David Nagel, MD
“Happy Pain Awareness Month!”
On September 1st, I received an email from a friend proclaiming those words. To celebrate the event, I went to work and experienced what has become a daily ritual. A patient, Mr. S, told me his physician would no longer prescribe opioids for him, stating he could no longer do so because of our “governor’s new law.” That was a blatant lie. Still, I understood his fears. This physician had treated Mr. S with opioids for twenty years. He had been a model patient, working at an executive level. His dose was remarkably stable over the years, and, because of the medication was able to function at a high level. Mr. S was freaking out, wondering how he would be able to maintain his demanding pace without it. He like, many other patients, wondered out loud why he should have to suffer unnecessarily because of the mis-behavior of addicts.
It is a story I hear nearly every day.
Fittingly, this month I celebrate my thirtieth year as a pain management specialist. I recall my early years. We knew very little as we were taught very little. We flew by the seat of our pants, and were told everything we were doing was sacrilegious, unethical. We were ostracized as much as the patients we were seeing. We persevered because we came to understand our patients were suffering from very real problems and deserved much more respect than they were receiving from the health care community and society as a whole.
Armed with that belief, it was a natural for me to become involved in advocacy. This is not a natural role for me. I am not a fighter. Too often, I will walk away from confrontation. This was a fight that I could not escape. In 1998, after sending an innocent email to colleague, wherein I expressed concern about the lack of a public policy on opioid prescribing in New Hampshire, I was asked to help found the New Hampshire Pain Task Force. Our first charge was to develop such a policy. Our goal, as we saw it, was to ensure that those in pain had access to pain medication, and their doctors had a right to prescribe it without undue pressure from regulatory agencies. The Federation of State Medical Boards made our job easier by releasing their model policy that same year, which we adopted. In doing this, contrary to current public criticism, we were not naïve. We believed that opioids had a role in managing pain for some patients. We believed it was the obligation of health care professionals to become knowledgeable in how to use this mode of treatment, and how to manage pain in general. We acknowledged the risks including addiction, but we believed this risk to be exaggerated. We pointed out the two parallel health care crises of poorly managed chronic pain and prescription drug addiction, the former greatly out-numbering the latter, and that public policies directed at both, often conflicting, were harmful to both. We believed a balanced policy was necessary, and we offered our services in making this happen.
I still believe everything we said. So, what happened? Albert Schweitzer said that “Pain is the most terrible of all the lords of mankind.” As a physician, and a human, I find it very difficult to be in the presence of someone who is suffering. Perhaps that is why my colleagues and I are so good at delegating this responsibility to nurses. It is so much easier to walk away. Still, there is a terrible uneasiness one feels when doing so. When I first chose to prescribe pain medication for someone greatly suffering, I was surprised to see the relief on the faces of my fellow doctors and nurses, people who would have been just as willing to criticize me for doing so. The year was 1987, and that was not something I was supposed to be doing. I did not think it to be a courageous act, but I found it had the effect of treating both my patient and those ministering to him. So emboldened, I advocated for change.
In the subsequent decade, the promotion of opioids for the management of chronic pain became commonplace, perhaps even “cool.” Many more lives were improved than harmed, and many were saved. There is no medical intervention that is without risk, and opioids have theirs as well. It is my impression that prescribing became too easy. The prescription floodgates went from a trickle to a torrent, serving an important purpose for previously impotent providers who were in need to have some tool to manage suffering; that of their patient and their own.
This dramatic change did not go un-noticed in our task force. We believed doctors really needed to develop the skills to prescribe opioids, a step that seemed to be overlooked. The decision to prescribe an opioid is not easy. There are many considerations. In our state, we provided Scott Fishman’s book; Responsible Opioid Prescribing A physician’s Guide to all physicians. I believe it was the rare physician who either read the book or were even aware the state rules existed. Using the physician mantra of “see one, do one, teach one,” prescribing for acute and chronic pain proliferated in the absence of these prescribing skills. We became aware of the growing problem when we created the Prescription Drug Abuse task force in 2003. I find it interesting in retrospect, how un-noticed our efforts went in the law enforcement community, the same individuals who are now blaming physicians for the crisis. The net effect was flooding the community with cheap and available prescription opioids more in-directly than directly, and certainly not intentionally.
So, who was using these readily available opioids? Were we really creating new addicts? I don’t think so. While there may be an opioid crisis, it is not at all clear there is an addiction crisis. It is my impression addicts are switching from one drug to another. Addicts follow the economic law of supply and demand. They use whatever is cheap and available. It is my belief that when opioids became cheap and available, addicts shifted their behavior to these more dangerous drugs. It is also becoming increasingly clear that prescription opioids were not the not the only source fueling this increasingly out of control problem. It is important to ask the question: why are street drugs such as fentanyl and heroin so cheap and available as well? While doctors do have some role in the creation of the opioid crisis, it is quite apparent that the problem is much more complicated than policy makers and law enforcement officials believe it to be. Many fail to acknowledge the rights of those who suffer from pain to have access to reasonable treatment modalities including opioids. The myopic public policies that have proliferated as a means of controlling the opioid crisis reflect this.
It is my perception that we have a problem of both over and under prescribing. Many patients who don’t need opioids receive them too often in too high a quantity. Many patients who could benefit are denied access by providers who are either afraid of the potential ramifications or who have mis-guided pre-conceived notions about those who suffer from pain. Since the passage of the CDC guidelines, we are seeing a growing third public policy crisis, that of “opioid refugees” (the other two being chronic pain as its own entity and addition). These are patients, like Mr. S who have been successfully managed with opioids for many years who can no longer find someone willing to prescribe. Where do they turn? They either go without or they seek other sources, street sources… or they die, just another overdose statistic, because that is the route they usually take.
It is 1987 all over again.
Patients are angry, and they have every right to be. They feel abandoned by a health care system, a public policy apparatus, and a law enforcement community that myopically and arbitrarily has the chosen the needs of the few, those who suffer from opioid addiction, over the needs of the many, those who suffer from chronic pain. I feel this anger every time I see a patient or give a talk. I recently gave a talk to the Marfan Foundation. One skill I do have is the ability to assess the feelings of those I am speaking to. My audience was angry, and I sensed the anger was directed at me, a pain specialist and a physician. Rather than bore them with a prepared talk, I turned the session into a dialogue, and the reasons for their anger became apparent. In some ways, the net effect was therapeutic. They were not alone. Neither was I.
So, are we on a bridge to nowhere? I believe we are. After 30 years in the field, it is hard to not be discouraged. The problem with the pain hierarchy is that those who suffer have the least power. That needs to change. The problem of pain and public policy is like a large tree that we are trying to fell with a hatchet. What is encouraging is a growing advocacy movement increasingly determined to take on this policy nightmare, one that hopefully can go toe to toe with the addiction community, not necessarily to their detriment, but hopefully to the benefit of both. The goals of the advocacy movement do not stop there, though. Beyond seeking the recognition of chronic pain as its own medical condition worthy of respect, they also seek access to other therapies, either those already existing or the development of new ones. It is sad that the public policy apparatus is oblivious to this. That also needs to change.
Hopefully, together, we can turn the hatchet into a very loud chainsaw and force change.
Happy pain awareness month!
David Nagel, MD is the author of Needless Suffering, How Society Fails Those with Chronic Pain, and is a frequent contributor to the National Pain Report.