A reader had some questions about my interview with Dr. Scanlan, a physician who conducts opiate detox in the Florida pill-mill hot-zone:

It would have been helpful if Dr. Scanlan had addressed those opiate addicts that became that way after dealing with chronic pain. If there is no long-term maintenance, how will they stay off of opiates? Maybe a different way to address that is how will they get pain relief? “Buprenorphine is now the 41st prescribed drug in the U.S.” Where is OxyContin, Fentanyl and morphine? Most opiate addicts became that way because of being prescribed pain medication for legitimate chronic painful conditions. Are they included the 5% of addicts that may need maintenance? Or are we just discussing the ‘recreational’ users?

These are good points. Many people do become addicted after seeking treatment for serious chronic pain conditions. For the last 15 years or so there has been a big push in the medical community to recognize pain as the Fifth Vital Sign, and to treat it aggressively with appropriate drugs. Along with treating more pain with more opioids comes the risk that more people will become addicted. Simple math.

I agree—those of us with chronic pain have to strategize about its treatment in order to avoid turning back to opioids. Speaking from my own experience, an important part of this strategy is recognizing that opioids are not the only solution for pain relief. They’re certainly not the best long-term solution for chronic nonmalignant pain.

If you have chronic pain and addiction, I’d like to ask, what have you done about your pain?

As for your other questions: Where are OxyContin, fentanyl and morphine in the list? Oxycodone in all its forms is quite high on the list, though not as high as hydrocodone, which is the top-prescribed drug in the U.S., bar none. Second on the 2009 list (the most recent) were cholesterol maintenance drugs, then amoxicillin (a trusty antibiotic). Codeine is also way up there, and lots of people get addicted via codeine cough syrup or Tylenol #3 for headache, for example. (I knew one professional person who always carried a bottle of codeine cough syrup in their bag—their way of dealing with stress.) See this Forbes piece for one explanation that includes good sources. …

Vicodin is being prescribed like a version of extra-strength Tylenol these days. People go in to have a tooth pulled or to have a wound stitched and are given 30 or 60 Vicodin. It used to be that they’d get 3-5 tablets, but physicians are so used to writing in counts of “30” or “60.” With that supply of a drug that strong on hand, the “addiction switch” (as I think of it) can get turned on within a matter of weeks. Then, when they beg but can no longer get any more refills from their doctor, they turn to other sources to keep the lights on.

A Florida corner-store pain clinic.

I’ve been told that, once you cross the Georgia-Florida border on I-95, the signs for places to score pills start appearing on the roadside, and they follow you all the way down the coast. It’s said that there are more “pain clinics” than McDonald’s restaurants in Broward County—and three times as many clinics as Starbucks outlets.

Dr. Scanlan’s patients, just like all addicts, have become addicted in all kinds of ways. In addition, he practices in this hotbed of pill-mills, some of which dispense painkillers without following good medical practice. These people may or may not be “recreational” users (from my experience, people who are taking 300-600mg of oxycodone each day are no longer engaged in “recreation”), but they’re still suffering from a problem they can’t control.

A Florida strip-mall pain clinic.

I don’t think Dr. Scanlan was talking about pain patients in particular as being in the five percent of addicted people who may need drug maintenance. Scanlan and others, such as Dr. Gabor Maté, some of whose patients live in extremely difficult circumstances—people from street conditions who continually relapse and can’t get sober-time not only because of the inherent power of the disease but also because of the corollary circumstances that go along with certain manifestations of it (homelessness; joblessness; criminality; needle-use; prostitution; etc.)—believe in drug-maintenance to help this set of people stop harming themselves first of all.

The way I understand Scanlan’s comment about drug-maintenance is, he thinks this option gets promoted (by greedy drug manufacturers and well-meaning but largely ignorant policy-makers who have little or no personal experience with addiction) as a “cure” for all addiction—when he many others know that there are non-drug solutions that are less costly to the individual’s physical health and also their wallet, and to society. He’s a living example, and he’s trying to bring that solution to the people who come to him asking for help.