Letters

Pain Reactions

Reading Jacob Sullum's "No Relief in Sight" (January) brought back some literally painful memories for me. In 1992, following minor surgery, I was given a prescription for codeine. Since the pain proved much less severe than my surgeon predicted, I used only one of the 30-pill supply. A year later, however, I became truly incapacitated with a lower-back pain: unable to walk, sit, sleep, or do anything but pound the pillow and cry. Assuming it was just a back injury, I began taking the codeine at night to get some sleep. It worked like magic.

A month later, when I ran out, I tried using over-the-counter analgesics, with no success. Eventually, I went to a doctor, begging for some relief. When I mentioned codeine, his face froze. I could see his thought process: He uses codeine, therefore he is an addict, therefore he is malingering. He prescribed, instead, some other painkiller that did virtually nothing to ease the pain.

Over the next two months, I saw two other doctors; both had the same reaction, and both prescribed ineffective medications. It was not until September--four months after the pain began that I was finally diagnosed with lymphoma, which responded admirably to treatment.

The result of these doctors' paranoia about opiates? Three months of unnecessary agony for me, and permanent nerve damage from the undiagnosed tumor. If they had not been so certain that I was only faking the pain to get recreational drugs, all this could have been avoided. Many times I thought about suicide; each time I told myself, "Just one more day." If I had known at first how long it would last, I doubt that I could have survived.

By the way: I obtained (illegally!) a small supply of codeine a year ago, which I am keeping in reserve. Relapses are all too common in lymphoma, and I do not want to endure that torture again. In the past year, I have felt no temptation to take even one of these pills. So much for theories of addiction.

Like many of your articles about government power grabbing, this one made me weep tears of frustration. I only wish that the bureaucrats at the FDA, DEA, and elsewhere were capable of seeing human suffering. In fact, I'd like to see them experience some of it.

Scott O'Hara
San Francisco, CA

I wanted to comment on Jacob Sullum's wonderful article, "No Relief in Sight." Chronic pain is an epidemic in the United States. It is often misunderstood and frequently mistreated. While opioid treatment remains controversial, it is clear that governmental regulations often create a chilling effect and a true barrier for patients and clinicians to work together. Articles like yours make a difference by making the public aware of this problem.

The American Academy of Pain Management credentials multidisciplinary pain management clinicians through board certification and program accreditation. In addition, we publish a directory of board-certified pain management clinicians, accredited programs, and a directory of pain clinics. This information is free on the Internet or may be obtained through a mailed directory. Our e-mail address is [e-mail], and our Web address is http://www.aapainmanage.org

Richard S. Weiner, Ph.D.
Executive Director
American Academy of  Pain Management
Sonora, CA

"No Relief in Sight" deals with a topic of general interest, as indicated by a recent 60 Minutes report on the same subject. Unfortunately, not only was the topic similar but the author also used many of the intellectually bankrupt methods typically employed by that TV program.

Before I begin a critique, it is appropriate that I indicate my qualifications. I have M.D. and Ph.D. degrees from Washington University Medical School in St. Louis and was a faculty member at Yale University, the University of Minnesota, and the University of Cincinnati. Toxicology and therapeutic drug monitoring was an area of clinical practice when I was a member of the department of laboratory medicine at these various institutions. Currently, I do research at a biotech company.

The premise of the article--that physicians underutilize narcotic analgesics--has a component of truth which I shall endeavor to place in perspective. However, most good lies also have a component of truth which significantly contributes to their credibility. Perspective is important here, for all drugs have benefit and toxicity, and the former must be judged against the latter. A fatal fault in this article is the failure to provide the reader with the information and perspective necessary to make a rational judgment. Facts are omitted or slanted, anecdotes are told to create empathy for the author's thesis, and "expert" comments are applied out of context or are not representative of the field.

If I were to write an article of the opposite bias, I might begin with a mirror-image anecdote to gain sympathy. Recently, Larry King interviewed Johnny Cash, who had a series of operations to correct a jaw injury. This famous singer could barely talk, let alone sing, without medication of the type described by the author. However, unlike any of the characters in the author's article, Mr. Cash became addicted to these drugs. He has been in and out of treatment for this addiction ever since. Mr. Cash is only one of many celebrities who have required treatment for addiction to painkillers, yet none of them appeared in the article.

The article fails to accurately describe the toxicity of narcotics. The author states that "compared to other pharmaceuticals, opioids are remarkably safe: The most serious side effect of long-term use is usually constipation, whereas over-the counter analgesics can cause stomach, kidney, and liver damage." In fact, opioids are lethal. As the book The Pharmacological Basis of Therapeutics says: "By the time he is seen by the physician, the patient who has taken an overdose of an opioid is usually asleep or stuporous. If a large overdose is taken, he cannot be aroused and may be in a profound coma. The respiratory rate is quite low (sometimes only 2 to 4 per minute), and cyanosis may be present. As the respiratory exchange becomes poorer, blood pressure…falls progressively….If hypoxia persists untreated, however, there may be capillary damage, and measures to combat shock may then be required….Urine formation is depressed. Body temperature falls, and the skin becomes cold and clammy. The skeletal muscles are flaccid, the jaw relaxed, and the tongue may fall back and block the airway. Frank convulsions may occasionally be noted….When death occurs, it is nearly always due to respiratory failure…or as a result of complications such as pneumonia or shock that develop during the period of coma."

As a wide variety of drugs are classified as opioids, crucial reactions may vary over the class. Nonetheless, the toxicities of the commonly used drugs such as morphine, meperidine, and codeine include respiratory depression, nausea, vomiting, dizziness, mental clouding, dysphoria, urinary retention, and hypotension. Frequently prescribed opioids like propoxyphene (used in Darvon) can have additional effects such as convulsions and toxic psychosis.

Finally, there is the addictive potential of these drugs. The consensus is that with proper use, rates are not high but they are significant. Unfortunately, adequate studies are hard to find. However, the rates are sufficiently high that a significant number of patients will experience addiction. Thus, the drugs need to be used with strict supervision in the appropriate setting to minimize addiction with its debilitating consequences.

The author fails to understand how the conditions of use can affect the addictive potential of the drug. His initial anecdotes concern treatment of chronic pain in outpatients. He also reflects on the use of these drugs by patients with terminal cancer and quotes health care professional in regard to these patients without drawing a clear distinction. He further muddies the waters by mixing the acute treatment of pain in the hospital with that of chronic pain patients. As an example, he cites 11,882 hospitalized patients treated, with only 0.034 percent becoming addicted. Later in that paragraph he cites 38 chronic pain patients of which two became addicted. The difference between the two groups is compelling: The hospitalized patients had an addiction rate of 0.034 percent, whereas the chronic pain patients had a rate of 6 percent. Thus, the two groups differ almost 200-fold in potential for addiction. The ramifications of an addictive rate of 6 percent are catastrophic and unacceptable. (To some extent I am playing the author's game here by over-interpreting data on a population that is too small for statistical significance and is poorly characterized clinically and demographically.)

A rational reader without prior medical training could easily draw unreasonable conclusions from this article. The information in it can lead the untrained reader to conclude that narcotic analgesics are safe--even safer than aspirin or acetaminophen (Tylenol), the "over-the-counter analgesics [which] can cause stomach, kidney, and liver damage." The reader might reasonably act on this information and substitute these "safe" (opioid) medications for aspirin or acetaminophen for headache relief. The consequence to the unsuspecting reader could easily be addiction, if not the acute toxicities noted above. I can only hope that one of your readers does not take the medical information in your article seriously and suffer consequences because of it. If nothing else this untoward potential should alert you to the care necessary when you indulge in writing medical articles. That care was not taken in this case. Thus, the article does a disservice to its readers because of an unintended but potentially lethal medical consequence.

The regulations and intimidation cited in the article are a good example of what happens when medical decisions are left to those not trained in medicine. Let us not conclude that the consequences of these regulations and our abhorrence of them indicate that the drugs they regulate are benign. The regulations are not benign and neither are the drugs. The author should have stuck to the issue of regulatory intimidation and not strayed into interpretation of medical data.

William Vine, M.D., Ph.D.
San Diego, CA

Jacob Sullum replies: I thank Mr. O'Hara and Mr. Weiner for their letters. The responses to my article, including several private communications from physicians, have been uniformly positive, with the exception of Dr. Vine's lengthy complaint. I am a bit puzzled by his condescending attitude, especially since he seems to agree with my thesis. I plead guilty to the crime of using anecdotes "to create empathy"; lock me up, along with every other journalist. As for the rest of the charges…

Dr. Vine accuses me of using "intellectually bankrupt methods," yet he fails to cite a single inaccuracy, logical fallacy, or piece of countervailing research. By using scare quotes, he insinuates that my sources are not really experts, but he does not explain the basis for that judgment. He says I used their comments "out of context," but he does not offer any examples.

When he gets down to specifics, Dr. Vine objects to my statement that, "compared to other pharmaceuticals, opioids are remarkably safe: The most serious side effect of long-term use is usually constipation, whereas over-the-counter analgesics can cause stomach, kidney, and liver damage." I was referring to long-term use of high doses for the treatment of chronic pain. In this context, opioids generally are preferable to aspirin, acetaminophen, and ibuprofen. Some patients treated with narcotics experience side effects other than constipation, including those cited by Dr. Vine, but these are either unusual or less serious. More important, opioids do not cause organ damage, even in people who take large doses every day for years.

Dr. Vine notes that "opioids are lethal," but so is any drug (including aspirin) in a large enough dose. In discussing the long-term safety of narcotics for the treatment of chronic pain, I assumed, not unreasonably, that doctors would not prescribe lethal doses and that patients would follow their instructions. Since I described the case of a patient who failed to do so and died as a result (and also referred to "doses of narcotics that would kill the average person"), the risk of overdose should have been plain even to readers who had never heard that opioids can be fatal.

My article was about the impact of drug policy on pain treatment; it was not intended as a guide to the advantages and drawbacks of narcotics. The notion that my passing comment about long-term toxicity might lead someone to take (illicit?) opioids instead of Tylenol the next time he gets a headache is a bit of a stretch, I think. And for the reasons outlined below, it is misleading to say that the result of such a decision "could easily be addiction." Even so, Dr. Vine's concern that I did not pay enough attention to the hazards of narcotics is reasonable. In an earlier draft of the article, I noted that some patients, including David Covillion, experience severe (though not life-threatening) side effects from opioids. That passage was eliminated during the editing process. Had space allowed, I would also have discussed the risk of respiratory depression, which can complicate the treatment of patients who are near death (though it is not an issue for chronic pain patients like Covillion).

Dr. Vine claims that I do not describe a single painkiller addict. I take it he does not count my references to addiction among Civil War veterans and patent medicine consumers, or my discussion of Mary Tyrone in A Long Day's Journey into Night (a character modeled after Eugene O'Neill's mother). Nor did he notice my description of drug abuse by one of William Hurwitz's patients. I suppose I could have thrown in Johnny Cash, and maybe Michael Jackson too, but somehow I doubt that would have satisfied Dr. Vine.

I never denied that some patients treated with narcotics continue taking them for non-medical reasons. I simply reiterated what appears to be the consensus among pain experts (in my reading and interviews, I did not come across any who disagreed): that such outcomes are rare. This conclusion, which Dr. Vine seems to concede, is supported by substantial research during the past few decades, including, but not limited to, the reports I cited.

Dr. Vine is correct that different studies in different contexts have found different rates of "addiction" or "drug abuse" that could be traced to pain treatment. It stands to reason that a patient who takes a narcotic for many years is more likely to get psychologically hooked on it than someone who gets a dose or two after surgery. But even in the study of chronic pain patients to which he refers, both individuals who developed problems had histories of drug abuse (as did Johnny Cash). This is an important fact, because it illustrates that addiction is not simply a drug effect; circumstances and personality play crucial roles in determining an individual's relationship with a given substance. That's why talking about a drug's "addictiveness" can be misleading. As former National Institute on Drug Abuse Director Charles Schuster, no wild-eyed drug legalizer, put it, "We have endowed these drugs with a mysterious power to enslave that is overrated."

Dr. Vine asserts that the "ramifications of an addictive rate of 6 percent" would be "catastrophic and unacceptable." Does he mean that, if this rate applied to chronic pain patients, they should not receive narcotics? Depending on who's counting, 5 percent to 10 percent of drinkers are alcoholics, yet we do not therefore conclude that no one should have access to alcohol, even though heavy drinking is far more debilitating than daily opioid use (assuming a reliable supply, no drug mixing, and sanitary injection practices). Surely the reason someone in pain wants opioids is at least as compelling as the reason someone unwinding after a hard day at work wants a beer or a cocktail.

Ba-a-a-d Example

I am writing in regards to "Eternal Life," an article by Jonathan Rauch which ran in REASON back in the August/September 1996 issue. Rauch's comments about the National Sheep Industry Improvement Center were incorrect and are continuing to result in inflammatory misinformation about the U.S. sheep industry as other publications--most recently the January 1997 issue of Reader's Digest--print excerpts from this one-sided, erroneous article.

Rauch started his article by writing about the wool subsidy established in 1954. That program was called the National Wool Act. It was enacted solely to level the financial playing field between U.S. sheep producers and their Australian and New Zealand counterparts, who were flooding the U.S. market with their products. What Rauch didn't include in his article is the fact that the Wool Act was phased out in 1993 under the guise of budget cuts. More important, he chose to omit the fact that the Wool Act was paid for by tariffs at no cost to taxpayers.

Since the Wool Act's three-year phase-out--which was completed last year--an estimated 25 percent of U.S. sheep producers have gone out of business. Their sudden withdrawal from the industry has resulted in crumbling infrastructure and economic losses, especially in rural communities where individuals derive a significant portion of their income from the U.S. sheep industry.

The National Sheep Industry Improvement Center addresses the U.S. sheep industry and rural economic development. It is not a continuation of the Wool Act, which provided payments directly to sheep producers, as Rauch said. It is a rural economic development program that will help rebuild the U.S. sheep industry's crumbling infrastructure.

It is only one of many programs designed to support America's working families who raise food and fiber, pay taxes, and support their communities. It is the industry's best hope for keeping alive an industry which economists estimate contributes $6.7 billion annually to the national economy. It is a $20 million one-time appropriation with a total of $50 million allowed over 10 years--a fraction of what's being collected through wool tariffs. It is an investment in American business and industry.

This working program for working families ought to be supported. Unfortunately, when irresponsible journalists like Jonathan Rauch start spreading misinformation and innuendos, the challenge for the U.S. sheep industry to persevere becomes unnecessarily more burdensome.

Steve Raftopoulos
President
American Sheep Industry Association
Englewood, CO

Jonathan Rauch replies: REASON readers can judge for themselves the importance of the National Sheep Industry Improvement Center. They can also weigh the rather bold argument that, because American consumers subsidize wool producers by paying tariffs, American taxpayers should also subsidize wool producers by financing a sheep industry center. But Steve Raftopoulos's sloppy letter does make me wonder whose article, if any, he actually read. He says, "What Rauch didn't include in his article is the fact that the Wool Act was phased out in 1993." I wrote: "Finally, in 1993, a Democratic Congress killed the whole thing." He says that the sheep center "is not a continuation of the Wool Act, as Rauch said." I wrote that the center is a new program enacted in 1996, empowered to "enhance production and marketing of sheep or goat products in the United States"--a direct quotation from the law.

To call any journalist an "irresponsible" spreader of "misinformation and innuendos" requires, it seems to me, the citation of at least one contrary fact. Otherwise, to whom does the charge stick?

Gay Rites

Nick Gillespie defends homosexual marriage on the basis of "free choice" and of the inevitability that our "evolutionary" society will ratify it in his editorial "Wedding Bell News" (December). Yet he fails to recognize that one person's choice in our complex society can never occur in a social vacuum where other citizens' equal right to choice is not infringed upon, or denied outright. Homosexuals may be free to choose their lifestyle, but government is not free to coerce other Americans into legitimizing such behavior.

When government, in the name of a city council, a governor, a legislature, or the U.S. Supreme Court, attempts to coerce citizens into legitimizing, crediting, affirming, and paying for homosexual behavior, whether dressed up in wedding gowns or any other garb, it is a violation of the American citizen's fundamental right to conscience, privacy, association, and, yes, our fundamental right to discriminate among personal behavior patterns, no matter whose. It is by precisely such coercion, as manifested by the Supreme Court when it provided near protected class status in response to Colorado's Amendment 2, that government loses its legitimacy.

Gillespie is correct when he tells us that a private employer has the right to offer employee benefits to anyone it chooses to, including homosexual partners. Consumers have an equal right to take such corporate policy into account in the marketplace.

By ratifying homosexual choice as part of society's evolution, Gillespie seems prepared to deny the rest of society their equal right to affect that evolution as they see fit. If Gillespie's comments represent contemporary libertarianism, it is not difficult to see why libertarians have such a difficult time in the political marketplace.

Whitney H. Galbraith
Editor
Rights In America
Colorado Springs, CO

The first two issues of REASON to show up in my mailbox left me feeling vaguely uneasy. I now understand why: There is no reason behind REASON. With no appeal to natural law, you have lost all force of moral persuasion. Nothing is left but personal preference. If my preference is otherwise, you can only whine in the wind or else bring down on me the compelling force of the state, which appears to be against your preference (today).

Personal preference, even though espoused by the majority, is a rotten basis for public policy. Personal choices usually have consequences that impact other people, and conversely, public policy guides personal choices. When marriage is nothing more than an adult consensual relationship, nobody has the motivation to work through the difficulties necessary to make it work in tough times as well as good, and if we cannot keep our commitments to family, what motive is there to do so for work or the neighborhood or the country? Children who have not yet developed moral habits understand this far better than adults. That is why the only reliable predictor for crime in the streets in the United States today is the lack of fathers in the home. We need one man and one woman, married and committed to each other. No civilization in recorded history has survived the breakdown of traditional marriage. We will not be the first.

The whole purpose for marriage benefits in the workplace and from government is to encourage that social good, and (by implication) to deprecate the alternatives. IBM lamentably has joined Disney and AT&T in being part of the problem; Congress, for a change in this one case, is becoming part of the solution.

Tom Pittman

"Wedding Bell News" misses the point, which is that the government has no business trying to shape social policy through tax policy in the first place. The benefits accruing to heterosexual marriage through the asinine, though admittedly warm and fuzzy, actions of our government were an attempt to provide for the well-being of the family, consisting, it was thought, of a man and a woman and their offspring. If the government had been willing to allow employers to pay employees whatever they were worth, in cash, and employees to know that they were going to have to take care of themselves, this whole question of homosexual marriage would be moot, since there would be no cash value to the institution.

Heterosexuals, homosexuals, molesters of beasts of the field, onanists, and those who have found other alternatives, all have exactly the same rights, and they are listed in the Constitution and the Bill of Rights. All else is tinkering. What is needed is not globules of gushing goo about how they should have just as many rights and privileges as them, poured forth in order that we may stand back and exclaim "what a good boy am I!," but a determined effort to drive government out of the business of running our lives. That accomplished, those people who stole the word gay and made it into something dirty won't have to whine and whimper; there will be no profit in it.

R.L. Fenerty
Turbotville, PA

Nick Gillespie replies: Why is it that few topics arouse more ire than those relating to homosexuality or, more precisely, public policy as it relates to gays and lesbians? My editorial did not examine whether the various government subsidies to heterosexual marriage, such as tax breaks, were a good thing. Asinine wouldn't be my first choice as an adjective, but I essentially agree with R.L. Fenerty that such policies are misguided.

However, I believe Fenerty misses one of the major functions of matrimony by assuming that gays merely want to realize the "cash value to the institution." Apart from potential tax savings (or penalties, depending on the relative earnings of the people involved), marriage also serves as a public declaration of feelings--and an acceptance of the various rights and responsibilities explicitly and implicitly spelled out in the marriage contract. If the federal government wishes to promote "responsible" behavior (as it always claims to), the Defense of Marriage Act strikes me as an odd bit of legislation.

In general, I also agree with Whitney H. Galbraith that the government should not be "free to coerce Americans into legitimizing" behavior which they find immoral and distasteful, and that citizens have "fundamental rights to conscience, privacy, association and dis- crimina[tion]." Those are reasons for advocating a minimal state--no one should be forced into supporting something they decry (including, perhaps, heterosexual marriage). Better we have a neutral referee that allows individuals and voluntary associations the greatest latitude possible in living their lives (the limit being, of course, infringement on others' equal rights). Galbraith, however, mistakenly draws an equivalence between a private employer and the state. IBM can only set policy for its employees and perhaps its customers, both of whom can leave whenever they want. While private employers should have a much freer hand in setting policy, the government, precisely because it has a monopoly on force, must be held to a different standard--one that rejects simple majoritarianism as a means of setting policy.

Tom Pittman accuses REASON of having "lost all force of moral persuasion" by espousing naught "but personal preference." What can I say? Perhaps the moral argument that individuals are ends in themselves doesn't move Mr. Pittman, whose recourse to "natural law" is opaque at best. His invocation of the "traditional marriage" certainly doesn't move me. Traditional in what sense and for what period? The institution of marriage continues to evolve over time; as Ludwig von Mises has pointed out, for instance, the idea of a marriage contract that treats men and women as equals is a relatively recent development and "a branch of the great liberal movement." Mr. Pittman's conflation of marriage with child rearing ignores the fact that many heterosexual couples cannot or choose not to have children. Apparently, his "natural law" would dissolve such "unnatural" arrangements. Finally, although tax laws make non-wage benefits relatively cheaper for employers and employee alike, businesses do not offer compensation of any kind primarily for a "social good." They do so to hold on to productive workers in a competitive marketplace.

Trade Disputes

In his review of my book Opening America's Market: U.S. Foreign Trade Policy Since 1776 ("Trade Happens," January), Ramesh Ponnuru misrepresents my views. He asserts that "Eckes attributes the election of the Republican Congress in 1994 to public anger over the North American Free Trade Agreement," and then attempts to ridicule that interpretation. Unfortunately for Ponnuru, he attacks a straw argument. Nowhere in the book do I make that simplistic claim. My interpretation is more complex: "Economic insecurity, including anxiety over globalization, job losses, and declining living standards, contributed importantly to this outcome."

This slipshod example typifies Ponnuru's superficial review. He faults the book for not giving enough attention to persons (like Albert Gallatin and Thomas Jefferson) and topics (the tariff during the Civil War, the arguments of early American free traders) that he deems important. This is arrogance at its worst. A reviewer can always slam an author for not writing the reviewer's ideal book.

Finally, Ponnuru seems to think that my facts do not square with his theories. This is the criticism historians frequently hear from amateurs and polemicists ignorant of the documentary record. Ponnuru needs to visit the National Archives and gather some dust under his fingernails reading primary sources. Familiarity with the documents might jar his sophomoric illusions about protectionism and Smoot-Hawley.

Alfred Eckes
Ohio University
Athens, OH

Ramesh Ponnuru replies: Despite Prof. Eckes's scholarly letter, I still don't quite understand why voters worried about "globalization" would have elected Republican congressmen, who tended to support NAFTA. But I'll confess to slightly oversimplifying Eckes's claim if he owns up to the statistical chicanery and slippery arguments which I exposed and which he now passes over in understandable silence. If he rereads my review, Eckes will see that I didn't fault him simply because he paid insufficient attention to figures like Jefferson and Gallatin, but because his attention was so selective and tendentious as to misrepresent their views. Prof. Eckes evidently believes that his archival work, impressive in some respects, entitles him to use such tactics and even to dispense with logic. I suspect I will not be able to argue him out of that position.