Maybe you’re better off not having the surgery but taking the painkiller.
– President Barack Obama
Director of Centers for Disease Control and Prevention urges regulations to limit physician’s prescription of opiate pain medication.
– News report
States enact laws limiting opiate pain relievers in both dosage and length of use.
– News report
In discussing his health-care plan, President Obama declared that chronic pain medication is an alternative to surgery in elderly or infirm patients – or perhaps all patients. More recently, the director of the CDC declared that chronic opiate medication is addictive and will be severely curtailed.
But these pronouncements are mutually contradictory. In fact, they may be seen as a cruel confidence game – pressure people to forego surgery in exchange for pain medication, then confiscate the pain medication. Whether this is done by design or negligence, it is politically fraudulent and morally inexcusable. To use an obsolescent term, it is a sin.
Bernie Madoff’s confidence game stole your life savings; this confidence game steals your life. Instead of walking around with a hip replacement, you lie in bed with a broken hip. Instead of walking normally with knee replacements, you hobble in pain with arthritic knees. And now even the pain pills are withheld. Madoff looks good by comparison. But he rots in prison, while the health-care gurus continue to spout their utopian notions – for generous fees, of course.
My father was a small-town doctor. He had a reproduction of this painting on his office wall. Note the poor family, with the child’s bed made of two dissimilar chairs. Note the distraught mother and the worried father, unable to pay a large fee, or perhaps any fee at all. But note the doctor sitting up all night with his small patient. Whom people choose as their role model tells a lot about them. This painting tells a lot about my father.
Later, when I was a medical student, an instructor asked what was the primary duty of a physician. A classmate replied, “To cure disease.” The instructor prompted, “Anyone else?” I said, “To relieve pain.” Later I learned this principle:
To cure sometimes, to relieve often, to comfort always.
– Ambroise Paré, 16th century surgeon
Currently there is agitation about the increasing incidence of deaths from overdoses of drugs prescribed for pain. This gives a whole new meaning to the term “painkiller.” The media are unclear as to whether the patients took more of the drugs than was prescribed, but this seems likely. Government regulators are instituting new restrictions on prescribing opiates. But as a result, heroin use is increasing – some to satisfy addiction, and some simply to relieve pain.
On the other hand, all physicians are required by the California Medical Board to take a course in pain management and end-of-life care. I thought this was a good idea − all doctors should be aware of modern techniques of managing pain. But the Board issued a statement by the deputy chief of enforcement – who is, as expected, a non-physician.
The statement warned that we could lose our medical license if we over-prescribed pain medication, or if we did not detect “drug-seeking” patients who can be “cunning.” There was not one word about under-treating pain, which was the subject of the course we had to take. There was not one word about whether a “drug-seeking” patient might be seeking drugs to relieve real pain. The article could have been written by a drug-enforcement agent, rather than by an official of a medical board.
What the Board is really saying is: “You must spend hundreds of dollars studying pain management, but don’t actually manage pain or we’ll punish you. The object of the course is to enrich those who give it, not to have you put the lessons into practice.”
If there is a more striking example of hypocrisy and double messages, I have yet to find it. For a more humane view, listen to the American Association of Physicians and Surgeons:
It must be noted that rather than indicating addiction, aberrant drug-related behaviors often signal the presence of under-treated pain.
But doesn’t excessive use of pain medication show a character flaw? Maybe, maybe not. First of all, what is excessive? The amount of pain medication required depends on several factors. Severe pain requires more medication. Larger people need more medication. Those who have become accustomed to medication need more. Those who are sensitive to pain need more.
In 20 years of treating patients with cancer, I learned that the proper dose of pain medication is the dose that relieves pain as much as possible, with as few side effects as possible. The dose varies with the individual and the situation. It can’t be dictated arbitrarily. There is no cookbook for medical care – not even if ObamaCare bureaucrats write the cookbook.
In all that time, I saw only one patient who died of an overdose of opiates, and he was a habitual user of illegal drugs before he got cancer. In my experience, almost all patients on opiates reduced or eliminated the medication if their cancers improved and the pain subsided.
Those who never had chronic pain often don’t realize how debilitating it is. They can’t imagine themselves in chronic pain, so they have no empathy for those who are less fortunate. Lack of empathy is a defect in any human being, but it is dangerous in someone involved in health care.
Illegal drugs ruin many lives. But the war on illegal drugs has nothing to do with preventing patients with medical illnesses from getting needed pain medication. Doctors who sell prescriptions to people who walk in off the street belong in prison jump suits, not white coats. But they have nothing in common with ethical doctors who try to relieve their patients’ pain.
Daytime TV is filled with interview shows, where people bare their emotional problems. They tell things to millions of strangers that I wouldn’t tell my best friend. Having emotional problems is now not only acceptable but almost desirable – it gets you on TV. What’s more, there are many ads for antidepressants and sleep aids. We learn that emotional problems should be treated with pills.
Evening TV is filled with “how to look young” reports, detailing the latest methods for erasing wrinkles and removing “cellulite.” Most people on TV – from reporters to actors playing coroners – are handsome, beautiful, and young. We learn to honor emotional problems, but to fear physical problems, especially those associated with aging or disability.
Many people aren’t religious. They no longer believe there is anything after this life, or that life has any purpose other than to enjoy ourselves. Of course people like that are terrified of old age, disability, or chronic pain – they don’t even want to think about such unpleasant topics.
Why did many people fail to protest when Terri Schiavo was being dehydrated and starved to death over 13 days? It wasn’t cruelty – they would have screamed if a dog were treated that way. No, it was fear – fear of disability, fear of not being physically attractive, fear of not being young and vigorous, and fear of not being in control. Fear is a powerful emotion, but a poor guide for social or legal policy.
Other than non-prescription medications like Tylenol and Motrin, there are no ads for pain-relievers on TV. Instead, there are endless cop shows in which drug dealers are the worst villains, which they are. But the lesson is that emotional pain is okay and should be treated with drugs, while physical pain is distasteful and repulsive – and treating it with drugs is shameful and possibly illegal. Even worse, state medical boards and federal narcotic authorities intimidate doctors from treating chronic pain effectively.
Perhaps bureaucrats feel frustrated by their failure to stem the illegal drug trade. Perhaps bureaucrats feel frightened by violent drug-dealing gangs and cartels. Perhaps they take out their frustrations on patients with chronic pain and the doctors who treat it – much safer targets. This is classical bullying − take out your frustrations on the little kids in the schoolyard, but give the biggest boys a wide berth.
Some people feel that if they hold “caring” beliefs and vote the “correct” way, it’s all they need to do to be “good” people – and then they can neglect their families, mistreat their employees, give little to charity, and show contempt for the elderly and the disabled. These people are wrong. What good are “caring” beliefs if they don’t lead to caring actions? Lack of compassion for people in pain is an odd trait for those who call themselves “caring” or “progressive.”
Some people profess compassion for “all the peoples of the Earth,” including criminals and terrorists – but not for those suffering from chronic pain, who apparently are not included among the peoples of the Earth. Someday soon, we hope to have potent pain medication that is non-addicting. But until then, we must do the best we can with what we have. Addiction is bad. Pain is worse. It is unacceptable to allow human beings under our care to suffer pain that we could alleviate. It is immoral and cowardly to turn the war on drugs into a war on patients.
During my years in medical oncology, I tried never to forget that the primary duty of a physician is to relieve pain. Not if it’s convenient. Not if it’s politically correct. Not if some faceless, unelected bureaucrat approves. Not if it’s in the official government cookbook. Not sometimes. Always.
Sir William Osler, the most distinguished physician of his era, called morphine “God’s own medicine.” Perhaps those who deny suffering patients adequate medication worship a different god, one with whom I am unfamiliar.
Divine is the task to relieve pain.
Contact: firstname.lastname@example.org. You are welcome to publish or post these articles, provided that you cite the author and website.