Chronic pain patients—and the doctors who prescribe for them— are being turned into scapegoats for the opioid crisis, writes a patient advocate. According to the Institute of Medicine, some 100 million Americans are affected by chronic pain– more than cancer, diabetes, heart attack and stroke combined.
Every first responder is familiar with the scenario. You are called to the scene of yet another drug overdose. Naloxone is administered. The comatose “victim” rouses and groggily stands up. Many refuse to be taken to hospitals and drift away.
You are tempted to call out “see you again soon…”
Odds are good that you will. Though Naloxone saves thousands from overdose, death is too often postponed rather than prevented.
I have never personally witnessed this scenario. I work the other side of the street. I’m a health care writer, patient advocate and social media moderator who interacts daily with thousands of chronic pain patients and their families. My wife and daughter are among them.
These are the people whom government policy is turning into scapegoats for the so-called “opioid epidemic.”
They are increasingly being told that because the nation must deal with its addiction crisis, and that they must be denied or taken off the only medical therapy which offers them even marginal quality of life. By this I mean opioid pain relief managed by their doctors.
This is a false policy choice, founded more on mythology than facts.
The US is now chasing the wrong epidemic in its efforts to reduce the death toll from narcotic drugs. Both pain patients and addicts are paying the ultimate price for this misdirection. Addicts die in droves from street drugs—mostly heroin and fentanyl. Patients denied effective pain management spiral into agony, disability, and sometimes suicide.
Doctors leave pain management practice, afraid of losing their licenses and livelihoods to a widely perceived Drug Enforcement Administration (DEA) witch hunt and a hostile regulatory environment. Meanwhile, other doctors, in frustration, have argued for a better “balance” in assessing the use of prescription drugs for chronic pain. Others have gone even further by calling the application of strict limits on opioid prescriptions “inhumane.”
The death toll from government policy is founded on mythology. One myth is that the relaxed opioid prescribing of the 1990s led to a wave of addiction and death. It is also claimed that over three-quarters of addicts begin with prescription drugs. Both statements are readily shown to be misleading distortions.
The demographics that supposedly connect chronic pain to addiction don’t work. The typical new addict is an adolescent or early-20s male with a history of family trauma, mental-health issues and prolonged unemployment. Young men from economically depressed areas are rarely treated long-term for pain severe enough to justify use of opioids.
By contrast, a majority of chronic pain patients (by a ratio of 60/40 or higher) are women in their 40s or older with a history of accident trauma, failed back surgery, fibromyalgia, or facial neuropathy. Women of this age whose lives are stable enough to allow them to see a doctor don’t often become addicts.
The second myth, that prescription drugs caused our addiction crisis, is also a distortion. A Cochrane Review in 2010 revealed that among properly evaluated pain patients who haven’t abused drugs before, risk of opioid abuse disorder was less than 0.5 percent during the first year of treatment for chronic pain.
Many young people first abuse prescription drugs and alcohol—but the drugs aren’t provided to them by a doctor. They are stolen from home medicine closets or purchased from street dealers. Drugs stolen at home or given by a family member cannot account for high volumes. Abusers quickly switch to drugs they can purchase elsewhere. We may now be coming to understand where some of that much higher volume originates. A Dec. 18 article in the Washington Post offers a startling story.
In the Post article, DEA investigators complain of being stymied by their own lawyers and Department of Justice prosecutors, when they sought to prosecute multi-billion-dollar national drug distribution companies for clear failures to report patterns of suspicious opioid deliveries.
Huge volumes that could never have been justified by medical demand were shipped into rural counties in West Virginia and western States. Proof was conclusive. But distributors were allowed to get off with what amounted to a minor tap on the wrist.
It seems highly plausible to many readers that DEA lawyers were likely bought by the companies they were supposed to regulate. The process was the same revolving-door policy that guarantees the complicity of Representatives and Senators who anticipate being paid well as lobbyists or defense lawyers if they are miraculously turned out of office by voters.
Turn a blind eye and your future is bright. Come after us and we’ll crush you.
This is not the end of the story. Unable or unwilling to pursue the truly major players in drug diversion, the DEA instead went after lower hanging fruit. They attacked independent pharmacies and pain management doctors who prescribe high dose opioids in local practices.
When they attack individuals, DEA “Diversion Investigators” appear to lack the tools or training to distinguish between small-scale pill mills versus doctors who specialize in difficult cases where high dose opioids are the only therapy that works. As multiple doctors have told me, DEA instead employs an arsenal of extra-judicial tools in this persecution:
- Prominent announcements of doctors under investigation, intended to ruin professional reputations and influence potential jurors;
- Confiscation of doctor (or pharmacy) assets, to render legal defense more difficult;
- Suborning witnesses by threatening prosecution unless they testify to doctor misbehavior;
- Deliberate delays of prosecution, grand jury proceedings and court proceedings, to put further financial pressure on doctors to sign consent decrees before cases go to court.
The number of doctors prosecuted isn’t high. But using press as a messenger works very well. Prescriptions of opioid pain killers are dropping steadily even as overdose deaths climb.
Denying pain management to people in agony doesn’t help anybody. But we know what is needed. For that story, we’ll need another article.
Richard A Lawhern, PhD, is Co-Founder and Corresponding Secretary of the Alliance for the Treatment of Intractable Pain. A non-physician patient advocate and writer with 20 years of volunteer public service. he has written for The Journal of Medicine, National Pain Report, Pain News Network and other online media. His wife and daughter are pain patients. He welcomes comments from readers.