GOTTA HURT

The Irreconcilable Conflict Between Drug Control and Pain Control

As part of its recently unveiled "strategy to confront the illegal
diversion and abuse of prescription drugs," the federal government
promises to close down pharmacies that sell narcotic painkillers online.

After all, only druggies need to purchase Vicodin through the online
"pill mills" that "bypass traditional regulations," selling to anyone
who fills out a questionnaire. People with a legitimate medical need
for such drugs can always get prescriptions from their doctors.

Don't you believe it. Swayed by anti-drug propaganda and anxious to
avoid legal trouble, physicians are so leery of these drugs that
researchers have given their attitude a name: "opiophobia," an
unreasonable fear of narcotics that leads to untold suffering by
millions of Americans. Opiophobia intensifies every time the
government announces a crackdown like this one. I have a friend (let's
call her Marcy) who periodically suffers from severe neck and shoulder
pain, sometimes accompanied by splitting headaches that can last for
days. During one of these bouts, she tried Vicodin (a combination of
the opioid hydrocodone and acetaminophen), which she had left over
from a prescription she received after knee surgery.

It worked much better than the ibuprofen she usually took, cutting
short the headaches and making the neck and shoulder pain bearable.

After she used up the Vicodin, Marcy discovered that her doctor was
unwilling to prescribe more, even as she warned Marcy that continuing
to take large doses of ibuprofen could damage her liver.

The doctor suggested muscle relaxants, physical therapy,
acupuncture-anything but the medicine that Marcy knew would work.
The doctor explained that such drugs "can be habit-forming." In
Marcy's case, this concern was ridiculous. She did not even like the
psychoactive effects of hydrocodone; she took the pills only when she
was in serious physical pain-not every day, not every week, not even
every month.

A bottle of 90 would last her more than a year.

Yet Marcy's doctor was implicitly telling her it was better for her to
suffer (or continue using a less effective, more dangerous medicine)
than to take the essentially nonexistent chance that she would become
a Vicodin junkie. That's how Marcy became a customer of one of those
online pharmacies the government wants to put out of business.

She continues to use the pills only when necessary and has never been
tempted to do otherwise. Contrary to what the government would have
you believe, Marcy is not unusual in this respect.

Research consistently has found that patients who use narcotics for
pain rarely become addicted to them, and those who do typically had
pre-existing drug problems.

It is simply not true, as Rush Limbaugh implied when he blamed his
pill habit on "highly addictive medication," that opioids have an
irresistible power to enslave people.

They are only as powerful as people's reasons for using them. The
government demands that doctors figure out what those reasons are,
threatening them with loss of their licenses and criminal prosecution
if they fail to do so accurately. But doctors are not mind readers,
and pain cannot be objectively verified.

Faced with a choice of trusting their patients or protecting their
livelihoods, they often will choose to play it safe, as Marcy's doctor
did. And Marcy is relatively lucky.

For patients who suffer not from occasional bouts of pain but from
constant agony that can be kept at bay only with large doses of
opioids, getting relief is both more important and more difficult.
Desperately searching for someone who is willing to treat them over
the long term, they begin to look more and more like "doctor
shoppers," the malingering addicts the government tells physicians to
avoid.

By raising the volume of such warnings and encouraging the
proliferation of prescription monitoring programs that look over
doctors' shoulders as they decide whether to believe their patients,
the government inevitably will compound the already scandalous problem
of undertreated pain. In response to such concerns, federal officials
assure us that nonmedical use can be prevented even while making sure
that pain is adequately treated.

But these two goals are fundamentally irreconcilable, because doctors
will never be omniscient gatekeepers. The Office of National Drug
Policy says "more than 10 million Americans suffer from chronic pain."
According to the American Pain Foundation, the number is more like 50
million.

That disparity, which suggests the extent to which drug warriors
underplay the need for narcotics, gives you a sense of the gap between
the government's assurances and the painful reality.