In Addiction and Art (a book I swear to G-d I’m going to review very very soon) the authors, professors of psychiatry and behavioral biology at the Johns Hopkins University School of Medicine, write that compared to other medical illnesses, addiction receives little attention from the medical and public health communities. The reasons: the perception that it’s primarily a law enforcement problem, not a public health problem; skepticism about treatment; and “poorly funded research, weak leadership, stigma, and stereotypes.”
The authors go on to add, “Many of these obstacles to appropriate action, however, are caused more by indifference and prejudice.”
We can see this in the kind of outburst registered last week on the comments section of the New York Times story about a piece of Washington state legislation that would require physicians to refer pain patients on increasing doses of opioids to specialists if their symptoms were not improving.
Note well, reader: not cut off the patients, but refer them for further consultation if symptoms were not improving.
Listen to the uneducated voices that went ballistic:
I would much rather have some people become addicted to pain medicine than to do anything which restricts people with legitimate pain from obtaining pain medicine. … There is not one bit of evidence to suggest that if pain medicines were not available for misuse that people inclined toward addictions would not just find another drug. That is the history of drug use.
Here we have a guy who would prefer to sentence some people to a deadly disease, rather than consider implementing reasonable regulations that might allow clinicians to distinguish who might not be benefiting from these powerful drugs.
Patients who use narcotic drugs for real pain relief need them and do not become addicts.
Well, yes, honey, I’m here to tell you that some do! Get yer head out of the sand.
Moreover, patients who use opioids for real pain relief may still be addicts. They might have ruptured discs or spinal stenosis or no cartilage left in their knees. These conditions, which may require pain treatment, don’t exempt them from having addiction as a disease.
There were a very few sane voices:
As 21-year-old who has arthritis (19 years)and fibromyalgia (6 years) and experiences widespread pain every day, I don’t really have a problem with these regulations. If a medication is not working, its use should be reevaluated, especially if the medication could cause further health problems. I’ve been on a variety of different NSAIDs (different than a pain killer, I know) over the years. Whenever the medication stops working or isn’t doing enough for me, I change meds. If a powerful painkiller isn’t making any difference, why would someone keep taking it?
During my residency I only prescribed OxyContin to terminal cancer patients. … It was abundantly clear that most primary care physicians have very little to no training in managing and prescribing chronic opiates. Many of these patients encountered were physically and or psychologically dependent. Some were addicts.
Even when physicians have training in managing and prescribing opioids for chronic non-malignant (that is, non-cancer) pain, they often do not have the first clue how to recognize addiction inside their offices. And if they can recognize addiction, usually the stigma and stereotypes take over: they see their patients as having become morally corrupt rather than as having an(other) illness.
Pain physicians are trained to get patients ONTO drugs, not OFF drugs. So, largely in fear of DEA reprisals, they kick addicts roughly out of their practices, they refer them to psychiatric hospitals, and the patient is faced not only with negotiating a disruption in continuity of care for their pain problem but also with setting up treatment for their addiction—about which they may be in severe denial—and having to do it in opiate withdrawal, while also having to work, and/or take care of kids, aging parents, etc.
Total nightmare scenario. One that every chronic pain patient who-deep-down-suspects-she’s-an-addict wants to avoid, so this is why she usually stays in denial. She does not know how to get out. She doesn’t need to be kicked out of the practice, she needs help.
I wish this kind of legislation had been around five or six years ago. All I had to do to convince my doctor I was doing well was to go in and say I was doing well. I was taking pain medication for two real, diagnosed, legitimate neurological problems (which I still have), but it had also dimly entered my awareness that it was helping me cope with psychological problems as well. (Of course, the two can’t really be separated. The wellbeing of the body is the wellbeing of the mind.) If my physician, who is diligent, had been required to submit me to a protocol of questions and demonstrations at each visit to determine my actual functionality, it might have been determined, over time, that the opioids weren’t actually helping me improve. But again, I was afraid of being kicked out, cut off, sent to the psychiatric hospital, forced to take care of my child in the interim while enduring opioid withdrawal, etc. It was a conversation I was afraid to have with my physician, because to broach it would be to puncture that can of worms and let escape The Stigma.
In my opinion, and this is just off the top of my head here, I’d really like feedback on this: every pain clinic should have a staff of certified addiction specialists who consider addiction to be a disease and not a moral failing. They would be there to protect the patient population from the risk and to help those who have the disease and who also have chronic pain (because, as above, pain patients can also be addicts).
If you’re going to call pain a disease and you’re going to be in the business of handing out opioids, you need to get real about the disease of addiction. And not in a punitive way.