No Relief in Sight

Torture, despair, agony, and death are the symptoms of "opiophobia," a well-documented medical syndrome fed by fear, superstition, and the war on drugs. Doctors suffer the syndrome. Patients suffer the consequences.

Jacob Sullum from the January 1997 issue

(Page 2 of 3)

Clinicians and researchers have long remarked on the link between opiophobia and undertreatment of pain. In a 1966 pharmacology textbook, the psychiatrist Jerome H. Jaffe, who later became Richard Nixon's drug czar, noted that patients who take narcotics long enough develop tolerance (a need for larger doses to achieve the same effect) and physical dependence (resulting in withdrawal symptoms). But he cautioned that "such considerations should not in any way prevent the physician from fulfilling his primary obligation to ease the patient's discomfort. The physician should not wait until the pain becomes agonizing; no patient should ever wish for death because of his physician's reluctance to use adequate amounts of potent narcotics."

Jaffe's admonition suggests that undertreatment of pain was common, an impression confirmed in the early 1970s by two psychiatrists at Montefiore Hospital and Medical Center in New York. Assigned to handle "difficult" patients, Richard M. Marks and Edward J. Sachar discovered a very good reason why so many continued to complain even after being treated with narcotics: They were still in pain. "To our surprise," they wrote in the February 1973 Annals of Internal Medicine, "instead of the primary issue being personality problems in the patient, in virtually every case it was found that the patient was not being adequately treated with analgesics and, further, the house staff for various reasons was hesitant to prescribe more."

Marks and Sachar's surveys of patients and doctors found "a general pattern of undertreatment of pain with narcotic analgesics, leading to widespread and significant distress." In part they blamed "excessive and unrealistic concern about the danger of addiction," which doctors erroneously equated with tolerance and physical dependence. Marks and Sachar emphasized the distinction between a patient who seeks a drug for pain relief and an addict who seeks a drug for its euphoric effects: The patient can readily give up the drug once the pain is gone, whereas the addict depends on it to deal with daily life. (The definition of addiction is fraught with social and political implications, but this distinction suffices for the purposes of this article.) Marks and Sachar estimated that less than 1 percent of patients treated with narcotics in a hospital become addicts. Although they urged better training in pain treatment, they concluded with a prescient warning: "For many physicians these drugs may have a special emotional significance that interferes with their rational use."

Subsequent studies confirmed that patients treated with narcotics rarely become addicts. In 1980 researchers at Boston University Medical Center reported that they had reviewed the records of 11,882 hospital patients treated with narcotics and found "only four cases of reasonably well documented addiction in patients who had no history of addiction." A 1982 study of 10,000 burn victims who had received narcotic injections, most of them for weeks or months, found no cases of drug abuse that could be attributed to pain treatment. In a 1986 study of 38 chronic pain patients who were treated with opioids for years, only two became addicted, and both had histories of drug abuse.

Despite such reassuring findings, many patients continued to suffer because of their doctors' opiophobia. In December 1987 TheNew York Times ran a story with the headline, "Physicians Said to Persist in Undertreating Pain and Ignoring the Evidence." Russell Portenoy, director of analgesic studies at Memorial Sloan-Kettering Cancer Center, told the Times, "The undertreatment of pain in hospitals is absolutely medieval....The problem persists because physicians share the widespread social attitudes that these drugs are unacceptable." He added that "many physicians fear sanctions against themselves if they prescribe the drugs more liberally." The article cited a recent survey in which 203 out of 353 patients at a Chicago hospital said they had experienced "unbearable" pain during their stay. More than half were in pain at the time of the survey, and 8 percent called the pain "excruciating" or "horrible." Most of the patients said nurses had not even asked them about their pain. The same study found that nurses were dispensing, on average, just one-fourth the amount of painkiller authorized by physicians.

The ordeal of Henry James, which began and ended the same year the New York Times article appeared, illustrates this stingier-than-thou tendency. James, a 74-year-old with prostate cancer that had spread to his leg and spine, was admitted to Guardian Care of Ahoskie, a North Carolina nursing home, in February 1987. Like many patients in the late stages of cancer, James was in severe pain, and his doctor had prescribed 150 milligrams of morphine every three or four hours, "as needed." The nursing staff thought that was far too much. They started cutting back his doses, substituting headache medicine and placebos. He received 240 doses in January but only 41 in February. The nursing supervisor, Rebecca Carter, told James and his family that she didn't want him to become an addict. She also said that if he took too much pain medication early on, it wouldn't work anymore when he really needed it.

James died after four months of agony. His family sued Guardian Care, and at the trial pain experts testified that the amount of medication Carter and her staff dispensed was grossly inadequate. They also noted that narcotic doses can be increased indefinitely to compensate for tolerance, so Carter's concern that the medicine would stop working was "ridiculous." In November 1990 the jury ordered the nursing home to pay James's estate $15 million, including $7.5 million in punitive damages. After the verdict, an unrepentant Carter told the Los Angeles Times "nothing whatsoever has changed....We still give drugs the way we always have."

Outside of Guardian Care, however, things were starting to change by the mid-'80s. As critics drew attention to the torture inflicted by undertreatment, the use of painkillers began rising substantially. Between 1979 and 1985, for example, consumption of oxycodone and hydromorphone rose 40 percent and 67 percent, respectively, according to DEA figures. The National Institute on Drug Abuse acknowledged the problem of opiophobia. In 1989 NIDA Director Charles Schuster confessed, "We have been so effective in warning the medical establishment and the public in general about the inappropriate use of opiates that we have endowed these drugs with a mysterious power to enslave that is overrated." A 1993 article in NIDA's newsletter said "these drugs are rarely abused when used for medical purposes" and lamented that "thousands of patients suffer needlessly." In 1992 and 1994 the U.S. Department of Health and Human Services issued guidelines urging more aggressive treatment of postoperative pain and cancer pain, respectively. The 1994 guidelines said 90 percent of cancer pain could be controlled with available methods. On the same day that HHS released the guidelines, The New England Journal of Medicine published a national study estimating that 42 percent of cancer outpatients do not receive adequate pain treatment.

It is startling to realize, as the end of the 20th century approaches, that the idea of giving patients enough medication to relieve their pain is just catching on. One reason for the slow progress is that advocates of better pain treatment have been fighting deeply rooted prejudices. Americans have always had mixed feelings about psychoactive substances. To deal with our ambivalence, we tend to divide drugs into neat categories: good and bad, legal and illegal, therapeutic and recreational. We are not comfortable with drugs that straddle categories, as the opioids do. The discomfort is strengthened by historical experience, ranging from Civil War veterans hooked on morphine to middle-class housewives hooked on over-the-counter remedies in the years before the Harrison Narcotics Act of 1914. The nexus between medical treatment and opiate addiction was vividly portrayed in Eugene O'Neill's Long Day's Journey into Night, written in 1940 and set in 1912. Mary Tyrone, the wife of a stage actor, is a shaky, nervous woman who uses morphine to escape her troubles. She became addicted as a result of injections she received following the birth of her son. "I was so sick afterwards," she says, "and that ignorant quack of a cheap hotel doctor--all he knew was I was in pain. It was easy for him to stop the pain."

Patients still worry about getting hooked on painkillers. Schnoll, the Virginia pain and addiction specialist, cites the impact of anti-drug propaganda "telling us that there's an addict on every corner, under every stone. So of course people are fearful. I find that my own patients are often unwilling. I have to convince them to take the medications I'm prescribing them." Foley, the Sloan-Kettering pain specialist, says the problem is especially vexing in the case of children. "Parents are so afraid of addicting their kids that they do not want to treat them," she says. "They say, 'The pain's not so bad,' or, 'We don't want him to be sleepy,' or, 'We don't want to make him an addict.' They say to the kid, 'Be tough.' But they're very torn and confused. They're afraid of the drugs, because every parent has heard Nancy Reagan say, 'Say no to drugs.' So they're saying, 'My God! Drug addiction could be worse than my child's cancer.' "

By perpetuating such attitudes, the war on drugs obstructs pain relief. Through efforts to prevent narcotics from falling into the wrong hands, it has a more direct effect. A 1987 DEA report cites declines of 30 percent to 55 percent in the use of Schedule II drugs within two years after the adoption of multiple-copy prescription programs in various states during the 1960s and '70s. "I think it's a testament to the percentage of misprescribing and criminal prescribing that goes on," says Gene Haislip, the DEA's director of diversion control. "I don't think there's any evidence that they're discouraging appropriate medical use. We think there's some evidence to suggest they're discouraging inappropriate prescribing, but I don't have any reason to think they really have an impact on legitimate practitioners." Haislip likens compliance with a multiple-copy prescription program to filing an income tax return. "We don't decide not to make money because we have to report it," he says. "And I don't think doctors are deciding, 'Well, this patient isn't going to get medical treatment that's appropriate because somewhere somebody may read something and ask me some questions.'"

The tax code, of course, has a big impact on the way people make (or don't make) money. And despite Haislip's reassurances, there is substantial evidence that prescription monitoring has a chilling effect on the practice of medicine. To begin with, a large percentage of doctors in multiple- copy states--in California, almost half--do not even request the special forms, which suggests that "legitimate practitioners" are deterred by the hassle and scrutiny involved. "When I was in Illinois," says Sidney Schnoll, "there were physicians who just didn't want to carry triplicate forms. Sometimes they would call me up and say, 'You have triplicates, don't you? Can you write a prescription for so-and-so?' That's not good medicine."

Furthermore, it hardly seems plausible that frivolous or fraudulent prescriptions could account for a third to a half of a state's licit narcotic use, as Haislip suggests. The limited research on this question does not support that view. A 1984 study reported in the American Journal of Hospital Pharmacy found that Schedule II prescriptions at a major Texas hospital dropped more than 60 percent the year after the state began requiring triplicate forms for such drugs. At the same time, prescriptions of analgesics not covered by the program rose. A 1991 study reported in The Journal of the American Medical Association found a similar pattern in New York state, which added benzodiazepines, a class of sedatives that includes Valium, to the drugs covered by its monitoring program in 1989. Prescriptions for benzodiazepines dropped substantially in New York, while use of several other sedatives rose, even as consumption of those drugs fell in the rest of the country. The researchers noted that "[t]he alternative sedative-hypnotic medications are less effective, more likely to be abused, and more dangerous in overdose than benzodiazepines." These studies suggest that multiple-copy prescription programs lead physicians to replace monitored drugs with less appropriate alternatives.

This sort of behavior is reinforced every time a conscientious doctor gets hassled by the authorities because someone thought his prescriptions looked suspicious. In 1987 two state drug agents visited the office of Ronald Blum, associate director of New York University's Kaplan Comprehensive Cancer Center. "They showed me their badges and guns, and read me my rights," he told the Journal of NIH Research. It turned out that Blum had filled out some narcotic prescription forms incorrectly. The Department of Health charged him with three administrative violations, including failure to report his cancer patients to the state as habitual drug users. A year and a half later, after Blum had spent $10,000 in legal fees, the state finally dropped the charges. In 1987 the DEA investigated Portland, Oregon, oncologist Albert Brady because he was prescribing high doses of Dilaudid to a cancer patient in a nursing home. Although the DEA concluded that Brady was not supplying drugs to the black market, it notified the state Board of Medical Examiners, which fined him $5,000 for overprescribing and suspended his license for a month. It does not take many incidents like these to "have an impact on legitimate practitioners." Brady told the Journal of NIH Research that his two partners "changed their practice overnight and became reluctant to prescribe sufficient doses of painkillers."

As the Brady case illustrates, even in states that do not require special forms for certain drugs, physicians have to worry about attracting the attention of state licensing boards. A 1991 survey of 90 physicians reported in the Wisconsin Medical Journal found that most were concerned enough about regulatory scrutiny to prescribe lower doses, indicate smaller amounts, allow fewer refills, or select a different drug than they otherwise would have. Given the attitudes of many regulators, such caution is understandable. In 1992 the University of Wisconsin Pain Research Group surveyed state medical board members throughout the country. The results, as reported in the newsletter of the American Pain Society, were striking: "Only 75% of medical board members were confident that prescribing opioids for chronic cancer pain was both legal and acceptable medical practice....If the patient's chronic pain did not involve a malignancy, only 12% were confident that the practice was both legal and medically acceptable." Since these are the people who define the limits of appropriate medicine, their beliefs are bound to affect the treatment of pain.

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