Gotta Hurt

The irreconcilable conflict between drug control and pain control

As part of its recently unveiled "strategy to confront the illegal diversion and abuse of prescription drugs," the federal government promises to close down pharmacies that sell narcotic painkillers online. After all, only druggies need to purchase Vicodin through the online "pill mills" that "bypass traditional regulations," selling to anyone who fills out a questionnaire. People with a legitimate medical need for such drugs can always get prescriptions from their doctors.

Don't you believe it. Swayed by anti-drug propaganda and anxious to avoid legal trouble, physicians are so leery of these drugs that researchers have given their attitude a name: "opiophobia," an unreasonable fear of narcotics that leads to untold suffering by millions of Americans. Opiophobia intensifies every time the government announces a crackdown like this one.

I have a friend (let's call her Marcy) who periodically suffers from severe neck and shoulder pain, sometimes accompanied by splitting headaches that can last for days. During one of these bouts, she tried Vicodin (a combination of the opioid hydrocodone and acetaminophen), which she had left over from a prescription she received after knee surgery. It worked much better than the ibuprofen she usually took, cutting short the headaches and making the neck and shoulder pain bearable.

After she used up the Vicodin, Marcy discovered that her doctor was unwilling to prescribe more, even as she warned Marcy that continuing to take large doses of ibuprofen could damage her liver. The doctor suggested muscle relaxants, physical therapy, acupuncture—anything but the medicine that Marcy knew would work. The doctor explained that such drugs "can be habit-forming."

In Marcy's case, this concern was ridiculous. She did not even like the psychoactive effects of hydrocodone; she took the pills only when she was in serious physical pain—not every day, not every week, not even every month. A bottle of 90 would last her more than a year.

Yet Marcy's doctor was implicitly telling her it was better for her to suffer (or continue using a less effective, more dangerous medicine) than to take the essentially nonexistent chance that she would become a Vicodin junkie. That's how Marcy became a customer of one of those online pharmacies the government wants to put out of business. She continues to use the pills only when necessary and has never been tempted to do otherwise.

Contrary to what the government would have you believe, Marcy is not unusual in this respect. Research consistently has found that patients who use narcotics for pain rarely become addicted to them, and those who do typically had pre-existing drug problems.

It is simply not true, as Rush Limbaugh implied when he blamed his pill habit on "highly addictive medication," that opioids have an irresistible power to enslave people. They are only as powerful as people's reasons for using them.

The government demands that doctors figure out what those reasons are, threatening them with loss of their licenses and criminal prosecution if they fail to do so accurately. But doctors are not mind readers, and pain cannot be objectively verified. Faced with a choice of trusting their patients or protecting their livelihoods, they often will choose to play it safe, as Marcy's doctor did.

And Marcy is relatively lucky. For patients who suffer not from occasional bouts of pain but from constant agony that can be kept at bay only with large doses of opioids, getting relief is both more important and more difficult. Desperately searching for someone who is willing to treat them over the long term, they begin to look more and more like "doctor shoppers," the malingering addicts the government tells physicians to avoid.

By raising the volume of such warnings and encouraging the proliferation of prescription monitoring programs that look over doctors' shoulders as they decide whether to believe their patients, the government inevitably will compound the already scandalous problem of undertreated pain. In response to such concerns, federal officials assure us that nonmedical use can be prevented even while making sure that pain is adequately treated. But these two goals are fundamentally irreconcilable, because doctors will never be omniscient gatekeepers.

The Office of National Drug Policy says "more than 10 million Americans suffer from chronic pain." According to the American Pain Foundation, the number is more like 50 million. That disparity, which suggests the extent to which drug warriors underplay the need for narcotics, gives you a sense of the gap between the government's assurances and the painful reality.