While use of prescription opioids for cancer and other end-of-life pain is increasingly accepted, if you are going to suffer in agony for years, rather than months, mercy is harder to find. Indeed, it seems a given by the media that because addicts sometimes fake pain to get drugs, doctors should treat allpatients as likely liars—and if a physician is conned by an addict, the doctor has only herself to blame.
But do we really want our doctors to treat us as if we were guilty until proven innocent? Do we really want the routine use of invasive procedures—ranging from nerve conduction tests to repeated scans and surgeries—to “prove” we’re really hurting? And do we actually want physicians to be held responsible for the actions of a patient who dissembles and does not take drugs as prescribed?
The answers to these questions are at the heart of the bizarre way we view synthetic opioid medications and the suffering of the 116 million Americans who have moderate to severe chronic pain, according to Institute of Medicine estimates.
In recent weeks, for example, New York Sen. Charles Schumer, anti-drug abuse advocates and reporters have inveighed against the potential FDA approval of an experimental opioid painkiller called Zohydro—professing to be horrified by the introduction of a new class of “100% pure” hydrocodone “superdrugs” that they have already dubbed “the next OxyContins.” And many states are weighing laws like one now in place in Washington state, which limits the doses of opioids that can be used by chronic pain patients.
When people consider the use of these medications in chronic pain, addiction fears are typically the first thing that comes up. Moreover, media coverage rarely includes the perspective of pain patients— or does so only to knock those who advocate for access to opioids as pawns of the pharmaceutical industry.
If the press—often quoting leading public health officials like Dr. Thomas Frieden, the director of the CDC—is to be believed, the US is in the throes of an “epidemic” of prescription painkiller abuse. Frieden even claimed at a recent press conference on opioid-related deaths that doctors are now more responsible than drug dealers for America’s addiction problems. “The burden of dangerous drugs is being created more by a few irresponsible doctors than drug pushers on street corners,” Friedman said.
However, the opioid issue looks very different when you examine the numbers closely. For one, the rates of Americans addicted to OxyContin, Vicodin, percocet, fentanyl and other products in our synthetic narcotic medicine cabinet are not rising. In fact, they have been steady at 0.8% since 2002, according to the government’s own statistics.
Moreover, fewer than 1% of people over 30 (without a prior history of serious drug problems) become an addict while taking opioids; for chronic pain patients who are not screened for a history of previous drug problems, the addiction rate is 3.27%. That means, of course, that more than 96% do not become addicted.
Yet these statistics usually go unmentioned in media accounts because they do not confirm the preferred panic narrative. Also left out is the fact that around 80% of Oxy addicts (a) did not obtain the drug via legitimate prescription for pain and/or (b) had a prior experience of rehab. Their contact with the medical system—if any—was not what caused their addictions.
So, the first thing the public really needs to know about what doctors call “iatrogenic addiction” is that it is extremely rare. If you’ve made it out of your 20s without becoming an addict, the chances that you will get hooked on pain treatment are miniscule—and even young people are not at high risk in most medical settings.
Nonetheless, the media continue to love them some “innocent victims”—and the real story of not-so-blameless drug users who move from heavy drinking, cocaine use and marijuana smoking to prescription drug abuse is just not as compelling. This, sadly, only contributes to the delusion that anyone who is treated for chronic pain with opioids is at risk for drowning in the—gasp!—ubiquitous riptide of addiction.
The panic leads to policies that require pain patients to be urine-tested, to be called in to their doctors’ offices for random “pill counts” and to make frequent visits—all of which is not only humiliating but expensive and time-consuming. There’s little evidence that such policing prevents addiction or does anything else beyond inconveniencing and stigmatizing pain patients.
And indeed, the stigma of addiction is what’s behind the curtain here. Imagine suffering from incurable daily pain so severe that it feels like your legs are being dipped in molten iron or your spine is being scraped out by sharp talons. Even if you did, in a worst-case scenario, join the tiny percentage of patients who develop a new addiction and became obsessed with using opioids, would this really be worse, especially if you had safe and legal access to them?
Most of the physical and psychological horrors of addiction come with loss of control and with being unable to be present for family, work and friends. But pain can produce even greater dysfunction and emotional distance, and its ability to destroy relationships is at least as monstrous. Moreover, maintenance on opioids can typically stabilize people with addictions, without numbing or incapacitating them. So why do we panic?
In the absence of true pharmaceutical innovation (Zohydro and other “superdrugs” are mere purer versions of VIcodin without the acetaminophen ), opioids remain the only medications that can even begin to touch severe pain, though they are far from perfect. But since they rarely lead to addiction—and since addiction (or opioid maintenance treatment) may actually sometimes be the lesser of evils—does it really make sense to restrict and even deny their benefits to pain patients?
When the situation is considered rationally, our outsized fear of addiction has little to do with the reality of chronic pain. Instead, it’s about the way we see addicts: gun-toting robbers of Oxy from pharmacies and other scummy, lying, sociopathic criminals—people we don’t want to be around or become.
Even though readers of this site know that drugs don’t somehow “make” ordinary people into such demonic figures—and that addicts can also be as kind, compassionate and hard-working as anyone else— the stigma runs deep.
Much of it, I think, comes from the same evasion of responsibility that allows us to blame doctors for addictions. After all, it’s not doctors who tell their patients to inject or snort their oral painkillers, to drink while taking opioids, to take more than prescribed or to lie, cheat and steal to obtain them.
These actions are deliberately taken by drug seekers. Doctors don’t “make” anyone make the ongoing choices that lead to impaired self-control. While trauma histories, psychiatric disorders like depression and/or genetics do make some of us more vulnerable to taking this path, no one can force us to do it. And if we see doctors—or, for that matter, dealers—as having “caused” our addictions, we open ourselves up to be dehumanized and stigmatized.
That is because if we are seen as incapable of making good choices, how can we expect respect for our desires and preferences? If we can’t control ourselves, why shouldn’t we be incarcerated to protect others from our actions? After all, when the public sees us as mindless zombies, their response is not sympathy for our supposed powerlessness but fear and disgust at our imagined violence.
Even the overdose issue is mismanaged due to our hatred of addicts. Overdoses have now overtaken car accidents as a leading cause of accidental death, but it’s unclear how much of this increase is due to the actual rise in the use of opioids and how much to medical examiners simply attributing more deaths to these drugs since they are now found in more dead people. What is clear is that most of these deaths occur in the context of drug abuse—95%, according to one study of one of the hardest-hit states. A large number of these deaths could be prevented by providing the antidote to opioid poisoning, naloxone, with prescriptions for the drugs. But because we want the wages of sin to be death, however, drug warriors have largely prevented funding for programs to broadly distribute that lifesaving medication.
The opioid problem is really the stigma of addiction writ large. Consequently, if we want to stop getting in the way of access to painkillers for people who genuinely need them, we need to take responsibility for our own actions and help fight this stigma. No one but you can make yourself into an addict. But chronic pain can happen to anyone.