In a recent New York Times op/ed, Dr. David Kessler, the former head of the FDA, labelled chronic pain patients as addicts if they insist they need opioid painkillers like OxyContin to control debilitating pain.
The piece was ostensibly about the failure of the medical profession to foresee the prescription opioid epidemic, but Mr. Kessler’s harshest words fell on patients.
“Some patients will make heart-rending pleas that they cannot live without their opioids. But we have failed to see this for what it is, the signature of addiction: ‘I need it. I can’t get better or normal without it,’” he wrote.
That definition would apply to “needing” food as well then.
Note that the former commissioner was specifically discussing patients in real pain, not malingerers feigning pain to get drugs.
It didn’t seem to occur to Mr. Kessler that pain patients who say they need opioids to maintain an acceptable quality of life are simply telling the truth.
It seems far-fetched to think that all of these patients and their doctors are deluded by drug company propaganda.
A more likely scenario is that many patients accept opioids, with their well-known side effects and their very real risks, because there are suffering terribly and these drugs are the best available option.
A stated need for pain relief is not proof of addiction.
On the contrary, the Diagnostic and Statistical Manual of Mental Disorders V—psychiatry’s diagnostic bible—stipulates that physical dependence is not a symptom of a substance use disorder when it arises in the course of medical treatment.
The hallmark of substance use disorder (DSM-speak for addiction) is compulsive use despite harmful consequences. Drug use shrinks the addict’s world, interfering with work and relationships. The exact opposite is true of the pain patients who rely on their medication to function at work and at home.
Under pressure to reduce their prescribing, doctors are forced to confront the messy reality of patients who attest that these drugs are in fact working for them.
Opioids may indeed be overprescribed, but that doesn’t change the fact that for some patients, they work when nothing else does.
The art of medicine lies in matching the treatment to the patient.
There is a misconception that chronic pain patients account for the bulk of drug overdoses victims.
In fact, most overdoses are caused by people using diverted drugs recreationally. One study found that only 13 percent of overdose victims had a chronic pain diagnosis.
The CDC guidelines reflect the new party line that opioids “don’t work” for chronic pain, regardless of what doctors or patients in the trenches say.
However, if you read the CDC guidelines carefully, it’s clear that the efficacy of opioids for chronic pain is unproven rather than disproved. There are simply very few studies that assess the question either way. In the real world, doctors and patients keep using these medications because they see benefits.
Yes, heart-rending stories of suffering abound. They can even be found in the straight news pages of the New York Times: “I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” Dr. Robert L. Wergin, a family doctor in rural Nebraska, told the Times, “A one-size-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”
Patients who report that opioids help their chronic pain are politically inconvenient for those who seek to cut back the supply of opioids on the market at any cost. Mr. Kessler and his finger-wagging ilk are giving doctors an easy way out.
If all these patients can be dismissed as addicts, their heart-rending stories can be written off as mere manipulation. By tarring these patients with the stigma of addiction, Mr. Kessler gives doctors and policymakers license to ignore their suffering.
Author: Lindsay Beyerstein is an investigative journalist in Brooklyn, NY who writes about criminal justice and women’s health.
Here is a response from a doctor and pain patient advocate, Dr. Lynn Webster:
Here’s where I respectfully disagree with Dr. Kessler: assessing pain as a 5th vital sign was not the reason for the opioid crisis.
Pain is Drastically Under-Treated
It is important to recognize pain as a major factor that affects the quality of life for tens of millions of Americans.
The problem is that physicians have never been adequately trained to assess and treat pain.
Asking patients how much they hurt does not mandate prescribing opioids.
To even suggest otherwise demonstrates the lack of understanding about what led to the opioid crisis.
Suggesting that the problem rests with doctors who ask patients to quantify their pain demonstrates the failure of our medical education system, and the need for more pain education in medical schools and residency programs.
It is the number one public health problem. Chronic pain is a problem without a solution.
We cannot solve the opioid crisis without first addressing the unmet need of hundreds of millions of Americans in chronic pain.
Not All Physicians are Irresponsible In Prescribing Opioids
Most physicians have been very responsible and concerned about the suffering of people in pain and the potential harm that opioids can cause.
These physicians have been squeezed between high expectations from their patients and the desire to do no harm
Dr. Kessler fails to mention the entity most responsible for the opioid problem may be the payers (that is, the insurance companies).
Actually, I disagree with this. The opioid problem is due to our country’s addiction problem and accessibility. As opioids are becoming more scarce and more expensive, addicts are already switching to other opioids, like heroin.
The opioid crisis is not just about opioids. It is about a flawed healthcare system that includes payers, physicians, and pharmaceuticals.
The discordance between patients’ outcomes and reimbursement for their healthcare has contributed to the crisis.
Short office visits and minimal reimbursement to treat very complicated chronic illnesses has fueled the crisis. Dr. Kessler should have cited this as a factor and called for a change that would align outcomes with reimbursement.
Dr. Kessler seems to think that the problem is largely that opioids are overprescribed, yet he does not recognize that the demand for overprescribing is at the root of the problem.
Why do so many people want to overuse opioids? This is where it gets complicated.
There are many reasons for the demand for opioids, and severe unrelenting pain is among them. Does Dr. Kessler suggest that people in pain not be treated? I doubt he believes this, but what are the alternatives? He doesn’t provide any during the CBS News interview.
Opioid abuse and addiction are a disease triggered by exposure, but opioids are not the cause of the disease.
Failure to recognize the fact that addiction is a disease and that the country has treated people with opioid addiction as criminals rather than with compassion has contributed to the number of deaths attributed to opioids alone.
It is easy to cast stones.
Honest appraisal of the current opioid crisis cannot overlook
- the lack of pain education,
- prejudices towards people in pain,
- lack of payers’ willingness to cover alternative therapies,
- inadequate NIH funding to find alternatives to opioids, and
- criminalization of addiction as factors that have contributed to our crisis.
Sadly, everyone is pointing fingers rather than collectively tackling the root causes to the problem.