David Borden, Executive Director, [email protected], 7/11/03
Last week's editorial, "Not Just in Texas," about the case of Dallas physician Daniel Maynard, who is facing the wrath and power of the government because of his pain treatment practices, prompted more reaction than we usually received. We heard from other doctors who have or are now fighting prosecutorial persecution for their compassionate prescribing of opioids (narcotics) to patients needing pain relief. We heard from pain patients and advocates of pain patients, grateful and excited for the show of support for their cause.
We heard from an addiction specialist, approving of our editorial stance, but also laying out some of the challenges, mistakes and occasional abuses that happen on the other side of the pain issue -- the common lack of understanding of pain treatment within the medical profession can lead to over-prescribing as well as under- prescribing, and other errors, not criminal but nor good medical care; pain treatment for patients also suffering from past or present chemical dependency is necessary but fraught with difficulties; there are some actual "prescription-mill" doctors who for personal profit knowingly help non-pain patients obtain opioid drugs, though those are the very infrequent exception.
We also got one complaint. One reader wrote to us "Chronic drug use is self-medication for chronic pain. Drug use is not maladaptive; it is a reasonable response to pain. There is a pogrom on against people in pain. I'm waiting for the day when the anti-prohibition movement will start standing up for ALL people in pain."
I agree with some of what our reader had to say Some drug use at least is a response to emotional or other kinds of pain -- though some drug use is also done for pleasure or for other reasons. I don't agree with the reader that the anti-prohibition movement, or at least a good part of it including our organization, doesn't stand up for the rights of those driven to drug use by other types of pain besides the medical kind. And we stand up for those who use drugs for other reasons too.
Looking back at my editorial, though, there was one term I didn't like, and decided to change. I wrote last week, "Doctors can suffer loss of license or even incarceration, when the inevitable mistake of providing medicine to a dishonest patient who may be misusing or diverting medication occurs." I went back to the web site version and changed the second clause of the sentence to "real or pretend patient who may be misusing or diverting medication, or using it for non-sanctioned purposes, takes place."
The original version was not incorrect; but there are other gradations to this issue that it didn't reflect well enough. It's true that someone who goes to a doctor seeking opioids, and who misrepresents his or her condition in order to get a prescription for them, is by definition being dishonest, and some such people surely deserve that description. But there's a difference between a deception for the purpose of causing harm or for profit or other personal advantage, and a deception made out of desperation, without the desire to harm others or the perception of doing so. Indeed, some pain patients, unable because of the drug war to find doctors willing to adequately treat them, will pretend to be addicts in order to receive methadone -- an opioid used to treat heroin addiction but also for severe pain -- from methadone maintenance clinics. Are those patients being dishonest? Technically, yes. But who can blame them?
Those who, because of emotional challenges, physical conditioning or other reasons, develop addictive needs for drugs, at that point are using those drugs to relieve a type of pain that is different from the pain of other medical patients, but which they feel nevertheless feel acutely. Ending drug prohibition, or at least allowing addicts to receive their drugs of need on prescription, would end their desperation and allow them to cope with their pain in the way they've found, without exposing them to the dangers of the criminal underground, the risks of impure or too-pure drugs, the threat of arrest and incarceration, and the enormous degradation and disruption of lifestyle which the laws and the resulting high cost of street drugs imposes on many of them; and ending prohibition, or legalization, to use a different word, would break the connection that illicit drug use has to the street crime and violence that hurts us all, and to the illegal profits corrupting our institutions and economies. And it would end the pain under-treatment crisis at the same time.
Pain patients desire and are entitled to be recognized as not being addicts and having medical needs for which they deserve to be treated and need to be treated to live a reasonable life. At the same time, however, addicts also have pain, of a different kind; and though in many cases their addiction was a result of their own past actions, nevertheless they also have the right to pursue their own form of relief, and should be permitted to do so.
Similarly, pain treatment advocates often speak of the need for doctors and drug enforcers to work together to reduce diversion, instead of being at odds, with honest doctors threatened with incarceration by the enforcers, and it's understandable that they would say and believe that. But the reality is that supply-side anti-drug measures in total, including diversion enforcement, cooperative or otherwise, are doomed to failure, all for the same economic causes -- it is human nature that some of us use drugs, prohibition makes the drugs profitable, and the supply will therefore always find a way to fill the demand almost all of the time.
Nor is it clear that a successful anti-diversion program would end up helping addicts or other non-medical users; the pharmaceutical supply is a lot safer than the illegally-produced street supply. And it is inevitable that diversion enforcement, successful or not, must always have some dampening effect on the prescribing of those drugs, in the proper levels, to at least some of the patients who need them, even if that problem were to be minimized by more enlightened officials and practitioners.
Pain patients are not addicts; yet the solutions to both their predicaments will be found together, not separately.