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7 Articles in Volume 5, Issue #1
Diagnosing and Managing Interstitial Cystitis
Intractable Pain Centers’ Treatment Approach
Musculo-Skeletal Diagnostic Ultrasound Imaging
Pain Management Pitfalls
Selection Criteria for Intrathecal Opioid Therapy: A Re-examination of the "Science"
‘High Dosage’ Opioid Management
‘Opiophobia’ Past and Present

‘Opiophobia’ Past and Present

The one drug class that has the optimum profile to manage severe, unremitting, intractable pain—opioids—is often shunned due to social stigma, lack of dosing guidelines, misunderstanding of side-effects (addiction, respiratory depression), and a pervasive fear of unwarranted regulatory persecution.

The word “pain” is derived from the Greek word “poin” which means “penalty” and the Latin word “poena,” for “punishment.”1 Indeed, the ancient Greeks believed that pain was a punishment from the gods.2 Today, we know better than our ancestors yet — despite great strides in understanding the mechanisms of pain — some pain patients continue to suffer with inadequate pain relief. Due to the intense regulation of controlled substances, the government at both the federal and state level has caused an extreme chilling effect on physicians’ willingness to prescribe certain powerful medications that would help these patients. No doctor wants to lose his medical license — his livelihood — over writing a prescription that another doctor could just as easily write. As a result, patients who need these medicines suffer needlessly.

The most egregious and widespread aspect of this problem is the flat out refusal of many doctors to prescribe opiate painkillers, the most effective analgesics known for both chronic and acute pain.3 This fear of prescribing opiate painkillers is known as “opiophobia” in reformist circles.4 Either doctors refuse to prescribe opiates at all, or they prescribe far too little — never enough to properly alleviate the pain. This phenomenon of opiophobia is widespread in America, and it results in patients with moderate to severe intractable5 pain being unable to obtain the necessary medication to live a tolerable life.6

Take, for example, the case of A.M.7 He was hit by a drunk driver, went straight through his windshield, and was left with severe head and back injuries. These injuries resulted in relentless chronic pain. A.M. went to nearly twenty different doctors, none of whom were willing to give him adequate pain medication. Instead, as is typical, they gave him anti-depressants and anti-inflammatories. Nobody was willing to properly treat A. M.’s pain, and he became suicidal. Fortunately, A. M. found another doctor who was willing to prescribe the medications required for him to function without the debilitating pain and helped get his life back from being completely bed-ridden. That same doctor subsequently came under investigation for his use of opiates to treat his patients’ pain. Eventually, the doctor will have to make a choice, and A. M. will be the one who suffers.

While the government’s “War on Drugs” is perceived as necessary for our society to function, the regulation of prescription medicine to avoid addiction and diversion must be balanced with pain patients’ ability to obtain the medication they need. These competing interests are currently — and have been for a considerable time — unbalanced and inequitable to those unfortunate patients suffering from intractable pain.

Historical Perspective

Opiates8 are natural or synthetic derivatives of opium, the juice of the seed pods of the opium poppy, Papaver somniferum.9 The major alkaloids contained in opium are morphine, codeine, and thebaine.10 Morphine is the strongest of the three, and the most important pharmacologically.11 In 1803, the German pharmacist Friedrich Wilhelm Sertürner isolated morphine from opium.12 Morphine was commonly used in hospitals from that point on, as it is much stronger than raw opium and capable of being measured precisely.13 With the isolation of morphine, many new opiates were derived from it.14

Up until opium became America’s first illegal drug with the passage of the Harrison Act in 1914,15 it had enjoyed widespread use ever since it became popular on these shores in the mid to late 1800’s.16 The earliest known reference to opium in America was in 1781,17 and Benjamin Franklin was known to use opium regularly.18 Up to the mid nineteenth-century, opium and its derivatives were considered extremely valuable medicines and were liberally used as such.19 Despite those medicinal qualities, opium would eventually become associated with crime, immorality, inescapable addiction, and end up feared and prohibited,20 as is the case still to this day.

Around 1848, in the midst of the California gold rush, many thousands of Chinese immigrated to America in search of a better life.21 Much work was available on the West Coast, thus a vast majority of the Chinese immigrants ended up there working in the mines and on the railroads.22 The Chinese instantly became the poor laborers, and racism towards them began almost immediately due to their appearance, language, and habits.23 One such habit brought with them from China was smoking opium and, before long, opium became inextricably associated with the Chinese.24 Rumors of Chinese men snatching white women and dragging them to hidden opium dens, where they would become addicted and enslaved, were quite common.25 As smoking opium was not popular with whites at the time, anti-Chinese laws were passed to ban smoking opium.26 As opium use became more restricted, those whose longtime tradition of smoking opium suddenly became illegal were classified as criminals if they did not cease.27-28 Increasingly thereafter, the smoking of opium became associated with crime, and this gave credibility to those who had been arguing against opium on moral grounds.

In the 1870s, the English Protestant churches and America joined together to campaign for temperance and against opium.29 Through a relentless crusade, the anti-opium movement was able to get a series of laws passed, each making opium more and more restricted. With each step closer to total prohibition, opium use was driven further and further into the black market. In 1914, Congress passed the Harrison Act.30 While the purpose of the Act was to “prohibit recreational use of opiates yet allow doctors to prescribe them in ‘good faith’ as part of a legitimate medical practice,”31 the overall effect was the near prohibition of all medical use of opiates, since opiate-prescribing doctors were frequently charged with violating the Harrison Act.32

Over the years, opiates only became more stigmatized. The medical establishment had come to the conclusion that the risks of opiate use far outweighed their clinical benefits.33 Early on, opium, morphine, and heroin “were the tools of Bolsheviks and trade unionists.”34 Later, they became tools used by the communists to poison our children’s minds.35 While these stereotypes may not have been grounded in reality, they have had their effect; opiates are not the über-analgesic of times past, but rather the atomic bomb of pain relief — admittedly effective, but to be avoided at all costs. Those costs, unfortunately, are not in proportion to the actual dangers of opiate therapy.

Impediments to Opioid Use

The history of opiate regulation in America has resulted in these drugs being severely underutilized in today’s pain management armentarium. There are three main reasons why doctors in America are hesitant to prescribe opiates:

  1. Fear of disciplinary sanctions or legal action36
  2. Fear of getting patients addicted37 along with general lack of knowledge and inadequate training regarding the true dangers and risks associated with proper opiate use38
  3. Cultural attitudes about pain and a pervasive fear of opiates39

These unnecessary impediments have created a system wherein “sixty to seventy percent of all patients do not receive adequate pain relief.”40 Considering chronic pain currently affects over 50 million Americans,41 this means at least 30 million Americans are suffering needlessly at this very moment. Aside from the pure inhumanity of allowing human suffering, this problem also has an economic effect — undertreated pain costs “over $70 billion per year in health care spending and lost productivity.”42 Controlling pain properly “enables rehabilitation”43 which means less time in the hospital and smaller medical bills.

Legal and Regulatory Deterrence

The single biggest impediment to proper pain treatment is the system of regulatory and legal control over what doctors can prescribe and how they go about doing so. The sine qua non of prescription oversight is the fact that many medicines are controlled substances which can be, and often are, abused. Indeed, individual drugs are classified, or “scheduled,” in the Federal Controlled Substances Act (“CSA”)44 primarily on their potential for abuse.45 There are five different schedules of controlled substances in the CSA, with Schedule I drugs being those that have a very high potential for abuse and no currently accepted medical use in treatment.46 Schedule I drugs are the most restricted and cannot be prescribed by any doctor; they are only available to qualified facilities, typically for research and industrial purposes.47 Drugs like LSD, heroin, mescaline, and marijuana48 are classified as Schedule I.49 Schedule II drugs are the next most restricted,50 and this is the class in which the most powerful medically-available opiates are delegated to.51 Extremely valuable painkillers such as morphine, hydromorphone, and oxycodone are listed as Schedule II.52 By definition, these drugs have a very high potential for abuse, but also have recognized medical uses as well.53 Drugs under Schedules III, IV, and V have decreasing potentials for abuse.54

The CSA sets forth minimum requirements (states are free to add more) which must be met in order to use controlled substances for medical purposes. Primarily, both physicians and pharmacists must have a federal license from the Drug Enforcement Administration (DEA) in order to prescribe and administer controlled substances.55 Such licenses can easily be taken away for any number of reasons;56 in the case of such a “property interest,” all that is required is a “fair and impartial” hearing before a DEA administrative law judge.57 As the ability to prescribe and administer controlled substances is central to a physician’s practice of medicine, the mere threat of having one’s license taken away gives the DEA a vast amount of influence on a physician’s practice of medicine.

Along with the licensing requirement, the CSA imposes special rules on the prescribing of Schedule II drugs. These conditions often result in inconveniences to both doctor and patient. The primary nuisance is the “no call in” rule which requires all Schedule II prescriptions to be in writing; a doctor can not “call it in” to the pharmacy.58 While this may not seem like much of a hassle at first, it means a pain patient (who is typically in a lot of pain) must make an office visit to his doctor every time his prescription is running low. Since many doctors simply won’t prescribe these medications, it may mean a patient must travel great distances to get a new prescription from his doctor. Having a few refills on each prescription would alleviate the problem, but refills are not allowed for Schedule II prescriptions.59 In addition, if the pharmacy doesn’t have enough pills to fill a Schedule II prescription, a partial filling of the prescription is allowed provided that the remainder be filled within 72 hours.60 If it’s not, the remainder is “lost” and a new prescription is required. The purpose of this rule is to close a loophole in the “no refills” rule. If this rule were not in place, a doctor could write a two-month, 100-pill prescription for a patient who is taking 50 pills per month; the patient would merely ask the pharmacist for half now, half later. These heightened prescription rules create a burden on pain patients by requiring frequent visits to their doctors.

While these are assuredly inconveniences, the CSA does not impose further restrictions such as limiting the quantity of medicine per prescription or limiting the number of prescriptions a physician can write in a given time period.61 In fact, the CSA itself does not impose the vast number of restrictions on physicians who wish to prescribe controlled substances. While the DEA is given great authority, in the area of medical and pharmacy practice it has traditionally deferred to the state medical boards to be the primary enforcers.62

State Medical Boards’ Enforcement Policies

In order to enforce state substance abuse laws and prevent diversion of controlled substances, state medical boards routinely monitor prescribing patterns and investigate physicians who are thought to be over-prescribing controlled substances, primarily opiates.63 Along with direct monitoring, medical boards rely on complaints from third parties such as pharmacists and family members of patients.64 While the actual chances of a physician having disciplinary action levied against him for over-prescribing controlled substances is somewhat small,65 the risk is present and physicians are quite aware of it. One commentator notes that “the regulatory risks involved with over-prescribing are perceived by most physicians to be real and far greater than those associated with under-prescribing.”66 This fear is escalated when state prescription monitoring programs are taken into account.

These programs come in two forms: multiple copy prescription programs and computerized database systems.67 Currently 18 states employ some form (or both) of these monitoring systems.68 They both accomplish the same thing: monitoring which doctors are prescribing Schedule II drugs (and in some states, Schedule III and IV),69 how much, and to whom. Multiple copy prescription programs (MCPPs) typically require physicians to use special triplicate prescription pads issued by the state when writing Schedule II prescriptions. One copy of the prescription is retained by the doctor, one by the pharmacy, and one is sent to the designated state authority; these copies are then retained by each party for two years.70 MCPPs create a record of all Schedule II prescriptions and allow the regulatory authorities to weed out “irregular” prescribing patterns, as well as doctor-shopping by individual patients.71 Electronic prescription monitoring collects prescription data (i.e. physician, patient, drug, quantity) and puts it in a central, searchable electronic database.72 It’s a more technologically advanced (as well as environmentally friendly) system yet the effect is the same.

“The single biggest impediment to proper pain treatment is the system of regulatory and legal control over what doctors can prescribe and how they go about doing so. The sine qua non of prescription oversight is the fact that many medicines are controlled substances which can be, and often are, abused.”

On their face, these programs don’t sound like a bad idea at all. The goal, of course, is to prevent diversion of controlled substances and penalize the extremely small minority of unethical doctors who flat out sell prescriptions — high class drug dealers.73 Since no doctor wants to be accused of such activity, which would necessarily involve an investigation by authorities and possibly result in sanctions, the prudent thing to do is write as few prescriptions — especially for Schedule II drugs — as possible. In fact, a 50 percent or greater decline in the number of Schedule II prescriptions written has been seen in every state that has enacted a form of prescription monitoring.74 At the same time, these states saw a rise in prescriptions of less potent, less regulated drugs.75 It is clear that these programs are impacting the use of effective pain drugs and greatly influencing physicians’ prescribing philosophies. The red tape involved in getting Schedule II privileges, having to participate in a state’s MCPP, along with the personal and professional liability that comes with owning a triplicate pad has caused many doctors to simply not apply for Schedule II prescribing privileges.76 Thus there are less doctors available who are legally capable of properly managing pain care. MCPPs also hinder advancement of a more reasonable standard of opiate use, because those physicians who do prescribe adequate amounts of opiates will appear to be over-prescribing as compared to their peers, thus openly subjecting themselves to investigation.77 In addition, doctors who specialize in pain management will necessarily be writing a larger amount of Schedule II prescriptions than regular practitioners. The regulatory authorities who review those prescribing habits do not take into account a physician’s specialty or the nature of his patients.78 In other words, the fact that a physician specializes in pain management may be a valid defense to an investigation, but it won’t prevent the investigation in the first place.

MCPPs act as a deterrent to physicians adequately treating pain. Each time a doctor writes a prescription that he knows will be sent to the state medical board, it serves as a blunt reminder that he’s being monitored and only reinforces the fear of an investigation.79 A 1991 survey revealed that forty percent of physicians questioned said “concerns about regulatory scrutiny, rather than medical reasons, led them to avoid prescribing [opiates] for chronic noncancer pain patients.”80 Likewise, in a 1997 survey of New York physicians, eighty-two percent admitted that they “prescribe drugs that do not require a triplicate form even when another drug is otherwise indicated.”81 Worst of all, a third of physicians questioned in a 1993 California survey “felt their own patients may be suffering from untreated pain.”82

Fear of Prosecution

These regulatory programs are exerting a chilling effect on physicians’ willingness to prescribe the medicines necessary to treat their patients’ pain. This is a product of the fear of legal and disciplinary actions perpetuated amongst the medical community. Are these fears justified? Regulatory and punitive horror stories are passed on like gossip from one doctor to another, and the inevitable result is an inflated fear of sanctions for over-prescribing accusations.83 It takes but one unjustified action by regulatory agencies to reinforce the fear of prescribing opiates within that state’s medical community. Many commentators have cited the case of Hoover v. Agency for Health Care Administration84 as such an example of an overzealous medical board.

In Hoover, the state board charged Dr. Katherine Hoover with over-prescribing Schedule II opiates based solely on pharmacy records.85 She was accused of prescribing “excessive, perhaps lethal” amounts of narcotics to seven of her patients, all of whom were being treated for noncancerous, intractable pain.86 The only evidence presented by the state board was the pharmacy records showing the various quantities of Schedule II drugs she had prescribed to these seven patients, despite the fact that the board’s two experts never examined her patients nor looked at their medical records.87 Regardless, the board — based on the recommendation of its medical experts (neither of whom treated chronic pain) — reprimanded Dr. Hoover, required her to attend continuing education on prescribing “abusable substances,” fined her four thousand dollars, and gave her two years probation.88 Dr. Hoover appealed. The court overturned the board’s sanctions while expressing its surprise at the imposition of disciplinary action “based upon such a paucity of evidence.”89 While Dr. Hoover was eventually vindicated by the court, reports of her legal troubles quickly spread through the medical community and most assuredly caused physicians to think twice before prescribing Schedule II medication.

Even more daunting are the occasional criminal prosecutions levied against doctors for prescribing Schedule II opiates. Dr. Frank Fisher, a family practitioner in a low-income town in northern California, was met one morning by heavily armed officers who had come to arrest him for multiple counts of murder.90 Dr. Fisher explains:

“[I] was jailed on fifteen million dollars bail. Prosecutors described [me] to the press and to the court as a drug dealing mass murderer who had flooded the community with OxyContin causing the addiction of 3000-5000 people and the deaths of many. After five months of incarceration, Judge Gallagher of Shasta County Superior Court dismissed all fifteen counts of murder as wholly unfounded and reduced bail, releasing [me.]”91

Dr. Fisher had been treating poor patients suffering from intractable pain with opiates, some of which (i.e. OxyContin) were Schedule II drugs. On his website,92 he gives a doctor’s perspective of how this affects pain care:

Law enforcement consistently seeks out rural solo practitioners to prosecute for suspected prescribing violations and the charges leveled are becoming increasingly exaggerated. In the past few years there have been a rash of murder and manslaughter charges leveled against well- meaning physicians around the country and several doctors have been sent to prison. The current state of affairs provides substantial disincentives to doctors even to be interested in learning about pain management.93

Physicians nationwide have been prosecuted under statutes not intended to curb prescription drug diversion.94 An exceptionally disturbing example is that of Dr. Robert Weitzel, who was convicted of manslaughter and negligent homicide regarding five of his patients.95 Throughout 1995 and 1996, Dr. Weitzel had been taking care of geriatric patients at a Utah hospital. Five of these patients were terminally ill and clearly suffering from severe pain. As these patients were dying, Dr. Weitzel administered moderate amounts of opiates, which is standard “comfort care.”96 At the same time, the state medical board and DEA were investigating Dr. Weitzel’s occasional in-office use of opiates to treat patients with severe headaches. Dr. Weitzel was told he was being investigated because “he was a psychiatrist prescribing opiates.”97 Although the DEA gave him urine tests (believing that he was diverting patients’ opiates for his own use), scoured through his files, rummaged through his garbage cans, and questioned his patients and friends, they could not find any evidence that Dr. Weitzel had done anything wrong.98 In 1999, the DEA discovered that five of Dr. Weitzel’s patients had died and that he had given them opiates.99 He was charged with five counts of murder on the theory that he had practiced euthanasia. Eventually, after liquidating his assets, declaring bankruptcy, and serving over six months in prison, Dr. Weitzel was given a new trial and found not guilty on all charges.100 His medical and DEA licenses still remain revoked.101

While cases like this are rare, the effect on the medical community is vast and detrimental to the overall practice of medicine. The Amicus Brief of the Association of American Physicians and Surgeons filed in Dr. Weitzel’s second trial states the influence cases like this have on physicians:

Prosecution of a physician for murder or manslaughter for prescribing pain relief would have an enormous chilling effect on all physicians. This chilling effect is multiplied when a physician is tried twice for a murder charge, despite an initial acquittal. Physicians will be even more inclined to under-prescribe narcotics than they already are. One example such as Dr. Weitzels [sic] is sufficient to negate numerous conferences and journal articles attempting to reassure physicians that they may and should exercise their own best judgment in easing patients [sic] pain. The specter of prosecution will be constantly in mind, especially if a patient fails to respond to an average dose. Patients will suffer needlessly, and some may even end their own lives prematurely because of unendurable but treatable pain.102

There should be no doubt that fears of being investigated, disciplined, or possibly being charged with manslaughter have considerable influence in regards to a physician’s decision to prescribe or not prescribe the strongest of analgesics. In such an environment, a physician risks his livelihood — and possibly his freedom — every time he fills out a triplicate prescription form. All of this, of course, presumes that a physician would be inclined to write such a prescription in the first place.

Fear of Causing Addiction

As discussed previously, opiates have experienced a sordid history over the past century. Their legitimate medical use today is primarily hindered by draconian government regulations which give all physicians a strong reason to say “just take two Tylenol.” As a result, opiate use is avoided at all possible costs. But there are other factors, aside from government regulation, which cause opiates to be avoided. While waging a war against these substances, it is also tacitly acknowledged that opioids are a necessary evil to be used, in the smallest dose possible, and as a last resort in dealing with pain. While the biggest impediment to adequate pain treatment is the sense of self-preservation and career-preservation among physicians, the fact that most physicians erroneously feel the risks of clinical opiate use outweigh their benefits insures that the accepted standard of care is, in fact, under-treatment of pain.103

“It is crucial to understand the difference between addiction and physical dependence. Addiction is psychological dependence... Physical dependence, on the other hand, is a normal physiological state resulting from prolonged opiate use...”

There are two aspects to this problem. First, physicians have an unnecessary fear of causing addiction in their patients.104 Second, medical schools do not adequately train doctors to treat pain — especially with opiates.105 One commentator notes that medical students are taught early on that opiates cause “respiratory depression, cardiovascular collapse, depressed levels of consciousness, vomiting, and, with repeated use, addiction.”106 These facts are, as she points out, entirely true.107 However, the students need to also be told that when used to treat patients with pain, these problems are rare and easily remedied.108 The “medical model” of pain is the standard taught in medical schools for how pain should be looked at and treated.109 According to this model, pain is to be viewed as a manifestation of a “real” pathology that, when fixed, will cause the pain to go away.110 The pain itself, however, isn’t worth treating separately according to the medical model.111 Compounding this state of affairs is the fact that most medical schools do not offer classes in pain management.112 That makes sense as long as the “medical model” is employed, since that class-time would be more wisely spent learning how to identify and cure the pathologies that cause pain, rather than treating pain directly.

In addition to ignoring pain management (which necessarily includes instruction on opiate therapy) in their curricula, medical schools are where doctors first catch the ‘opiophobia’ bug. One medical student was quoted as saying:

“From the minute I entered medical school to the day I finished my residency, I had it drilled into my head that narcotics should be used sparingly (if ever). We spent hours listening to professors describe how patients will do anything to get their doctors to prescribe narcotics and yet not more than a minute or two discussing their therapeutic uses.”

He adds that his experience as a resident confirmed this view for him.114 It seems that after several semesters of having this “drilled into [his] head,” any time a patient requests an opiate for pain, it will be, per se, suspect and most likely illegitimate — ”just another drug addict seeking a buzz.” It is extremely unfortunate to have this “addict presumption” whenever a patient says they are in pain and wants painkillers. Most people who go see a doctor do so because they’re experiencing pain.115 To the patient, alleviating the pain is primary; curing the cause of the pain is secondary. The current standard of care, however, dictates the exact opposite from the doctor’s viewpoint. While the American Medical Association’s Code of Ethics states that physicians have a duty to “relieve pain and suffering[,]”116 one doctor notes, “at present many training programs tacitly inculcate values and behaviors that are antithetical to the humane care of patients.”117

Causing addiction in patients seems to be the primary internal factor which causes the medical community to dislike opiates (compared to the external factor of government regulation).118 If a patient gets addicted, that patient or his family may file a grievance with the state medical board or maybe even sue the doctor for malpractice.119 Yet many studies have shown that when properly used for the treatment of pain, opiates rarely cause addiction.120 For example, one study of over 12,000 patients on opiates showed that “only four (0.03 percent) were considered to be addicted, and only one had signs of major dependence.”121

It is crucial to understand the difference between addiction and physical dependence. Addiction is psychological dependence, a “behavioral disorder characterized by compulsive seeking of mood-altering drugs and continued use despite harm.”122 Physical dependence, on the other hand, is a normal physiological state resulting from prolonged opiate use and — if stopped abruptly rather than having the dosage titrated down slowly — withdrawal symptoms can occur.123 Doctors who do not know the difference avoid opiates for fear of them producing this very normal, predictable effect associated with their use.124

Cultural Attitudes About Pain

Many commentators have noted that Western society not only has a general lack of concern for pain, but actually respects and rewards it.125 We respect those who suffer, and look down upon the weak who “just can’t take it.” One man spoke of his father:

“I couldn’t understand why my father was so embarrassed by [his] inability to withstand his pain until I started to study religion and history in high school. Christians believe it was necessary for Jesus to suffer the physical pain of crucifixion to redeem mankind from sin. Because of this, people who bear lots of [physical] pain in the name of God are turned into saints and martyrs. People who take pain in the name of country are given medals . . . . The real heroes in our society know . . . it’s best to suffer in silence. And if Jesus is the standard, you know the bar is going to be set pretty high.”126

Going back even further, the Old Testament portrays Job’s suffering as a positive, noble thing.127 Has Western religion first caused us to value pain as a righteous attribute, and then thousands of years later,128 led a world-wide movement on banning opium and its derivatives to ensure that we can’t relieve our pain conveniently and adequately? Whatever the answer, the latter is frequently justified on economic grounds:

It would be total chaos if we gave [opiates] to everyone suffering from chronic pain. America would grind to a halt. That’s how powerful these drugs are. Sure [opiates] reduce pain, but they dull [patients’] senses . . . too. This is why [drug laws] are necessary. We all have a stake in pain management too. Can you imagine what would happen to American productivity if everyone who claimed to have chronic pain was treated with [opiates]?129

Putting aside this flawed economic approach, some in the medical community feel as though the very act of treating pain is morally questionable. For example, one pharmacist notes:

“I know that there are only a limited range of things anybody can do to make pain go away and there are only so many things that can cause it. To borrow a phrase, “pain happens.” We have to be careful not to make too much of pain. It’s my job to alert the proper authorities [when a doctor] gets carried away with a patient’s complaints and prescribes morphine or some other narcotic at levels that hurt more than help . . . . Some serious pain in life is just unavoidable . . . . It is misleading, and probably unethical and illegal, for any [health care practitioner] to suggest otherwise.”130

It often seems that pain is portrayed as one of the greatest manifestations of weakness in our society. The only thing more pathetic than pain is addiction. Making matters worse, the anti-drug media campaign makes no distinction between dependence and addiction, legitimate use and illegitimate use.131 Patients who see this media onslaught are made to feel like they have to become a junky if they want to treat their pain. Their friends and families may not understand either:

“When I realized that without the medication I could not function [due to low back pain], I felt like a “druggiedruggie” . . . no better than a crack-head. My husband pleaded with me to stop [taking the prescribed medicine] for the sake of our family . . . . He harassed me and the doctor. I was forbidden to mention that I took the drugs even to my closest friends. After a while, I started to act like a drug addict. I hid my medications from him and from everyone else. I drove miles to have my prescriptions filled at drugstores where no one knew me. No one ever explained to me that it was “okay” to need my medication[.]”132

Society needs to recognize how currently out of balance the competing interests of drug control and pain care are, and shift around some of the weights on the scale to help rescue those hopelessly crippled with excruciating pain.

Our society seems to make no distinction between a person suffering from chronic pain who “needs” narcotics and a heroin addict roaming the streets who “needs” narcotics. To “need” a drug is to be addicted to the drug, regardless of the circumstances. The attitude is that people who say they “need” opiates for their pain are simply making excuses to get high. “Just say no” is the prevailing philosophy when it comes to using opiates to treat pain, and it’s not just the doctors saying no — tragically, suffering patients do so as well.


The inadequate education physicians receive in medical school regarding pain management — along with the “treat the cause, not the effects” paradigm — has produced a vast field of ignorance about how opiates work and how they should be used. Those who suffer the most from this institutional denial are those intractable pain patients already suffering needlessly.

Unless drastic changes are made, pain will remain vastly under-treated. If mere humane treatment isn’t a good enough reason to re-examine attitudes towards pain care, then surely economics are. Society needs to recognize how currently out of balance the competing interests of drug control and pain care are, and shift around some of the weights on the scale to help rescue those hopelessly crippled with excruciating pain. Not alleviating pain when one has the power to do so is morally equivalent to intentionally inflicting the pain upon them.

Last updated on: January 5, 2012
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