Last week the Drug Enforcement Administration published a set of 28 "frequently asked questions" about pain treatment. The pamphlet, which was produced in consultation with pain experts, is ostensibly aimed at reassuring physicians that they need not worry about getting into legal trouble for prescribing narcotic painkillers, as long as they do so in good faith and with due care.
I'm not sure it will accomplish that goal, since the DEA's tips on how to avoid trouble are rather daunting. In a section about when to consult with specialists, for example, the DEA advises: "In some situations, consultation prior to, or during, opioid therapy may be requested solely to address the concern that specialist review would be reassuring to a regulator should the therapy ever be questioned. Although this is not a medical justification per se, it may be appropriate given the evolving nature of opioid therapy in medical care."
Likewise, it may seem generous for the DEA to admit that "any physician can be duped" by fakers looking to get high or sell drugs on the black market. But the solution it offers–that physicians should familiarize themselves with the DEA's guidelines on "how to spot a drug abuser"–is bound to make doctors wonder what happens if they fail to apply these suggestions the way the DEA thinks they should. In this context, the pamphlet's description of "pseudoaddiction"–"an iatrogenic phenomenon in which a patient with undertreated pain is perceived by health care professionals to exhibit behaviors similar to those seen in addiction but is not true addiction"–is both welcome and worrisome.
Still, the pamphlet includes some important clarifications. "Unlike tolerance or physical dependence," it explains, "addiction is not a predictable effect of drug exposure but represents an idiosyncratic adverse reaction in biologically and psychosocially vulnerable individuals, for which drug exposure is only one of the etiologic factors. Simple exposure to opioids does not produce addiction." Confusion on this point, the DEA notes, "can lead to the withholding of opioid medication because of a mistaken belief a patient is addicted when he or she is merely physically dependent," to "inappropriate targeting of practitioners and patients for investigation and prosecution," and to "excessive and unfounded fear of opioid use among patients and the public."
The very existence of this pamphlet testifies to the chilling effect that drug law enforcement has on pain treatment–a phenomenon the DEA has long sought to minimize or deny. "Society has a compelling interest in ensuring both the ready access to controlled prescription drugs when medically needed and ongoing efforts to minimize their abuse and diversion," the DEA pamphlet says. "These two goals are not in conflict; they coexist and must be balanced." Yet it's obvious from all the talk of striking a "balance" between diversion control and pain treatment that the two goals do come into conflict. Since pain cannot be objectively verified–as the DEA pamphlet notes, "Self-report is the 'gold standard' for pain measurement"–it's impossible to make sure that no one uses prescription painkillers for nonmedical purposes without condemning many legitimate patients to unrelieved suffering.