Tale of Two Suicides; Lessons for Opioid Public Policy

Tale of Two Suicides; Lessons for Opioid Public Policy

David_J_Nagel_MD_2

David J. Nagel, MD

For one it was the best of times, for the other, the worst.  At no time did the paths of their lives cross, but they shared the same fate, one most would consider a tragedy.  Their legacies, for pain and public policy, could not have been more different…

I knew one, only heard of the other; both dramatically affected my life.

Bob was a marine.  He had valiantly served his country, and he was proud of it.  His identity was so tied to his service that he could not handle the thought of being any less of a marine, a warrior… a man, whatever that means. His back injury robbed him of that identity, and he struggled in a futile attempt to regain that which he no longer was, or, at least thought he was.  Perception is reality, and his perception was that he was no longer what he wanted to be, needed to be.

Surgeries and elixers, therapies traditional and non-traditional.  All tried in a vain attempt to rid himself his pain.  All failed.  Some made his pain worse.

He used pain meds to numb the pain, but they couldn’t restore his manhood.  In desperation, he kept taking more and more.  After a while, he gave up the hope for a cure.  He was a broken man, not just physically, but also mentally and spiritually.  The meds became a temporary reprieve from his painful reality.

I was his doctor.  I never really saw that brave marine.  Rather, I saw a broken, staggering man, subservient to the world his pain had created for him.  Our goal for any treatment is to improve one’s function.  For many, opioids accomplish that.  Not for Bob.

In Bob, I saw a gradually fading light, one I felt that I desperately needed to find a way to re-ignite, if not for him, then for me.  Being in his presence was so challenging.  I had two options; I could fight or take flight.  For me, the latter was not an option.  I decided to fight.  One day I tried to challenge that marine, suggesting he could use that bravado that had served him so well in the past to challenge his pain, to find a way to survive, to thrive despite it, and, in so doing, find a sense of meaning in his life that was missing.  That needed to be his calling and was his only option.  I never really thought there was another option.  I told him that I could no longer prescribe the medication for him as I saw it harming more than helping.  I promised to be there for him throughout.

It was so strange, but he was instantly transfigured into the warrior he once had been, one who could and would take control, just not in the way I envisioned.  He suddenly stood tall.  Walking over to me, he placed his cane at my feet, saying he no longer needed it; in fact never needed it.  I know he did not stand at attention or salute me, but it seems like he did, and that is my final image of him.  He turned and walked confidently out the door.

I never saw him again.  That night, he died by his own hand.  Suicide.  It doesn’t really matter how, he just did.  Could have been a gun-shot.  Could have been a car accident.  He chose to take every pill he had.  It was not the meds that killed him.  It was his misperceptions and his pain, neither of which he could tolerate any longer.  That is not how the coroner saw it; accidental overdose he ruled it.  Kierkegaard said: “Once you label me you negate.”  By failing to describe in detail the reason for Bob’s demise, he negated him, and, is so doing harmed so many others.

When we look at the roll call of those who have died from drug overdose, the numbers never tell us why.  We really do not know the true secondary morbidity and mortality of chronic pain.  There is evidence to suggest that patients with chronic pain are 2-3x more likely to commit suicide and that most would choose drug overdose as their preferred means.  How many of those who have died from drug overdose are trying to escape their pain?  It is an important question to ask, but one we fail to.  Mistakenly categorizing these suicides as merely drug related harms much more than helps.

There were no candle-light vigils for Bob.  He was gone, and quickly forgotten.  Most palliated their grief by rationalizing his demise:

“He’s a in a better place, one without pain.”

It is amazing how well mental gymnastics can serve to alleviate our uncomfortable and unwelcome feelings; there but the grace of God, go I??  No, can’t be so.

Absent his palpable suffering, most were actually relieved.

I stare at his cane as I write these words.

*   *   *

Billy was an adventurer, a thrill seeker.  He never really served anyone but himself.  I’ll give him a pass.  He was young and stupid, like I had once been.  It has been said that it is a miracle anybody survives adolescence.  The difference between he and I was that I never intentionally challenged my mortality.

I never met Billy, but I knew plenty like him.  There is something we like, even admire, about thrill seekers, and Billy was no exception. All of his endeavors were greeted with accolades from those around him, whether he was getting or giving a head injury on the football field, breaking bones BMX bike racing, or whatever else he chose to do.  His parents were so proud.  The accolades were an elixir, one he longed for, no matter the setting.  He was addicted to them.  He was never one to back down from a challenge.  One day, his friend challenged him with some oxy’s.  So challenged, his fragile ego left him no out.  He took it.  80 mg.  Chewed it for the better high.  In short order, he was dead.  Technically it was not suicide, but you can only challenge your mortality so long before you lose, and such behavior is suicidal…

A young man lost, one with “his whole life in front of him.”  I struggle to understand what that actually means, but that is what we say.  Life is a gift, one we can use or abuse in any way we choose.  Our contributions to the whole of life are not measured in time, but, rather in the quality of our thoughts and actions.  We all make mistakes, but some, like Billy’s, are terminal.  Then there is no whole life in front of us, only behind, and all we are left with is a legacy.  Billy’s was not good.

It is customary to embellish those we lose.  Billy suddenly became a wonderful person, a role model, someone to emulate.  Awards were created in his name.  The community came together to mourn his loss.  His suddenly over-inflated image left no room for fault.  Someone was to blame for his demise, and it surely could not be him.  Doctors who prescribe pain medication and pain patients who can’t deal their pain took the fall.

Billy’s parents took to the legislature to exact vengeance.  While few would ever be driven to action to help Bob, there were many who sought to vindicate Billy.  There are few things more motivating than a grieving mother’s wailing, and the legislators were not immune.  Soon, laws were being enacted in a vain attempt to “stop the carnage.” In a world fueled more by emotion than reason, the land of “feel-good law,” the law of un-intended consequences reigns supreme.  Soon, laws were passed.  Addicts still died.  Those in pain struggled to find someone with the courage to defy those laws and care…and they died too, but their cries went unheard.

*   *   *

It is unfortunate that discussion about pain management seems to come down to opioids.  However, our options are limited and they will always be a part of the pain equation.  They occupy their dubious position because of their un-predictable ability to help or harm.  Depending on personal experiences, individuals choose sides, and arbitrarily define them as good or evil, black or white.  Nothing is ever so simple.  The aims of pain management and the treatment of drug abuse inevitably conflict, and that is the problem.  Somewhat paradoxically, despite their substantially smaller numbers, the cries of those who suffer from the ill effects of drug abuse overwhelm those who suffer from un-remitting pain, and the ramifications for public policy are huge.  However, it is not the addict in the street that inspires these modern day Spartans to win their legislative battles.  Rather, it is the Billy’s, the well off, the ones so like me and you that we seek to protect them, no matter who else we harm.  We certainly do not see a value in emphasizing the needs of those in pain, those we stigmatize, ostracize, and blame for their own infirmities.  They fight a losing battle in this legislative cataclysm.

We pay legislators to fix problems even if they are un-fixable.  Their chosen weapon is the creation of new law.  I would argue there are really three related crises in our culture:  addiction, chronic pain, and the excesses of government regulation.  I would argue that the last of these has created the greatest carnage in physical and human terms.  Still, legislators seek to fix complex problems with generic, all-encompassing laws which cannot possibly cover every contingency and often create more problems than they solve.  In the world of opioid legislation, the results are unnecessary barriers to prescribing.  While it is not clear what the effect on drug abuse is, the effect on the pain patient and his or her doctor is huge.

Fifteen years ago, I initiated a process of creating a set of opioid prescribing rules in our state that I envisioned would protect the rights of physicians to prescribe pain medication and the rights of patients to receive them.  My role as a physician is to care for those who are suffering, and after careful risk-benefit analysis, it is often my responsibility to prescribe these medications.  It is somewhat ironic that most of the patients I care for would do anything to rid themselves of these medications, ones we share a fear of, while, at the same time, addicts crave them.

As a physician, I have the right to assume that the person seeking my care is in legitimate need of help.  While I accept that addiction is an obsessive-compulsive disorder which creates great suffering for the addict and those around him or her, I resent that they would misrepresent themselves to me to obtain a legitimate drug for illicit use. Furthermore, I resent any attempt by legislators and law enforcement to create public policy to protect such individuals at the expense of my patients, something that is clearly happening.   I sought to create state rules which would emphasize the needs of those in pain, and, to some extent we kind of succeeded.

Recently, our state governor chose to dramatically alter those rules on an emergency basis.  Her motivation for doing this is open to question, and I will leave that to others to consider.   However, I was told the epidemic of death due to prescription and non-prescription opioid abuse was the reason.   To bolster her political position, she needed to do something.  To minimize public dialogue, initial discussions were held behind closed doors.  Had she been successful, it would have been extremely challenging for patients with any type of pain to receive care, acute or chronic, terminal or not.  There is no harder place to keep a secret than in the world of politics.  The word got out and it was exciting to watch a unified front of pain management advocates from all persuasions challenge her and block the full effect of the proposal.

The battle has only started, and it is not just in the legislatures, and not just in my state of New Hampshire.  It is also in courtroom. In the chilling wake of a second degree murder conviction for Dr. Hsiu-Ying “Lisa” Tseng, accused of prescribing opioids in the course of her practice that led to the deaths of three patients, I, like many others feel lost and vulnerable. Deputy Dist. Atty. John Niedermann, who argued the case against Dr. Tseng issued the threat:  The message this case sends is you can’t hide behind a white lab coat and commit crimes.  A lab coat and stethoscope are no shield.

The definition of the word “crime” is not always clear, and it was not clear in this case either.  Medical decisions often harm more than help; sometimes a death results.  Is that a sad twist of fate or is it a crime?  Many details are missing, and I am not a position to judge the actions of the doctor or the prosecutor, but I am not willing to give the latter a pass.  While we would like to assume that prosecutors are un-biased individuals who put the needs of the community against their own, the reality is that is often not true.  Often, they are flawed, myopic individuals who often selfishly use their position to climb the legal ladder, often caring little for whom they harm in the process.  The problem is these individuals are powerful and their actions have great potential to harm or help.  While I have no ability to assess Mr. Niedermann’s motivations nor the merits of his case against Dr. Teng, his quite bellicose statement has sent shockwaves throughout the pain management community, threatening the legitimate care that many patients seek and deserve.

Am I willing to risk jail to do what I think is right?

In the wake of these deaths, we are in severe need of guidance.  Aristotle said the law is reason free from passion.  In seeking a balanced solution, one which respects the needs of all, we seek reason, but passion is the rule of the day.  We must put passion to the side and objectively attend to the needs of Bob and Billy and all those who suffer.  Such a solution comes about only with great thought, communication, and energy. However, anything less cheats those who suffer, be it from pain or addiction.

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Authored by: David Nagel, MD

There are 25 comments for this article
  1. Justine Saine at 11:40 am

    I really hate to say this,but it sounds to me that tall officer was a facade,an attempt at not getting arrested for what he really wanted to say and do. He knew he wasnt going to get any more meds nd decided to end it. Thats really sad. Im not trying to mak you feel bad doc,but im just being honest. Alot of us have no light left,but that doesnt mean meds dont help. They help enough to keep us going and sonetimes thats all we will ever have,we have dealt with it. We accept it. Our familys feel so bad for us. They hurt because they cant do anything to help or fix it. But just be glad were still around, maybe we arent the best company,sometimes you wanta strangle us. We get it,we want get strangled most of the time. Were sick of ourselves but were here. For some,that alone just has to be enough.

  2. Dave at 5:47 am

    It’s plain to see pain care in America has become an interminable case of the blind men looking at the elephant- with the DEA, pain specialist, politician, mainstream doctor, pain care organization, pain sufferer asserting both their freedom to do as they please and claiming their vision of the elephant is the best. So we’ll continue to hear that the pain specialists couldnt be more right about pain care and that they need to be free of all who dont see things as they do. We’ll continue to hear from people in pain who just want to be free to take an opioid or have their insurer pay for denmai acupuncture or bikram yoga, of course. We’ll continue to hear that the DEA wants to be free to go after doctors and patients who may not be using medications as they see fit. Freedom-but no virtue or vision. Their narcisissm and lack of critical self reflection is only too apparent.
    Its clear that the pain specialist, the poltician, the person in pain glorifies their own wisdom and refuses to evolve beyond what they believe and do. Each aspect of our pain care system lacks vision and a willingness to evolve and make pain care much better or different then it is. Each doesnt believe that is necessary and each is quite certain of their own beliefs and values. And so again I say things in pain care wont become much better anytime soon-for no one wants to make a real effort to change the way they do things in a substantive way. Pain care-just like a Greek Tragedy writ large.

  3. Kristine (Krissy) at 9:35 pm

    Gnomic, I know what you mean…trapped. I don’t have that plant either, but wish I did. The problems that come up once you’ve found help, like new stuff (migraines, myalgia, etc.) are so disappointing. Keep writing replies to stories like this. Write to congress, write to newspapers and online pubs. Join pain websites if only just to write to them. We will get a voice. It’s just that the political process is long and painful, just like our lives. A stiff upper lip = if we can manage that, we can keep talking and standing up for our rights. If you live far from a doctor that would work out, some allow you to take 3 Rx slips with you for 3 months so you don’t have to go every month. I take 75 mcg Fentanyl patch, 40 mg of oxy and 2400 mg of Ibuprofen every day. That allows me to stay sane but not to do normal activities. I found a passion and I search and research on the Internet in bed and just read between sleeps. What is your favorite thing…start researching it and read, read, read. Write music, poems whatever it is you are interested in. It helps. Good luck and just hang in for a bit. Help is on the way.

  4. Gnomic at 6:52 pm

    For 3 years, starting in high school, I suffered thru PT, drugs, tens, more PT.. None of it helped. I eventually figured out how to deal with it. Then the migraines started. More drugs. Eventually they stopped. And the… Myalgia. And more drugs, including opioids, lyrics, muscle relaxants, Aleve, tramadol… And “controlled” is what the doctor calls it, but she doesn’t see the nights I can’t sleep, the dreams of burning, crushing, pain, the constant exhaustion. And I can’t find a pain management Doctor, neither can my doctor or insurance company. I’m slowly building up resistance, and can see my own slow decline.

    Oh, and there it a plant that offers some relief in some states. Not mine.

    Death, pain, exhaustion, feckless doctors, fear… Hey, I’m only clinically depressed. Wonder why.

    Trapped.

  5. Brooke Keefer at 4:53 pm

    Interesting thing happened when I went to a pain management doctor who turned out to be anti-narcotic pain medication and pro spinal cord stimulator. For some reason he felt compelled to tell me the story of a patient he had who was on narcotic pain meds. The doctor convinced the patient the meds were bad and he needed to get off them and get a spinal cord stimulator (by the way, this is very common). The doctor said his patient got little help from the spinal cord stimulator and it was because the patient wasn’t open-minded to the fact no matter what, he would always be in pain. The patient committed suicide and the doctor said, “I am telling you this because the stimulator worked for this man, but he was still in pain and couldn’t handle it.” Ok, my take away was, doctor, you took away his meds and undertreated chronic pain is enough to make anyone want to kill themselves. I know this dilemma. I ran far from this pain doctor and eventually found one who was open-minded to pain medication. My pain is not perfectly gone, but I absolutely have an incredible quality of life compared to when I was denied medication and a potential guinea pig for a stimulator, which there is no solid substantial evidence-base works for foot neuropathy and chronic pancreatitis. What I would like to know, is whether the author’s patient was provided adequate pain relief. Was it ever insinuated to the patient they were “less than” because they were on pain medication. Was pain medication reduced? I am hearing of many suicides occurring not because a patient couldn’t stand the pain anymore while being adequately treated with medication, but because they are being cut off, reduced, and demeaned as narcotic pain medication patients.

  6. Cynthia at 3:43 pm

    Dee, thank you for writing down your story. It is so powerful. I hope someone tells you where to send it so the powers that be can read it. They need to….

  7. Dee at 2:47 pm

    I am a 55 yo disabled ER nurse. I hurt my back very badly in 1996 while doing CPR on a 500lb patient on the floor. Over the years since I have developed severe Fibromyalgia and CFS among other diagnosises.I am unable to work. I received no pain medications from the time of injury until 2009. I suffered horribly over those years. Horribly. I went to pain centers and they gave me everything but narcotics. None worked. To numerous to count PT sessions, acupuncture, u name it I tried it. I wanted to seriously die. Finally when I was about to give up I was referred to a kindly older Physiatrist. He listened to my story with no judgement, no questions, and he put me on the Fentanyl Patch with Vicoprofen prn for breakthrough pain. Finally some relief. All those years of being called a drug abuser, drug seeker, crazy where finally over. I get no high from my meds, only pain relief. I want to live again. He retired but referred to another MD who carried on the regime. Suddenly months ago this new doctor decided she was not prescribing opioids anymore. To much pressure from the gov, pharmacists calling and of course problems with true drug seekers. I panicked and spent weeks in terrible angst about would my suffering return me to my bed. Thank God I found another pain management doctor who continued my meds. My life is impaired but I can live with that. I am glad I don’t get high or feel the need to abuse my meds. I have been on the same dose if not less for years. I worry for ppl who are losing the ability to get relief appropriately. It is no game to many ppl. This clamp down is causing ppl to turn to street drugs. I wish I didn’t need to take what I do but thank God again that I have legal access to a life, as small as it is. Providers and nurses, please think about me before you automatically assume narcotics equal drug abuser. There has to be a solution to this problem or more ppl will die.

  8. Kristine (Krissy) at 12:17 pm

    Come again? You have contradicted yourself, now can you explain this again please?

  9. Dave at 9:09 am

    Virchow said their are two causes of disease- pathological and political. For professionals to suggest that pain care could be free of politics, is remarkable and begs the question why we have government in the first place. It also betrays the fact that so many professionals are in charge of pain care in government and the rest of the country. I guess the fish are the last to discover the water. But it is tragic that professionals- be they pain specialists or physical therapists see themselves as blameless and perfect when it comes to their orientation to people in pain- what hubris. Moreover, it shows professionals are unwilling to make the effort to make pain care much better or different than it is. And this is the backstory to why pain care hasn’t evolved much over the past several years- too many proud and certain professionals unwilling to make much improvements in their practices. The same professionals sought to minimize the voice of people in pain weighing in on the National Pain Strategy- for they believed their professionalism was so perfect there was no need to hear from independent voices of people in pain. And the same professionals ill continue to give short shrift to any person in pain who doesn’t share their views. So clearly this article reflects that professionals don’t believe in democracy-they just believe in the freedom of professionals to treat people in pain anyway they wish to.
    Professionals who dominate political discussions in pain care, don’t allow people in pain their say in their care. If they did, we wouldn’t hear so much about the need for patient-centered care. They have done little to address the pain literacy of people in pain-again they believe perfect professionals are all that is needed to address
    Practitioners are not angels. The evidence is quite clear that proud and certain experts made a terrible mess of pain care and wish to blame anyone but themselves for the sorry state of affairs for people in pain. What hubris professionals have and what lack of ability to engage in reflective self practice.
    For people in pain to be heard by government or professionals they need a new, bold energetic bundle of rights- interesting how professionals don’t wish to talk about ensuring the rights of people in pain. Professionals seem to focus on their own rights to be concerned with the rights of people in pain.

  10. Cathy at 8:35 am

    Thank You Doctor!
    I am not as articulate as I used to be before 20 Years of Chronic Pain. I am afraid that next Month my Meds will be taken away. I am seeing a pattern of utter ridiculousness when it comes to Pain. I have had friends and acquaintances die in severe pain, and get denied treatment. It appears health providers won’t even acknowledge pain. I am also noticing they do not acknowledge other issues that might be complicated or cost the Provider money. The Hold of the Media, which only publishes the sensationalized distortions, Big Pharma which has it’s own agenda, and the insurance companies is just overwhelming. I studied Geology in College, one of my Professors claimed that “Geology is the only Science where opinions mean something.” Medicine is no longer Scientific, it is like it is based on old wives tales or whatever is convenient. I used to think that sooner or later someone in the Medical Field would catch on, but other than my PM Physician they do not.
    I feel like I am in the Movie “Idiocracy” when I speak up. I spoke to someone on the State Pharmacy Board a couple of years ago, explaining the situation, when they changed a Law and a lot of Pharmacies were not even stocking Pain Medications. All he could say was “Drugs are bad”, “people are dying from Drug overdoses.” We do have a drug problem in this area. But the heavy handed Policies have made things worse, while there seems to be no shortage of illegal drugs.
    I have noticed another pattern in Health Care, a subtle and not so subtle shaming of people with health issues, and not just Chronic Pain. People postpone or delay medical care, when it would have been healthier, more cost affective and even preventable to get a diagnosis. It is confounding. Nothing makes sense anymore, whether it is International Politics or local Policies. The System is broken. I used to have hope that things might improve, but no more, speaking up only made me a target. I have been waiting 2 Years for a Surgical consult, about an implant in my C-Spine. This type fails at a rate of 50 % at 5 Years, yet my PCP would not even acknowledge it’s existence. One way our local Medical providers have dealt with the ACA or just general greed is to not hire any new Neurologists, so they can’t diagnose those kinds of conditions. Our last one died over a Year ago, and no replacement. Anyone with a condition requiring a Neurologist would have to travel over an Hour. This is just one more way they are ignoring and denying pain and other Neurological conditions. I am seeing some people in the Health Care industry actually noticing the pattern, but they won’t speak of it. They just shut down.
    I have been following the News about the billion Dollar Insurance Industry and the Big Pharma Mergers, no Elected Official is speaking up. We have a “Health Care System” based on Propaganda and increasing profits, not Health. I am in my mid 50s and seeing a dystopian future, one that Science Fiction prepared me for. Anymore most of what we hear is Orwellian Double Speak! If dying people are denied pain care, because “they might get addicted” there is no sense in even arguing with people who think like that.

  11. Terri Lewis at 2:56 am

    Give pain a voice.
    Pain is not exclusive to patients. It creeps out on little cat feet to care partners and providers. As David points out so powerfully, we are all impacted by chronic pain.
    It is not the opioids that harm us.
    It is the influence of the community, positive and negative, on our relationship to health, wellness, and illness.
    Until we look this squarely in the face and make eye contact with it, we will make no progress in this discussion.
    Chronic pain is personal. The solution will never be political.

  12. Cynthia at 9:04 pm

    Thank you, Dr. Nagel, for this very good article. What a shame that doctors are being squeeZed now. My mother took her life because of pain and inoperable mouth/throat cancer. Her pain was never managed well and she was treated like an addict. So many mistakes are being made by people in power around this issue, and so many are suffering . Soon , it could be me. We are all at risk now.

  13. Jackie at 5:49 pm

    Have you wondered if telling Fred you were taking away his medication (his main means of controlling his unrelenting pain) may have in fact been the catalyst for his suicide? As a chronic pain sufferer I know a few sufferers who have done so when no longer able to get the medication they need. It is a very frightening thing to face the kind of pain you know is going to come. My pain is managed by opiates, but my strength fortunately comes from somewhere else.. So it’s never an option I would take, but I certainly understand why others may not want to have to deal with unremitting pain for the rest of their lives.

  14. Shari at 4:34 pm

    I have Chiari Malformation and EDS and several other chronic debilitating conditions. I am to the point that I have PTSD because of the treatment I have received due to patient profiling and being labeled a drug seeker. Because of this I am unable to go to any dr. and would rather die in my home than go to the ER because of severe anxiety just thinking about calling to make an appointment let alone actually go to it. I don’t drive and have been house bound since August ’14 and spend most of my days in bed or on the couch. That wasn’t the case when I was going to pain management. I actually engaged in life rather than waiting to die like I do now. I’m 43 I do not receive ssdi and live with family because I have a 9 year old daughter and I am unable to properly care for her! Physically or financially. The thought of living another 5 or 10 or 20 years like this is daunting to say the least! But as I hear far too often “it could be worse, at least you’re alive!”
    REALLY??? I fail to see how that would be worse!

  15. Dave at 4:32 pm

    While I think Dr Nagel is correct in pointing out that sometimes the outcomes of pain care are not under the control of pain speicalists- or anyone other than the individual in pain-it is a stretch to suggest that is why government should stay out of pain care. Moreover, it seems government has largely left pain care to “self-regulating” medicine. The same self- regulating medicine that, according to Dr Volkow has all of 7 hours in pain management education- compared to Veterinarians having on average 75 hours. I have yet to see any article that clearly states that doctors cannot afford education in pain management. I have heard from some on state pain alliance that they didnt believe education in pain management would make any difference. And I have personal knowledge of doctors and nurses opposing legislation in NYS requiring education in pain management.In addition, the pain specialists have made it clear that mainstream medicine has mistreated and undertreated pain-that was not the result of government regulation-but due to self regulating medicine.
    Docotrs and the health care industry have been remiss sonce the 1970’s when it comes to pain care. Government doesnt force doctors to provide Blacks and Latinos half the pain care of whites. Government officials dont force ER physicians to yell at or disrespect people with headaches in the emergency room.
    It is unfortunate how those in the house of medicine have rose colored glasses when it comes to their collegues and how they point a finger at government-and even people in pain for the problems in pain care. Medicine has failed to convince even NIH to substantially increase funding for pain- as we well know funding for asthma is far in excess of migraine, at NIH-doesnt Dr Collins present a budget to Congress every year- gee I wonder how many times he mentioned migraine funding- after allp-only 36 million Americans with migraine in this country. Wasnt it Dr Grady from the pain consortium who said in 2008 NIH neglected neuropathic pain Isnt she a nurse? It is clear to me that peoplein glass houses shouldnt throw stones and when it comes to pain in America- no one should be throwing any stones- especially not the health care industry.
    Only the virtouous are capable of freedom- the health care industry has acted negligenetly and carelessly toward people in pain- if anything they need government to tell them they need to take peoples pain seriously.

  16. Kathy Hastings at 3:46 pm

    Thank you so much for this article! I cannot seem to find the words to string together to state how wonderful the article is for the reader. I used to have very good literate skills, prior to the chronic pain intruding into my brain pathways. There just has to be a way to give access to the medications a patient needs and the ability to treat those with addiction. The numbers now show us, with the supply cut off of prescription meds, addicts are turning to heroin or the “make your own meth,” I do not pretend to have the answers, but there has to be a way to “Do No Harm” to all of us. Thank you again and I am a fortunate patient, who has found a good PM Dr. and Pharmacist, who both work with me. I advocate for those, who are not, in the same position or physically able to advocate for themselves.

  17. Kristine (Krissy) at 3:18 pm

    Bravo Doctor N. You have put down the utmost of important words in this article.

    Saving lives, helping people live with some decency and protecting us like we were your children is what you do.

    You have no idea how much we appreciate you. I can say that because I know how much I appreciate my PM doctor.

    Thank you for such an eloquent article, which I have to imagine, was very difficult to write and express with their being sadness in your heart today.

  18. Abigail at 2:36 pm

    I am so disturbed by what is happening !! It scares me to death ! I am an Ehlers Danlos, lupus , Graves’ disease (along with other junk lol) and have been in pain medication for a very long time . In my state, it is so hard to get the treatment that you need!! I have been reduced to 2 norcos a day! I have No quality of life anymore! Most days I can’t even get out of bed ! Politicians need to let doctors be doctors!!!!

  19. Suzzanne Nazar at 1:47 pm

    Thank you for saying what I wish I could say to my PCP, Specialists, and pain management DR’s. I am on ibuprofen, a shell of who I used to be. After 12 years of falls, testing ( fibromyalgia and small fibre peripheral neuropathy, idiopathic) I have been treated badly over and over, labeled a drug seeker ( if one looked at the past 12 years of my record, it would be evident that this is untrue) non-compliant due to the fact that I refused physical therapy. The pain of it and the worsening of my condition during and after ward, defiant, because I told my pain mgmt. Dr that 2/ultram a day was insufficient. He then told me perhaps nothing would be better. So it has been for years now. I recently diagnosed myself with Levaquin antibiotic toxicity with some help with internet research. My plan is to take the pain as long as I can, then use a gun on myself. Pills are unreliable because you can vomit them up ( my husband has enough blood pressure and heart meds to make a stab at it). I would be mortified to waken in an institution with yet another lable. I will tell those I love, and why. I believe I’d like to take the small amount of dignity the medical system has left me along with me. Thank you so.

  20. Pharmacist Steve at 1:24 pm

    I am seeing a change in the nomenclature from “accidental drug overdose” to a “drug related death”.. so that they can include more “deaths” in their “death watch”.. so much so that they are now also including OTC’s in those “drug related deaths’.
    We have some 40 K – 50 K non-drug related suicides in this country.. and we don’t know – because we don’t count/segregate those accidental drug deaths from the suicide by intentional drug overdose.
    Why would one expect a chronic pain pt to use another means than their medications to exercise their “final choice”.
    People have survived suicide attempts by physical means… why would someone suffering from chronic pain chose to commit suicide by a physical means only to survive .. most likely in more pain… and guilty of another crime and once again denied pain management. They chose their meds, maybe some alcohol or other sedating substance to finally numb their pain and finally escape their pain.
    When you count the known 40K – 50K known suicides and the 46 K drug over doses that could be all/mostly suicides.. all of those nearly 100 K lives were suffering from some degree depression or mental health issues and we, as a society, seem to have blinder on in regards to this health issue. As a society, we have a lot fewer people killed/die from other issues that has a much higher public/media profile. Apparently, some lives JUST DON’T MATTER !

  21. Lynn Webster at 12:49 pm

    David this is beautifully written and truly reflects the attitudes in society. Congratulations. I hope those who see the opioid issue as black and white would take in a deep breath and ready your column.

    Thank you for writing it.

    Lynn

  22. Scott michaels at 11:57 am

    i have just 2 words for you.
    THANK YOU!

  23. Dee Green at 11:35 am

    Very insightful statement. The pendulum is swinging in this country at the moment and along with it the chronic pain community will once again, be forced into cruel & intolerable pain. Unless the 100 million chronic pain suffers & they’re families & physicians stand up and bring reason to this rhetoric. The War on Drugs has been reduced to the war on pain patients & their physicians-for political and financial hidden agendas, not based on science or care delivery, but on fear mongering and political aspirations. 😔

  24. Deb at 10:44 am

    oh how i wish we could get everyone in government that are making laws to supposedly protect us to read this. but cases are tragic but who is speaking for the marine? i wonder if we all forward a copy of this to Obama if he might read it. Would our Presidents feelings on this subject matter? Thank you for taking the time to write this Dr. Nagel. It makes me wish i were your patient. It shows you really care about those you care for.

  25. LouisVA at 10:18 am

    Dr. Nagel,
    You have written a very powerful and moving article. I’m 65 and have been on opioid therapy for over 5 years. As one that has suffered pain since childhood, I can honestly say that the last 5+ years has been the highest quality of life I’ve had as an adult. I’m happy and productive as I am able to do things I haven’t been able to do in many years. Yet I am frightened – frightened about my future access to these medications that have helped me so much. I am afraid of becoming another statistic as I don’t have the fortitude to bear that kind of pain again. Thank you for writing this and please keep up your work as a physician and advocate.

    Sincerely,
    Louis Ogden