pain killers. Another is that some factions in the 12-step recovery movement have fought the use of opiates to treat chronic pain (see “The Politics Of Pain”.) While claiming to be proponents of the medical model when it suits them – alcoholism is a disease and should be treated as such – the adherence to a medical model goes out the window when talking about pain. (Please note: I’m saying “some” factions of the recovery movement — not all.)  These folks share an abhorrence of psychoactive substances with the temperance movement that brought us Prohibition.  The intertwining of character, substance use and the Protestant Ethic have been with us for a very long time and continues to pervade our culture.  (I wonder if the 12-steppers and the religious folks would feel any better if they knew that the euphoria associated with opiates is either greatly diminished or non existent in chronic pain patients?)

Doctors are a big part of the problem – some of the factors are beyond their control, some of them aren’t. When patients ask them for pain medication for an ailment that isn’t necessarily provable with tests – back aches, tooth ache, joint pain, fibromyalgia, migraines – they often aren’t sure what to do. The best of them don’t want to under-treat pain but they don’t want to be duped by drug addicts and, if the patient has chronic pain that requires high doses of opiates, they don’t want the Drug Enforcement Agency (DEA) breathing down their necks. In some cases, aggressive prosecutors have gone after doctors for excessively prescribing pain medication.

The result for a patient suffering from serious pain is this:  unless you walk into the ER with half of your femur poking through your skin, you are guilty until you can prove your innocence. Guilty, in this context, means that you are a “drug seeker,” the pejorative term both 12-steppers and doctors use to describe addicts. I completely understand why doctors hate being duped. It’s human. On the other hand, it’s terrible to be in pain and have the doctor look at you with both suspicion and revulsion.  But I have to believe that the doctor who gets played is better off than the patient who’s suffering and isn’t believed.  I must confess that when I’m in the throes of a migraine, I have a death penalty view of it: it would be better for nine “drug seekers” to acquire opiates to feed their habits than for one pain patient to be unfairly deprived of relief.

What is routinely overlooked in articles about the dangers of over-prescribing opiates is that chronic pain continues to be enormously under-treated in this country. Estimates are that 50–70 million people in the United States are either under-treated or not treated at all for painful conditions. (“Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain”, Douglas L. Gourlay MD ,Volume 6, Issue 2)

If you take the criminals out of the equation, much of the solution lies with education. Neither pain management nor addiction treatment is studied adequately in medical schools. Also, too many doctors who prescribe opiate treatment, don’t educate their patients satisfactorily about opiate use or vigilantly monitor their use. The pain many of these people suffer may be intractable, but the problem of how to manage it is not. In the medical community, pain management requires, along the desire to treat, sophistication about both addiction and pain and the need to work within complicated legal parameters.

Last week the Senate announced that it’s investigating financial ties between drug makers, pain specialists and patient advocacy groups. Someone in the Senate seems to believe that advocates for people suffering from chronic pain are shills for pharmaceutical companies who manufacture drugs. A crackdown is implied. If crackdown means more education for doctors, more sensitivity to pain patients, more treatment for drug addicts, more sensitivity and treatment for both groups, then I’m all for a crackdown. But I fear crackdown means only one thing: more pain.

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