Pseudoaddicts vs. Pseudopatients

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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.

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  1. Actually, it seems more like “pseudo-addicts and pseudo-patients” vs. “pseudo-doctors.”

  2. An indirect solution to the rising health care costs have been found. Start suing the DEA for malpractice! Should be easy since I am sure none of the agents and Asscrack have a medical lincense allowing them to practice medicine.

  3. US pain doctors are permanently in an “internment camp,” with Colonel Klink being so kind as to nail the Cider House Rules to the walls.

  4. If all medicines (drugs or whatever you choose to call them) were legal and available, then we could all make our own choices, isn’t that what freedom is all about. I feel sure we could all make better choices than the DEA.

  5. I spent 11 nomths in prison for forging prescriptions, which I needed for pain and couldn’t get through regular channels. Now I’m on much stronger pain relievers,(largely through the intervention of my Parole officer!) and doing better. If only doctors didn’t have the responsibility/power of the prescription pad! What does that make me? Pseudocriminal???

  6. The problem with reasonableness AND a hard and fast line comes from the fact that when you’re talking about pain they are the same thing.

  7. Fuck the DEA!

  8. Legend,

    Since you were imprisoned for something that shouldn’t be a crime, I’d say the term “pseudo-criminal” is a good one. The people who imprisoned you were just criminals.

  9. This story illustrates a general problem with government regulations. The politicians and regulators have no idea what is actually like to be subject to the regulations they impose. They do not understand the difference between statements of principles and concrete action.

    Out in the real world people who will face the force of law if they fail must turn vague statements of principle like “reasonable” and “good faith” into hard numbers of pills prescribed or money spent. They will have no way of knowing what numbers constitutes “reasonable” until they have been prosecuted.

    Vague laws do not seem a problem until one has to actually try to comply with them. When your freedom and livelihood are on the line you want hard and fast lines clearly delineating what you can and cannot do instead of someone waving their hand and saying you’re fine as long as you actions are “reasonable.”

  10. Actually, Shannon, that’s only a problem when the people who are making the judgement call don’t have the credibility to do so. If the AMA, for example, was charged with deciding these cases on an individual basis, rather than the drug warriors, I don’t think there would be a problem with regulations that reference reasonableness.

  11. Most “crime” is defined into existence as part of a make-work plan for police and their support bureaucrats.

  12. “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”–”

    I wonder if this “profile” includes white, male, fat, high-income, fascist radio hosts who support the drug war?

  13. Ironically, it was the RL incident that got me “out of the closet”, so to speak. I knew I needed to relieve my pain, but I was still a little bit confused and ashamed at being an ex-con. But, if someone so anti-drug (publically, at least) could have done something so similar to what I had done, I felt that I had not only the permission, but the duty to speak out!

    BTW, I met Mr. Sullum at the MLP convention, and won one of the copies of his book, “Saying Yes”. Hope he writes one on this kind of “drug abuse”. If you do, JS, my writing and file are at your disposal! In any case, keep up the good work!!!

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