“The Doctor”

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 praying and the worried father, clearly 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.

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 these principles:

To cure sometimes, to relieve often, to comfort always. – Ambroise Paré, 16th century surgeon

Divine is the task to relieve pain. – Hippocrates, Father of Medicine

Morphine is God’s own medicine. – Sir William Osler, Professor of Medicine at Oxford, sufferer from kidney stones

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 opioids and other anti-pain drugs. But as a result, heroin use is increasing – some to satisfy addiction, and some simply to relieve pain.

Two-thirds of opioid deaths are due to illegally manufactured fentanyl, but they are included under “prescription drugs.” [MMWR Vol 68, p 737-744] Fentanyl is a powerful synthetic opioid. If heroin or other illegal drugs, or counterfeit legal drugs, are surreptitiously laced with fentanyl, it has no relation to Dr. Smith prescribing pain pills for Mrs. Jones. Repeat: No relation.

In discussing hip replacements for the elderly, President Obama declared, “Maybe you’re better off not having the surgery but taking painkillers.” Now the government wants to withhold the painkillers as well. Have a nice day.

Physicians are required by the California Medical Board to take a course in pain management. But the Board issued a warning that we could lose our medical licenses 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 U.S. Centers for Disease Control (CDC) proclaims:

PRESCRIBE SHORT DURATIONS FOR ACUTE PAIN…Three days or less will often be sufficient; more than seven days will rarely be needed. [Emphasis added]

How does someone reach middle age, and never have an athletic injury, be hurt in an auto accident, sprain an ankle, break a bone, or have a surgical operation or dental procedure? How could reasonable people come up with the “three days” nonsense? On what planet do they reside? No on Earth, surely.

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.

After 25 years of treating patients with cancer, I concluded that the proper dose of pain medication was the dose that relieved 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 Big Brother writes the cookbook.

When I had severe back pain, I tried to take opioid-containing medication. Some people get a “high” from opioids and have difficulty stopping them. But I became nauseated, constipated, and drowsy, so I stopped the opioids and got by with Tylenol. I preferred more pain to the side effects of opioids. Still, I had enough insight to recognize that this wasn’t due to my strength of character − it was due to my body chemistry.

Not everyone has insight. Those who never had chronic pain often don’t realize how debilitating it is. Those who are lucky often don’t realize they are lucky, and instead attribute their good fortune to their own good qualities. 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.

Perhaps bureaucrats feel frustrated by their failure to stem the illegal drug trade. Perhaps bureaucrats feel frightened by violent drug-dealing gangs. 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.

Do you suppose there is a connection between those who favor open borders and those who favor stringent controls on doctors’ pain prescriptions? Are they often the same people? The fewer legal pain medications are available, the more business there will be for illegal drug dealers. Open borders? No “wall”? Only three days of pain medication?

But who benefits? Surely not patients in pain. Surely not frustrated, bullied doctors or pharmacists. No, the only ones to benefit are the drug-cartel chiefs. They move their money in 18-wheelers. They have plenty to spare for bribing compliant politicians and bureaucrats. Campaign contributions from political-action committees (PACs) and “bundling” are hard to trace – assuming anyone cares enough to trace them.

Am I accusing anyone? No. Am I raising a pertinent question? Yes.

Some people profess compassion for “all the peoples of the Earth,” including criminals and terrorists – but not for those suffering from chronic pain. They apparently are not included among the peoples of the Earth.

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 it won’t cause trouble. Not if a constipated bureaucrat squeezes out permission. Not if it follows a one-size-fits-all government cookbook written by “experts” who never see actual patients. Not sometimes. Always.

Hippocrates

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