Tuesday, June 19, 2007

Drug War IV

In my continuing series on the “War on Drugs”, I want to turn our discussion to the doctors who are now under attack by the DEA as drug pushers. It appears that the trust relationship between doctor and patient is now under scrutiny. Are there doctors who prescribe too many and too much prescription medication? Of course there are, but one must be careful when confronting this issue. It is reckless prosecutions that can send chills throughout the medical community and cause needless suffering on the part of legitimate patients. We live in a drug seeking culture, if you are not completely happy then take one of these pills and you will be. The pharmaceutical industry is spending millions on trying to find the perfect feel good remedy for all of us depressed Americans.

It’s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction — which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful — occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn’t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. “Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older,” says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.

According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.

Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily — for oxycodone or OxyContin, that’s just 80 milligrams per day — without the patient’s also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. “There are just not enough pain specialists,” says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. “Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise,” Fishman says.[1]

Despite popular belief, not everyone that takes drugs become addicts. I know from my own experiences that there are millions of people who take drugs and do not become addicts. The problem is no one can tell by looking who will and who won’t become addicted. But there is also the physiology of drugs and the human body. There are drugs that are physically addicting no matter who takes them (ie opiates such as heroin, morphine, etc.). It is these powerful drugs that are used to manage pain in most cases. Pain is not always a readily identifiable condition; there are sometimes no physical blueprints to follow. What degree of pain a person can tolerate varies greatly with each individual and also whether someone is actually in pain. There are no accurate tests for specific pain. I had a friend that suffered from migraines for years. He would go from doctor to doctor and no one could help him, sometimes they couldn’t even identify the pain that he was suffering. For many years in this country pain management was not part of most doctors practice's or part of any medical school courses. For that reason, many people suffered needlessly from under treatment of their pain symptoms.

But what are we to do with those who are addicted? They appear the same initially as the real pain patient, if anything they may appear more normal. Is the doctor responsible for what a patient does with his medication? Can a doctor accurately monitor a patient’s behavior that he may see once a month? Is it fair to expect that type of scrutiny from our doctors with our 15 minute HMO visits? It is questions like these that will cause many to suffer from pain or lack of treatment for other ailments due to the fear on the part of doctors to be arrested, sued, or even investigated. An investigation can cause a doctor to lose his livelihood.

Will another casualty of the “War on Drugs” be that patients suffer due to fear on the part of their doctors to do their job? There will always be people who abuse the system for their own personal gain, which goes for patients as well as doctors, but we must not allow the government in their zeal to fight this war to intimidate those trained to alleviate pain and suffering. As anyone who has read my writings know, I am not a fan of big pharma, but I am also not a fan of an intrusive government that under the guise of fighting a losing war is causing needless suffering. It is up to the doctors to decide the plan of treatment for their patients, after all that is what they get paid the “big bucks” to do. Let’s keep the government out of the examination rooms and peeking over the doctor’s shoulder. Should we monitor the performance of doctors? Of course we should, but their treatment should not be micro-managed by bureaucrats and drug agents.

[1] http://www.nytimes.com/2007/06/17/magazine/17pain-t.html?ref=health

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