Readers of Mad in America are deeply familiar with the tangles of public policy which surround voluntary or compelled interventions with psycho-active drugs in people who are experiencing life crisis. Some readers will also be familiar with a different kind of crisis and its policy tangles, in the difficulty which many people encounter getting medical assistance for chronic intractable pain.
I have previously written at MIA concerning the inappropriate application of psychosomatic medicine to people who are written off as “head cases.” (See “It’s NOT All In Your Head”) I would now suggest that a largely bogus “war on drugs” has also become a war against pain patients. And at this stage of public discussion, pain patients seem to be losing.
Much has been written lately about an “epidemic” of opioid overdose deaths, in some cases advocating for a blanket reduction in the availability of prescription opioids. Regrettably, many readers will not penetrate beneath the sensational headlines to grapple with the complicated realities of this issue. Few who aren’t themselves in pain may realize what harm such articles are doing to tens of millions of people.
In March of this year, the US Centers for Disease Control released “voluntary guidelines” on prescription of opioid medications to adults with chronic non-cancer pain. Unfortunately for 100 Million US chronic pain patients (estimated by the US Institute of Medicine), the document is in actuality neither voluntary nor a guideline. Combined with recent draconian laws in several US States, the CDC protocols have become a mandatory restrictive practice standard which is driving doctors out of pain management and patients into agony by the thousands. Patients are being involuntarily taken off opioids — or outright deserted without referral by doctors who fear US Drug Enforcement Administration prosecution if they continue to prescribe the only treatments which give many people even a marginal quality of life.
None of this is to say that over-prescription or diversion of prescription opioids never happens or that prescription overdose deaths do not occur. Clearly both are real issues in public health, and tragedies for families most directly affected. But there is ample evidence that neither sad outcome is the core reality of drug abuse in the US. As recently explained in Scientific American by neuroscience journalist Maia Szalavitz , “Opioid Addiction is a Huge Problem, but Pain Prescriptions Are Not the Cause.”
As Szalavitz points out, “efforts to reduce opioid deaths will fail unless we acknowledge that the problem is actually driven by illicit — not medical — use.” Likewise, “…according to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.” The real problem is not chronic pain patients. Part of the solution might be securing of potentially addictive medications under lock and key when used at home.
The largest contributing factors in drug abuse are not medical prescriptions. Again from Maia Szalavitz, “If we want to reduce opioid addiction, we have to target the real risk factors for it: child trauma, mental illness and unemployment.” Not coincidentally, people who experience these problems are much less likely to receive medical treatment for any cause, including chronic pain. Moreover, “…in general, new addictions are uncommon among people who take opioids for pain in general. A Cochrane review of opioid prescribing for chronic pain found that less than one percent of those who were well-screened for drug problems developed new addictions during pain care…”
There is real and valid concern for the avoidable death and destruction which are wrought by illicit opioids in the US. But the contribution of prescription opioids in pain patients is tiny, and even the number of deaths is over-blown. Why do we ignore the 88,000 alcohol-related deaths that occur every year? Or the even larger number of deaths by medical misadventure and error – the third highest cause of death in the US? Something seems seriously out of whack with our sense of proportions.
Present public attitudes and assumptions toward chronic pain must change. A fraction of the millions diagnosed with incurable pain conditions will be prescribed opioids. But among that minority, opioids are a last resort and a necessary enabler of life. Take them away, and you may contribute to a wave of suicides and a surge of people seeking street drugs out of desperation.
A huge majority of pain patients are not addicts or abusers. Most do not get a high from taking prescription opioids, even if they become physically dependent on them for pain control. We cannot reduce drug overdose deaths by denying relief for the agony of millions.
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Adapted from Richard Lawhern’s article in the National Pain Report
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.