Shortly after a 48-hour bout of immobilizing back pain and a visit to the emergency room where he received Percocet, my husband went to his primary care doctor to discuss managing the continuing pain and numbness. What he encountered took him aback. Perhaps concerned about “drug-seeking behavior,” the primary care physician commented offhandedly that back pain eventually goes away; the physician failed to do a physical examination, asked no questions about his level of pain or work situation, and offered no suggestions for dealing with the numbness or a recurrence. When asked about pain medication, his physician gave him a bottle of naproxen (which he was already taking) with no instructions regarding appropriate dosage. After two weeks and no further treatment, the pain began to subside; nine months later the numbness and tingling had diminished.
My husband’s experience could have simply been an unfortunate encounter with a busy physician. Or it could be symptomatic of a new attitude towards pain patients and prescription opioids by primary care and public health practitioners. With increasing deaths from overdoses since the early 2000s, public health concern over the abuse of prescription opioids for pain management has mounted. Last month's tragic death of actor Philip Seymour Hoffman from an overdose has heightened awareness of the social burden of addiction and raised anxieties about prescription opioids as “gateway” drugs to heroin.
In 1996, the Food and Drug Administration approved OxyContin, a potent pain reliever marketed by Purdue Pharmaceuticals in a long-acting time-release capsule that industry promotional materials claimed would minimize abuse. Within a few years, however, reports of abuse, addiction, and death from overdose of OxyContin surfaced, and the Drug Enforcement Administration kicked into gear, lobbying for more intensive regulation and surveillance of prescription opioids. Public health and medical experts joined the DEA and the FDA in promoting heightened state oversight of medical providers, pharmacies, and manufacturers. Primary care practices revised their policies towards chronic pain patients to include pain contracts – written agreements intended to discourage abuse by them or others – profiling of “drug-seeking behavior,” frequent office visits, calls for “evidence-based” practice, and urine toxicology screening. The discussion soon moved from concerns over the addictive properties of OxyContin to calls to dramatically limit such widely prescribed opioids as Vicodin and Percocet.
A 2010 editorial in the Archives of Internal Medicine by Mitchell Katz, then director of the San Francisco Department of Health, legitimized this emerging shift in attitudes. Drawing on personal experience, Katz made a sharp distinction between two kinds of pain patients: those with cancer or “life-threatening diseases,” and those without. As “a believer who has lost his faith,” he concluded with the comment that “learning how to cope with pain can be more empowering for patients than trying to find a pill to completely eliminate it.” This view was endorsed by Abigail Zuger in her New York Times health column and, most problematically, inserted into protocols in hospitals and primary care practices to set rigid limits on opioid prescriptions to non-cancer pain sufferers.
In December 2011, New York City’s famed public health crusader, then Mayor Michael R. Bloomberg, appointed a task force, which led to the severe restriction of pain relievers in New York City public hospital emergency rooms. Citing lack of evidence for use of prescription opioids in non-cancer chronic pain, the advocacy group Physicians for Responsible Opioid Prescribing filed a petition with the FDA the next year to reduce the dose and duration of approved use, and make the treatment of “moderate” pain an off-label practice. Two weeks ago, Tom Frieden, director of the Centers for Disease Control and Prevention, commented on a report that specifically found that most abusers of opioid pain relievers got them from friends, relatives, or drug dealers by saying: “Health care providers need to screen for abuse risk and prescribe judiciously by checking past records in state prescription drug monitoring programs. It’s time we stop the source and treat the troubled.”
One week ago in Washington, Sen. Joe Manchin called on the Obama administration to overturn the FDA's approval of the latest new painkiller. And in Harrisburg, Senate Bill 1180 sets up a prescription drug monitoring program that requires health-care providers to check a state database before prescribing narcotic pain relievers to every new patient, leaving nothing to the doctor's discretion.
During the 2000s, journalists, too, shifted their stance on opioids. Oftentimes collapsing legal and illegal drugs, different types of opioids, different dosages, and different types of chronic pain patients, media accounts highlighted skyrocketing emergency room visits, rising overdose fatalities, pill mills, and teenager abuse. Reminiscent of the “crack baby” and “ice baby” narratives of the 1980s and 1990s, tales of abuse included heart-wrenching stories of infant withdrawal from opioids.
In the rush to solve the apparent crisis, however, many questions about the social context of this “epidemic” remain unanswered. Is the harsh regulatory response proposed by many experts – and now approved by the FDA – proportionate to the magnitude of prescription opioid abuse? Are the needs of the diverse category of “chronic nonmalignant pain patient” being lost, dismissed, or trivialized in the rush to a simplistic regulatory solution? Why have prescription opioids come to be viewed as such a pressing social concern at this particular historical moment?
Popular and scientific debates about prescription opioids have been shaped by moral beliefs and values deeply rooted in US culture. Moralism has shaped health provider attitudes toward pain patients, leading to under-use – especially along racial and class-stratified lines – of substitution opioid therapies such as methadone maintenance. Moral beliefs and values have influenced biomedical conceptions of and research on addiction historically. Cancer pain has now received the stamp of legitimacy; non-cancer pain is morally suspect. This dichotomy has had profound effects on attitudes towards pain patients. Though addiction and overdoses are increasing, with undeniably tragic consequences, they remain infrequent outcomes of long-term opioid use for chronic pain.
There are many reasons for this shifting attitude towards pain and pain patients. Managing pain is challenging, time consuming, and uncertain. Success depends on patients’ experience, resources, tolerance, perceptions, co-existing conditions, social context, and relationships with clinicians. It requires skill, empathy, and understanding of the social assumptions that undergird drug policies and influence clinical practice. Overwhelmed primary care providers -- caught between dissatisfied patients, low reimbursement, and frequently changing “evidence-based” practice guidelines -- have little time to acknowledge the ambiguous symptoms of pain patients. With minimal pain training in medical school and residency programs -- and virtually no education in the fraught history of shifting U.S. regulation of opiates -- physicians understandably feel inadequate to the task. The result is that state regulation of prescribing practices, drug contracts, and urine testing all assume an irresistible appeal.
As history has demonstrated repeatedly, excessive regulation cannot address the broad social problem of addiction and overdose. There is already evidence that regulation of prescription opioids has led to an upsurge of heroin use in depressed areas of New England. While improved monitoring and controlled-substance databases certainly can help, the very real dilemmas of pain control and opioid overuse could be addressed more effectively by non-moralistic, thoughtful education, increased federal support for treatment of opioid addiction, and more careful attention to the conditions of life and labor that produce pain and addiction. Nonetheless, even well-intentioned programs are doomed if not informed by a nuanced understanding of the social, cultural, and political histories of U.S. drug policy and pain management. The public health community should be especially wary of initiatives driven by the DEA. Even former DEA agents acknowledge that its infamous “War on Drugs” has been a disastrous failure.
Primary care doctors are on the frontlines of a complicated dilemma, akin to that of the moral panic centered on crack cocaine, for which there is no easy solution. The best way to manage back pain like my husband’s is controversial. There is no question but that pill mills must be shut down. Yet the vast majority of non-cancer pain patients, including those with back pain, do not abuse drugs. If we continue with the current excessive regulation of prescription opioids, pain will be under-treated and physicians will be turned into medical police – or at least probation officers. And, as we have seen repeatedly in the past (and the present), the burden of inadequately treated pain will fall disproportionately on the poor.
Lundy Braun teaches the history of medicine and public health, including the history of drugs and addiction, at Brown University.
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