In a new pamphlet offering advice to doctors, pharmacists, and regulators about the appropriate use of narcotics, the Drug Enforcement Administration acknowledges that people who behave like addicts may simply be patients desperate for pain relief. It notes that "drug-seeking behaviors" such as visits to several doctors, requests for specific narcotics, demands for more medication, and unilateral dose escalation "cannot immediately be ascribed to addiction" and may instead be due to unrelieved pain.
From the perspective of doctors anxious to avoid prescriptions that attract the government's attention, the DEA's discussion of this phenomenon, known as "pseudoaddiction," is both welcome and worrisome. On the one hand, the DEA admits that distinguishing between legitimate patients and people looking to get high can be tricky. On the other hand, even while calling uncontrolled pain "an enormous public health problem," the DEA denies there is any conflict between preventing nonmedical use of opioids and making sure that people who need painkillers can get them in adequate doses.
Announcing the publication of the pain medication pamphlet, which was prepared in consultation with leading pain experts, the DEA's Patricia Good said the government's goal is "ensuring both the ready access to prescription opioids and the elimination of their abuse and diversion." Since pain cannot be objectively verified—as the pamphlet notes, "self-report is the 'gold standard' for pain measurement"—this mission is plainly impossible, and insisting on it is a mark of delusion or bad faith.
The pamphlet itself is less grandiose, implicitly conceding that the complete elimination of nonmedical use is unrealistic, but it still does not come to terms with the unavoidable conflict between drug control and pain control. "These two goals are not in conflict," it says. "They coexist and must be balanced."
Yet the very idea of balancing these goals means there is a tradeoff between them. A less skeptical attitude toward patients, for instance, means fewer people in pain will be turned away, but it also means some fakers will slip through.
Although the DEA generously allows that "any physician can be duped," its proposed solution—watching for the tell-tale signs of drug abuse—hardly seems adequate in light of pseudoaddiction, which it says "greatly complicates the assessment of drug-related problems." Likewise, the pamphlet tells pharmacists to watch for "red flags" in prescription patterns and customer behavior but cautions that they do not necessarily mean anything illegal is going on.
"The parameters of acceptable medical practice include patterns of drug prescription...that may raise a 'red flag' for both clinicians and regulators," the DEA admits. It also notes that misconceptions about addiction—in particular, the idea that "simple exposure to opioids" is enough to produce it, or that tolerance and withdrawal symptoms are its essence—"can lead to inappropriate targeting of practitioners and patients for investigation and prosecution."
In case of such targeting, physicians are advised not only to keep careful, detailed patient records (a good idea anyway) but to consult pain specialists even when their guidance is not needed, because a record of having done so "would be reassuring to a regulator should the therapy ever be questioned." Such defensive maneuvers do not seem to jibe with the DEA's aspiration that "law enforcement and regulatory authorities should avoid interfering in pain management."
The DEA says there's no need for law-abiding doctors to worry, because "the arrest and indictment of a physician cannot occur unless he or she can be shown to have knowingly and intentionally distributed or prescribed controlled substances to a person outside the scope of legitimate practice." In reality, of course, this determination does not happen until trial (assuming there is one), and by then the damage to a doctor's reputation and livelihood may be irreparable.
Even conscientious doctors worry that state or federal regulators might suspect them of operating "outside the scope of legitimate practice." This pamphlet, though presumably intended to be reassuring, demonstrates there are ample grounds for such concern.
During the same press briefing in which the DEA's Patricia Good denied that drug law enforcement has a chilling effect on pain treatment, David Joranson, one of the experts who helped produce the pamphlet, noted that "the medical and regulatory environment for pain management seems to be worsening," with physicians increasingly fearful of investigation and reluctant to prescribe opioids. "In some ways," he said, "the use of pain medications has become a crime story when it really should be a health care story."