An Overview – Part 6 of 6

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By R Carter

The act of escapism requires the suspension of belief in self-harm.

R Carter

We did this to ourselves

The idea of an opiate crisis as something which we collectively, as a society, did to ourselves will no doubt rub some the wrong direction. For those who have lost loved ones to addiction and abuse I empathize, I too lost my wife after years of liberalized medication prescribing and then eventually to an overdose. I also lost a sister-in-law and a niece, so I feel the pain and frustration that so many others feel.

So I am grateful for the nearly three decades I spent practicing anesthesia and my sixteen years as a chronic pain patient, to help balance my views. This has allowed me to have a broader perspective and has tempered the anger I feel for the many shortcomings in this system we now have. Since 2010 I have continued to research the issues as best I can, to understand and absorb as many views as I can and look for answers which address all concerns. This blog, while not comprehensive, is a culmination of those efforts. The goal is to share what I’ve learned and help other chronic pain sufferers navigate a landscape more interested in eliminating opiates on ideological concerns than on using decades of science. To guide our policy initiatives by acknowledging those instances in which opiates are the most effective treatment, with minimal risks when prudent standards of care are followed.

With education and feedback from the public, hopefully new insights can be gained on how to best balance the needs of government, healthcare and patients. There will be no single answer that addresses everyone’s concerns, consequently the compromises that are reached will not make drug addiction go away, but if we learn from the successes we’ve had, we can better educate society to identify the warning signs that lead to early identification and treatment. And in doing so, avoid the tragedy of pushing patients with legitimate medical needs, out onto the street and into the black market.

It’s a given that in the evolution of the opiate crisis, people are the problem and by extension, the roles and positions people hold in our earthly institutions make those institutions contributors to the final outcome, regardless of whether that outcome is good or bad. Any solution to the opiate crisis will involve these four groups, government, healthcare, patients and concerned citizens. That said I hope to make good points in identifying that everyone carries a burden of responsibility, either through direct actions they’ve taken, through inaction or by trying to remain neutral.

There are no innocent groups or individuals because the subject of treating chronic pain with medications produced by industry, regulated by government, used by patients and sometimes abused by citizens, for whatever reason, is too complex of an issue to be the fault of any one group. Tightening the grip on opiates in an effort to prevent them from falling into the wrong hands has limited benefits, if taken to far or done indiscriminately; those efforts historically become a net contributor to illegal use. Patients desperate for relief, blocked from healthcare for all the reasons discussed, turn to the black market in their efforts to survive a medical problem. We can’t let this become the legacy of a shortsighted rush to judgement.

Those who work in the substance abuse and recovery community recognize that escapist behavior can lead to addiction in many forms, not just those related to medications. Some forms of escapist behavior are socially acceptable, even though they may lead to outcomes not unlike those associated with substance abuse. In Melinda Fish’s book, “When Addiction Comes to Church”, she outlines a number of different types of addictive behaviors, some of which she identifies as “Process Addictions”. These are behaviors which when practiced obsessively, have the same detrimental effects as any substance abuse problem. Some of those which she identifies are:

  • Gambling
  • Eating
  • Spending Money
  • Making Money
  • Sex
  • Codependence
  • The acquisition of power in its various forms
  • Even attending church

A good understanding about any of these should tell us something about the human species, our innate ability to lie to ourselves and fall into denial even when we are absolutely convinced our behavior hurts no one but ourselves. The ability of the human psyche to believe in something when the facts in front us are screaming otherwise, knows no limits. Our ability to discount or dismiss the suffering of others for our own personal gain is deeply entwined in our survival instincts. So it becomes easy to believe that as long as our behavior is rewarding us, its detrimental effects to ourselves and others can easily be dismissed or rationalized.

The smoking gun of any type of addictive behavior is denial, or as they say in the 12 step programs, “Don’t Even Know I Am Lying”. Denial is not isolated to individuals; denial can operate in mass on a whole nation of people, take for example the German Nazi movement which put millions of Jews to death, or the 2008 banking crisis brought on by selling subprime mortgages to individuals who couldn’t afford the payments. And denial is not limited to those doing something destructive, even men and women of good character and values can operate in denial when suffering from codependence, a disorder typically called people pleasing, which when left unchecked, can lead to cross addictions involving drugs. In fact most process addictions when left unchecked often lead to some form of substance abuse and addiction.

After twenty seven years of working in healthcare with ties to those treating substance abuse and addiction, I am convinced the need to escape our environment, reward ourselves and our propensity to fall into denial, will always be with us, it is hard wired into our brains and psyche. Only through education, early detection, treatment and a rigorous commitment to honesty with self and others, can we prevent it from going so far that it kills us or kills others.

Legislating behavior can only go so far, my point being, you can legislate in order to monitor, limit and control access to addictive substances, any further than that and you simply drive it underground and onto the black market. This has proven true in America for the last one hundred and fifty years.

Pain is a normal and healthy early warning sign of something having gone wrong in our bodies. Unfortunately pain can get its wires crossed and when that happens, some conditions produce long term chronic pain. For some the only effective treatment for restoring them to normal and returning to productive work lives, is using opiates. Despite some articles which claim that opiates have no more benefit in relieving pain than aspirin or Tylenol I say this. Let me pound your hand with a hammer several times, and then we’ll see how long you can get by on aspirin or Tylenol.

Anyone with any common sense can see through such deception, so why do some researchers continue to publish such junk? I will take up the problem of bad research and bad publishing in a future post, but for now suffice it to say that it’s not valid research, it’s likely not peer reviewed nor is it based on empirical data. Such claims published in medical journals are in fact Op-Eds, opinions masquerading as legitimate research.

What is most destructive about such articles is the manner or context in which they are presented, published in medical journals as if they are based on quality research when in fact, few are. As I stated in a previous post, essentially no research has been done on the use of opiates beyond six months, when looking at chronic pain suffers. Everyone knows that opiates are the best treatment for painful conditions, what is lacking is the empirical data needed to define what conditions are appropriate for long term use. Yet with a 3 billion annual budget for research, the NIH spends little to nothing on research of opiates in managing long term chronic pain.

There are some truths which get lost in these debates around chronic pain and opiates which I believe are worth addressing here in what I’m calling

The Pain Patients’ Bill of Rights

  • Individuals complaining of unrelieved pain should be treated compassionately and as earnest, until proven otherwise with facts and a thorough medical assessment.
  • The only person who owns (knows and understands) the pain, is the person having it. No one has the right to redefine that reality other than the person having pain.
  • There are no tests which can measure how much pain a person is having. Therefore:
    • A thorough medical history and physical assessment by a licensed physician are required in order to prescribe an appropriate treatment.
    • Prescribers must have knowledge of disease processes and conditions.
    • Prescribers must make regular observations and reassessments.
    • A patient pain diary should be part of the medical record until a patient’s condition is stabilized.
    • All complaints of HIPAA and ethical violation from patients should be investigated thoroughly.
    • Preventing addiction and abuse of opiates should never take precedence over treating acute pain following surgery, injury or trauma.
  • For patients who present reasonable evidence of poorly managed pain with opiates, pharmacogenetics testing is mandatory, especially since these tests now cost $300 or less.
  • When concerns of abuse occur with prescription medications, existing treatment must continue until concerns are investigated by an addictionologist and a diagnosis made.
  • Physical dependence on opiates should not be confused as addiction to opiates; the former occurs under the supervision of a doctor, the later occurs through self-medicating.

As a society our failure to recognize our collective denial, which is both pro and con opiate, and learn from history, drives us towards making the same mistakes again and again. Maybe one day we will conquer that denial, until we do, we need continued research for both treatment of pain and prevention of addiction, policy and procedure based on empirical data which is in the best traditions of medical research and a separation of concerns, leaving medical care to healthcare professionals and a government creating laws and regulations which balance the needs of all citizens equitably. Somewhere between the extreme right and the extreme left is a middle ground, a place where all of us can survive and flourish.