Is the War On Addiction Becoming a War On Pain?

Also, fertility drugs.

I’d hope so.
But from a New Yorker article on this some years ago, it seems the problem isn’t some addicts/patients, it is a small set of doctors who overprescribe for the benefits the drug companies gave them. Of course once these doctors get people addicted, if they cut them off then they’ll go on the street.

Could there also be a gender gap? Just reading here and something I happened to notice as I read down it appears like there is more withholding of such drugs for females than males (who tend to get to them).

Multiple back surgeries, “can’t live without” opioids, whenever he doesn’t have access to opioids his brain’s reward system puts him in “chronic pain” until he gets loaded again, plan is apparently to be on prescription opioids for the rest of his life for a problem that has no identifiable organic cause and magically will not respond to any treatment besides permanent opioid use…

But how does the doctor distinguish between someone like that and an addict?

What do you think you are describing here? This is exactly what “the opioid crisis” is - people with insurance and access to the legitimate medical system who live in nice suburban neighborhoods and think that “addicts” look like someone else. “Chronic pain” is a symptom of opioid addiction, not a disease to be treated with medication.

This. Opioid use tends to reinforce itself in the long run by causing pain and hyperaesthesia on withdrawal. Opioids are literally a life saver when it comes to managing acute pain and pain during and after surgery. But for chronic conditions and especially neuropathic pain they tend to aggravate the problem and cause addiction on the way. Especially in individuals who have already suffered from addictive disorders in the past great caution is necessary, as with benzodiazepines. At least in the Netherlands we’ve always been taught this, and my experience in psychiatric and addiction medicine is identical, with only marginal difference in addiction risk for tramadol/oxycontin vs heroin/methadone. This of course doesn’t mean that opioids aren’t prescribed in situations where they shouldn’t, but I think doctors are in general more aware of those risks, not to mention the patients themselves. Plus the Netherlands has a tradition of low key watch and wait medicine, combined with an “either it kills you or it goes away on its own” attitude in especially GPs.
Standard practice in kidney stones here is diclofenac IV. Since the crackdown your side of the pond we’ve become even more reluctant, to the point of withholding opiates where they are actually indicated, like an acute ear infection in adults (as was the case with one of my colleagues). Which is excruciatingly painful but self-limiting, so doesn’t bear the risk of prolonged use.

What’s he’s discussing is a relative in chronic pain. Whatever the cause, there is still a distinct difference between someone like that and drug seeking behavior, which is what was being discussed. The question was how a doctor can tell the difference.

You can’t know for sure that the opioids are the cause of his pain. There are tons of situations where pain comes in despite a lack of any clear physical source. But, even if they are the cause, so what? If no other treatment helps, and he is able to function on his current dose without getting more, why shouldn’t he just keep taking it?

That’s where you get into the war on pain management. Because we’re now treating those who are dependent as if they are addicted, you get into all of the bad ways we treat addicts. You get the callousness and refusal to try and help.

Sure, there’s nothing wrong with trying to take someone off the drug to see if it can help alleviate the pain. But there’s also nothing wrong with finding out that it doesn’t work, and leaving them on it. You can decide that you screwed up with giving too much without assuming that the remedy will be to take everyone off.

Sometimes the solution for future patients is not the same as the one for current patients. But the way these “crackdown” seem to work is that they ignore this. They seem to think the goal is just to reduce opioid prescriptions in general, and not focusing more on new patients. This is a problem that took generation(s) to form, and it will likely take that long to even back out.

In the mean time, doctors do still need to be able to tell the difference from someone in chronic pain (even if due to opiates) and those who are drug seeking addicts. There is a difference in how the two need to be treated. Though, granted, we would do well to treat addicts better, treating it like a disease and not a moral failing.

The problem with this is that there’s not always a distinction. Often it is both, and it’s not clear where one problem ends and the other begins. I have a case like that right now, where someone in excruciating dental/jaw pain was prescribed opiates by her GP and benzodiazepines by me, in close cooperation with said GP. We decided that the benzodiazepines might alleviate some of the pain as they are muscle relaxants. What we didn’t know was that she used a LOT more than we prescribed, bought on the Internet by her mother. Right now I have her on a steady albeit high dose, and we’re looking into addiction treatment. These things happen. And I agree with you that complete abstinence is not always possible or even desirable. Harm reduction is key. And addiction is a disease, not a moral failure. It almost always starts out as a way to manage an otherwise unbearable situation. The problem in the moral sense comes from the association with gluttony, which of course is a sin and can’t go unpunished in the eyes of many.

Sure there’s a difference,. The difference between “idiopathic chronic pain” and “opiate addiction” is whether the person being diagnosed has health insurance, white skin, and access to a CVS as opposed to a stolen stereo and access to a guy on the corner.

You can’t know for sure that the opioids are the cause of his pain. There are tons of situations where pain comes in despite a lack of any clear physical source.

I guess this guy’s brother-in-law could be the first person in history to develop ‘chronic pain’ after multiple back surgeries and not be an opiate addict, but I’m playing the odds here

But, even if they are the cause, so what? If no other treatment helps, and he is able to function on his current dose without getting more, why shouldn’t he just keep taking it?

Why shouldn’t he live his whole life in the thrall of the worst addiction there is? I’ll leave that as an exercise to the reader.

No one is saying addiction isn’t a disease or that there shouldn’t be compassionate treatment for it. But let’s stop pretending that “chronic pain” is something other than addiction for rich white people or that “just live the next 40 years constantly checked out of life on oxy pills, assuming you don’t OD before then” is some kind of answer.

This dichotomizing and dragging to extreme is not going to bring a solution any closer, either. Like I said things aren’t so clear cut. And chronic pain may well be a consequence of increased life span among affluent populations, like in Europe or the US. There are people who survive cancer but are left with pain due to surgery (lymphatic edema, for instance) or post-radiation. Or simply because of wear and tear. I remember way back when I was treating someone with an addiction to alcohol and opiates who kept complaining about joint pain, so I sent him to the GP. Turned out he had severe arthrosis of BOTH hip joints, most likely caused by rough living. He was a lot younger than your average candidate for hip replacement. Don’t forget addicts are usually in an abominable physical condition because of the lifestyle associated with it. This is an extreme example, for sure, but the fact that medicine has progressed as far as rooting out most conditions that kill you quickly and timely has attributed a large part to this. This isn’t a black-and-white subject, and there are no easy solutions. Of course, a culture that doesn’t accept suffering in any way, at least for those who can afford medical care, doesn’t help, and that’s why IMO the problem in the US is bigger than it is in the Netherlands.
By the way, constantly being in pain doesn’t really help being present for life, either.

I’ve written several rants on this topic in other past threads, but for some reason just don’t have the energy to write the long screeds pages that I usually do. But if you are interested you could find them if you search my posting history.

My story revolves around my wife who has suffered from extreme neuropathic pain due to an underlying neuromuscular disease (current hypothesis is that it is HMSN-6 but we are waiting to get a genetic test). She was initally prescribed OXY Codone, but switched to methadone because the extended release provided longer term relief.

She has been on the same methadone dose for over 10 years, she has never taken more than prescribed and never felt any sort of “craving” for the medication beyond the desire for pain relief. She has a pain management doctor who regularly prescribed her current dose without any cause for concern.

Then about a year ago, the insurance company decided without any examination that she was taking too much, and so they unilaterally cut her dosage by a third and canceled her anti-anxiety medication. Her pain management specialist suggested we might try reducing the methadone dosage and replacing some of it with an alternative that might give her more relief (since it was slightly different formulation (and so it was less likely that she would develop a tolerance) while still keeping the overall amount of opioid (measured in mophine quivalents) below what the insurance felt she could have. But the insurance said that she wasn’t allowed to have those prescribed together, and so canceled that prescription. I should note that when the insurance cancels a prescription it isn’t just that they won’t pay for it, they actually prevent you from being able to pay for it out of pocket.

So the last year has been pretty bad, without her anti-anxiety medication she can’t sleep well, and without her full dose of pain medication she is in a constant level of moderate pain. So its been a pretty lousy year for her, much of it spent in bed. Fortunately I’ve been home and able to help her out but we are both scared about what happens when I’m called back to the office.

Ironically her pain level is further exacerbated by the fact that she has started forgetting to take her medication. Previously she would know that its time to take the medication when it started hurting, now it always hurts, so its just a question of how much it hurts, which can also depend on whether she is having a good or bad day.

In any case from our point of view this suffering is totally unnecessary. For the last 10 years she had been doing, if not well, then better than she is now, and its only some nameless bureaucrat who hasn’t seen her or talked to her, deciding that he/she knew better about her condition than her actual doctor, and as a result has made her life much much worse.

(Hmmm it looks like I found the energy after all)

If chronic pain is just an opiate addiction, then cutting the addict off from their supply would eventually resolve the pain. How long do you think this takes? In other words, if Joe’s doctor stops prescribing painkillers (and Joe isn’t able to get a replacement supply), and X (months/years) later Joe is still in pain, is there any value of X that would make you think that Joe’s chronic pain might not just be withdrawal?

I don’t claim to be an expert on addiction treatment but my understanding is that quitting opiates cold turkey without any sort of support has a very low success rate, so I doubt that exact scenario would come to pass. I do know from experience with addicts I have known that people who do get the appropriate resources to stick with sobriety will often find their “chronic” pain and other conditions alleviated, yes.

It was a pretty simple question for someone making such a bold assertion. Perhaps you shouldn’t paint with such a broad brush (“the first person in history to develop ‘chronic pain’ after multiple back surgeries and not be an opiate addict”?) if you lack even that rudimentary level of expertise.

I don’t know how to perform retina surgery either, but I know what a blind person is.

No, this is more akin to you asserting that a person isn’t legally blind when you don’t actually know what the cutoff for legal blindness is.

OK. Meanwhile I’ll again point out that what you are describing is the textbook example of how people become addicted to opiates. Back pain → surgery → prescription → “chronic pain” → multiple followup procedures with less and less identifiable organic causes, each of which justifying another few years of pills, has been a cliche for years because it is what happens. Same problem as above - you want to draw some distinction between “the addicts who look a certain way and live in a certain place” and “the insured, once-employable people who ‘need’ to be on heroin in pill form for the rest of their lives because if they aren’t, they get withdrawal symptoms like idiopathic pain.”

There is no distinction, the fact that people can’t see this is exactly why millions of suburban white people are currently addicted to opiates. Every one of them is doing the same process you are of performing outrage at the notion that “the addict” is them and that something that started for a “good reason” like a work-related injury is now a problem of drug addiction. If this wasn’t true then we would not be discussing an “opioid crisis” or a “war on addiction” or how responsible the pharmaceutical companies are for pushing the pills.

Have you actually read Buck_Godot’s post? Or mine? Your assumption is wrong. The solution is not take away the meds. People who function on a steady dosage, do not experience craving and do not need to up the dosage because the effect wears off ARE NOT ADDICTED. they’re on medication and it works. Same with benzodiazepines for anxiety. For someone who claims to be not an expert you DO make some very bold statements, and you don’t seem inclined to have others inform you. That’s annoying, at least to me.
@buck_godot: So sorry to hear your story. Insurance companies shouldn’t have this much power. Unfortunately in The Netherlands things are heading in your direction. Appalling and very frustrating. All the best!

Wise words. You express a truth that seems to be anathema here in the US. Addiction here is almost always regarded as a moral failing, the result of a simple desire to get high, without understanding why the addict is using whatever he/she is addicted to, be it opioids, or alcohol, or benzos. Almost always (sure, there are exceptions) the user is trying to manage something unbearable, some awful pain, whether physical or mental or emotional.

I’m sorry. I really am. I’ve seen people suffering because of a stupid bureaucratic attitude about painkilling medication. And I’ve experienced that a bit myself (albeit to a much lesser extent than your wife).

It’s just wrong.

:blush:thank you. At the beginning of my residency I worked for a year at a Double Diagnosis (i.e.psychiatry and addiction) clinic and outpatient facility. A lot of what I learned there has been very useful throughout. Those of us that are lucky enough to have a life that isn’t so painful that it’s livable without anaesthesia should not be judging those who are less fortunate. We should count our blessings instead of judging others. At the same time addiction is a very nasty ailment that does need proper treatment, if only to give people the ability to choose again. It robs you of your free will, because doing drugs or alcohol comes before anything else in an addict. And that alone leads to situations that are traumatic (having to sell yourself for the next fix does leave scars), which in turn increases the need for dulling the pain. We always had a couple of street hookers on the ward, most of them started out at a very young age because they needed to escape an abusive home, hung out with the wrong crowd, and things went downhill from there. Of course, that is a different population from what the OP is referring to, but no one plans on becoming addicted. They’re people just like us. Which doesn’t mean you should put up with everything and not set limits, but it isn’t useful to treat people like crap or pass moral judgment.