Take a Pain Pill…If You Can Find One

By | April 11, 2016 | 5 Comments


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.

         

“The Doctor”

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.
Hippocrates

Contact: dstol@prodigy.net. You are welcome to publish or post these articles, provided that you cite the author and website.

www.stolinsky.com

5 Comments

  • Texican14 says:

    You mention the increased deaths from prescription drug overdoses, but then seem to forget about it. Don’t you think that Big Pharma just wants to sell more pain drugs, and we have to do something about this problem?

    • Yes, we have to do something, but what? We could educate patients not to misuse medicines, and clamp down on the small minority of doctors who just sell pain-pill prescriptions to anyone who walks in off the street. Instead, we deny needed medicine to patients in real pain. This makes no sense.

      You seem to believe “Big Pharma” is conspiring to sell unneeded pain pills to make money. You like conspiracy theories? How about this one: Since we have been restricting the availability of pain pills, heroin use (and overdoses) have been rising. That is, the drug cartels are increasing their profits because we restrict legal pain medication. Is it just barely possible that the pain-pill restrictors are being paid off by the cartels? No, I don’t believe it, but if you’re a conspiracy theorist, try that one on for size.

  • You’re not worried yet? An article in the Journal of the American Medical Association is titled, “Zero Pain Is Not the Goal.” Granted, we don’t expect to achieve it. But if it isn’t even the goal, what will we achieve? 80% pain relief? 50% pain relief? Would you believe 20% pain relief? Stay tuned. See:
    http://jama.jamanetwork.com/article.aspx?articleid=2503504

    The CDC has just issued “Guidelines for Prescribing Opioids for Chronic Pain – United States, 2016.” Please tell me what part of the Constitution empowers the CDC, made up largely of non-practicing scientists and bureaucrats, to instruct practicing physicians on how to treat pain. One revealing quote on managing ACUTE pain with opioids: “…often 3 days or less…more than 7 days will rarely be needed.” Anyone who ever had a serious military, vehicle, or sports injury will not know whether to laugh or cry. See:
    http://www.cdc.gov/drugoverdose/prescribing/guideline.html

    “For the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.” [Emphasis added.] So wrote Dr. Thomas Frieden, Director of the CDC, in the New England Journal of Medicine. Opioids have been used in medicine from the time of ancient Egypt. But 4000 years later, the benefits are still “unproven.” Really? In short, from now on, if a doctor prescribes opioids, Big Brother will be watching closely. Have a nice day. See:
    http://www.nejm.org/doi/full/10.1056/NEJMp1515917

    To top things off, the CDC recommends urine tests for drugs before prescribing opioids for chronic pain. But who will pay for this? Why should patients give consent? How do you maintain a doctor-patient relationship when you, in effect, accuse your patient of being an addict, and reduce the doctor to the level of a parole officer? The bureaucrats don’t say.

    Oh, one more thing. If you hope to get an opioid prescription from your doctor, and you suspect he or she may require a urine test, don’t eat any poppy-seed bagels in the week before – the urine test may turn positive for morphine. See:
    http://www.snopes.com/medical/drugs/poppyseed.asp

    How long before the “guidelines” are made mandatory by government regulations? How long before they become the “standard of practice” for professional organizations? And how long before law-abiding citizens are forced to seek out an illicit drug dealer to get needed pain pills? As I said, stay tuned.

    I wish you good luck and good health. You’ll need both in a world where “zero pain is not the goal.” No, it’s not their goal. But it is my goal, and the goal of most of my medical colleagues.

  • cindy says:

    Thank you sooooo much for writing this! I told my daughter that I feel as if everyone in the pharmacy is looking at me as if I’m a drug abuser. I feel this way every time I go there. My daughter happens to work at a pharmacy and says …”mom, the people who fill prescriptions talk crap about almost everyone who comes in for pain pills accusing people of being drug addicts and it makes me furious! It’s not your imagination.”

    • Thanks for your kind words. I have no use at all for drug dealers. But I also have no use for people who have no empathy for those in pain. In fact, I don’t understand them. How do you grow up and reach middle age without having some painful injury or disease?

      Even worse, how do you lack empathy for others when you have had pain yourself? I don’t get people like that, and I don’t want to be around them. They actually scare me a bit. I believe some of them are high-functioning sociopaths, who – let’s be frank – tend to rise to high levels in bureaucracies.

Leave a Reply

Your email address will not be published. Required fields are marked *

Current ye@r *

Social Widgets powered by AB-WebLog.com.