A true epidemic, with no easy scapegoats

Today an article on the web site Medscape describes the epidemic of opioid dependence in this country.  The article describes what people who work with addiction already know– that use of opioid medications has increased in a way never seen before for any medication.  The article does a good job of presenting the statistics, and puts forward the more obvious conclusions that can be made about the cause of the problem and some possible ways to reduce the magnitude of the problem.  As the article suggests, the databases that have been established in many states to monitor narcotic prescriptions will reduce doctor shopping.  Some experts are calling for special training and certification for doctors who prescribe opioids.  I am surprised that at a time when so many states are recognizing the problem, there are still numerous pain clinics throughout Florida that each pump out thousands of scripts for opioids, seemingly without any effort to stop them.  What’s with Florida, anyway?!

Death rates due to accidental overdose

The largest newspaper in Milwaukee Wisconsin has featured several articles about the local prescription drug problem.  I spoke with the author of the latest front page story about the subject, and tried to explain the complex nature of the problem.  I hoped that he would do the topic justice by writing something deeper than the typical ‘find someone to blame’ article that most papers resort to these days.  I even offered to set him up with a patient of mine who used those Florida-based pain clinics in the past, who ended up on ridiculously-high amounts of pain medication, and still struggles years later to lower his tolerance level.  The patient would have explained that it isn’t just ‘bad doctors.’  He would have explained that sometimes the problem is that a person will have severe pain, and will not be able to say ‘no’ to relief of that pain.  He would have explained that more and more doctors are simply ‘opting out’ of prescribing pain medications;  that if he had the gall to say to his primary care doc that his back hurt, his doc would have cut off the discussion and looked at him suspiciously from that point forward.  Because so many docs won’t deal with the difficulties associated with treating chronic pain, patients are left searching for pain pills in all the wrong places– and left taking them with little or no guidance or supervision.
Unfortunately the Milwaukee Journal-Sentinel writer took the easy way out, and instead of trying to capture the true essence of the problem he wrote a hack piece about ‘pill pushing doctors.’  I don’t personally know any of the docs he pointed out by name in the story– the story he wrote from the safety of behind his desk, where like most reporters he never has to make the tough decisions himself.  I wonder, though, if all of the docs he smeared were ‘bad docs,’ or rather if some of them were struggling with the tough questions that many docs now choose to avoid.  The article featured a photo of a tearful couple who lost a family member to overdose;  their daughter was being treated by one of the pain docs presented in the article as the lowest-of-the-low, a pill-pusher who destroyed the girl’s life.  And my heart goes out to those parents.  I see many people just like them in my practice; parents who have lost a child or who are struggling with the decision whether to put their addict-son or addict-daughter out on the street, or to instead let them live in the basement where they are using every night, where the parents dread looking each morning, into the dark silence, afraid of seeing their worst fear come to pass.
Drug deaths become number one

I don’t know the pain doc smeared in that article, but I do know what it is like to sit in the office with a person crying out in pain, begging for medication to provide relief from that pain. I was an anesthesiologist for ten years, after all, working in a pain clinic of my own.  And when treating someone’s pain, there is no way to get inside that person and determine exactly what the person is experiencing.  Yes, there were many times when I wondered if the pain was REALLY that severe.  There were some things I could try to use to determine whether the patient was ‘faking;’  I could check the respiratory rate, the blood pressure, and try to determine if the tears were real, or came from the drinking water down the hall.  My answer about faking, most of the time, was that the patient was NOT faking.  The patient was experiencing severe pain.  I knew that many people with the same injury would NOT have such severe pain, but for some reason this person DID have severe pain.  Who was I to say differently?  How can any doc listen to a patient describe severe pain, and then look at the patient and say ‘no– you are not in pain.’  Would YOU go to that doctor? 
Are you ready for the complicated article that Tom Kertscher of the Milwaukee Journal Sentinel SHOULD have written?  Those grief-stricken parents in the picture in his article about pill-pushing doctors, who are mourning the loss of their daughter and struggling to assign blame, are blaming the guy who might be the ONE doctor who truly cared, and who tried to help their daughter.  The daughter came to him, looking for help for her pain.  Other doctors turned her away, and told her ‘you DON’T have pain,’ when in reality they didn’t know whether she did or not.  They just knew it was easier to tell her to take a hike, or to say ‘I’m sorry, but I don’t prescribe pain pills,’ or to say ‘my healthcare system won’t let me prescribe them.’  Those doctors who ignored her pain didn’t know if her pain was real or not.  But there was one thing that they DID know– they knew that if they DID empathize with this patient, someone’s daughter, and if she ended up taking too many of the pills one night, they knew that some reporter hack would come ’round and blame them in some one-sided, simpleton-pleasing, ‘gotcha’ article in the Milwaukee Journal Sentinel.  So those docs closed their hearts to the pleadings for pain relief from a patient and kept their licenses for another day.  And the doc who couldn’t say no to her requests for help– who gave in and prescribed pain-relieving medication for the couple’s daughter– ends up being the bad guy.  Go figure.
Deaths rise as prescriptions rise

I have to point out that for non-malignant pain that has no finite endpoint, narcotics are rarely a good answer.  I have had patients say to me ‘I would rather live without pain for today and die next year, than have pain for the next twenty years,’ and to that I have said ‘that is why you need a doctor.  I cannot let you make that choice.’  I recognize that there ARE docs who prescribe pain pills MUCH too easily and loosely, causing a great deal of trouble for the patient in the end.  But they don’t prescribe because they are ‘evil;’  they prescribe because they have a hard time ignoring someone’s pain.  Maybe they need help dealing with confrontation.  Maybe they need to toughen up a little bit.  But they are not ‘evil.’ 
This is a little of the story that SHOULD have been written about the pain pill epidemic.  Then it could go into how people these days want everything to be ‘fixed,’ and that is why everyone takes pain pills.  Or it could say that the bad economy puts so much pressure on people to avoid missing work that they cannot rest an injury, and that is why everyone takes pain pills.  Or it could say that the violence of the inner city or the divorce rates in the suburbs leave people with emotional pain, and THAT is why everyone takes pain pills.   If only every problem had something to blame. 
I’m struggling with closing this post, and it is getting way too late.  I’ll just say one last thing– for those with young kids, keep talking about how horrible this problem is.  Don’t glamorize it, because it is not pretty– just let them know that unlike many things that young people do, taking pain pills incorrectly causes something that lasts a lifetime.  I invite people to check out some of the links in my ‘blogspot’ to see some of the faces of the epidemic, and to share those with your kids as well.
JJ

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