The Politics of Pain Margo Schlichter University of New Hampshire English 2 May 2012
The Politics of Pain Imagine two people walking into the same doctors office looking for a prescription for pain medication. Susan Shinagawa is a forty-four year old Japanese American that lives in San Diego California. She was diagnosed with breast cancer in 1991 and has had recurring problems with the cancer every since. She has been in constant, chronic pain ever since her original diagnosis and she takes prescription opioid narcotics through an infusion pump every day to lower her level of pain (Rosenfeld 57). Reid Ferris is a successful twenty-three year old entrepreneur. He owns his own house and his own business, but his wealth has led him down a destructive path of partying. He originally took oxycontin pills as a way to get high, but now he needs them just to function (Biaso). As these two, very different people went to the doctors office, imagine that they got treated the same way when asking for pain medication. Reid, who is actually addicted to the drug, continuously makes it harder for patients like Susan to receive the prescription medication they need. This causes Susan to be handled with suspicion as she struggles to prove to her doctor that she actually needs the medicine to relieve pain. According to the Institute of Medicine, we are in a “public health crisis” regarding pain and medication (IOM 1). In today’s society, when pain killers such as Oxycontin and Vicodin are brought up, we immediately jump to irrational conclusions. We think of celebrities spiraling out of control due to their prescription drug use, or of patients that can no longer function normally because of their drug abuse. In reality, these opioid drugs were created with a specific and careful purpose; to relieve chronic pain. The public perception of pain medication and the underlying goal of pain medication seem incongruous. While the public views daily pain medication as an addiction that
can ruin lives, the main goal of pain medication, taken properly, is to help people function normally in their everyday life. The subjectiveness of pain and the publicity of these drugs have made the issue controversial to a point where a stigma has been attached to those who take pain medication. The question is continually asked, where is the line drawn between providing adequate pain relief for patients and supporting a drug habit? Doctors are now increasingly reluctant to treat patients for their pain, leaving those with chronic illness in a debilitated state of life. The focus on the negative aspects of pain medication in the media has led to an increased skepticism over the necessity for medication, leaving patients with real, chronic pain untreated and suffering. Scott Fishman, directior of pain medicine at the University of California, Davis School of Medicine said, “For many patients, chronic pain becomes a disease itself,” (Hitti). The urgency of this issue has captured public attention in recent years when an increased number of chronic pain sufferers have been denied treatment. According to the Institute of Medicine, approximately 100 million adults experience some type of chronic pain in the United States (IOM 1). Serious health issues such as cancer, multiple sclerosis, and arthritis can account for the wide range of health conditions that can cause the debilitating pain over an extended period of time (Sifferlin). It has been recorded that only 50 percent of chronic pain sufferers that had spoken to their doctors about their issues got sufficient relief (Rosenburg). Pain management is clearly a national controversy. The fact that pain is personal and subjective makes people wary to treat it. Pain leaves no physical evidence, meaning that those who suffer from pain have to self-report their problems. This leaves doctors with the ethical dilemma of learning when and how to trust patients. Chronic pain in the United States totals $560 to $635 billion each year due to medical bills, lost work productivity, and
workers compensation (IOM 1). It is in the country’s best interest economically to treat chronic pain adequately, yet it is not being done because of the stigmas attached to pain relief medication. While many people suffering from chronic pain are being under-medicated, the cause of reluctancy to prescribe such medication has come from a solid reasoning. In the United States, over 7 million Americans abuse pharmaceutical drugs and 75% of all drug-related overdose deaths in the U.S. are attributed to prescription drugs. Three out of every four deaths from an overdose of pills involve opioid pain relievers such as Oxycontin (U.S. Center For Disease Control and Prevention). Clearly, the abuse of pain-relieving drugs has made doctors reluctant to prescribe them. However, the majority of the misuse of opioids stems from patients that feigned chronic pain to obtain the drugs for recreational use. Many people obtain pain-relieving drugs from others in an illegal way, and use them as a drug instead of for pain relief. This accounts for the majority of opioid abuse. In the Institute of Medicine’s new report on pain medication it says, “The majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others,” (IOM 145). The misuse of prescription drugs by people that do not need them are negatively affecting those that do. This is the reason why doctors and laws are more strict upon prescribing medication and why people with chronic pain are suffering from being under-treated. The U.S Department of Justice Drug Enforcement Administration has recently addressed the issue of chronic pain and its treatment. It was noted that the abuse of prescription drugs has increased in the United States. According to a survey performed by the U.S. Department of Health and Human Services, the number of Americans 12 or older who have engaged in illicit
use of pain relievers during their lifetime has risen to 31 million (DEA). It is noted that a portion of this drug abuse stems from doctor’s dispensing controlled substances without legitimate medical purposes. It also notes that chronic pain is a very serious problem for many Americans. The report states, “It is crucial that physicians who are engaged in legitimate pain treatment not be discouraged from providing proper medication to patients as medically justified,” (DEA). The report also acknowledges that the majority of physicians who prescribe pain medication do it lawfully and for legitimate medical reasons, which includes the treatment of chronic pain. There are patients who have chronic pain that are not given enough medication and are suffering accordingly. Because of the stigma attached to pain medication and the fear of addiction, many patients believe they can just tough it out and deal with the pain, but this can lead to many severe health problems down the road. Patients that do not receive treatment for pain are at risk for high blood pressure, which can lead to heart attacks and stroke. Pain causes high levels of hormones to be released in the body, which can also cause more stress on the heart and lungs. A large amount of the body’s energy is consumed when experiencing pain. This can cause a person’s immune system to weaken, leaving them at a higher risk for disease and infection. In extremely dire situations, patients that experience chronic pain and are not treated for it can experience severe depression and commit suicide (Rosenberg). It is a common misconception that patients suffering from chronic pain cannot take pain killers without becoming addicted to the drug. Patients suffering from chronic pain that take opioids such as Vicodin and Oxycontin can take them on a daily basis without becoming mentally addicted to them. Any person can become tolerant to a drug after taking it for an extended period of time. However, a tolerance is accumulated in any kind of drug being taken, whether it’s a
pain killer or not. Therefore, the idea that pain killers are the only drugs that cause physical tolerance is false (Hitti). It is important to realize that physical tolerance to a drug is different from an addiction to a drug. According to Christopher Gharibo, director of pain medicine at the NYU Langone Medical School, physical tolerance will happen to any person taking any drug for an extended period of time (Hitti). The process of becoming physically tolerant to a drug and increasing a dosage accordingly is called titration (Rosenburg). People mistakingly think that they are addicted to a drug if they have to increase their dose, but this is just something that happens naturally in the body for every type of medication. This physical dependence is normal and does not cause addiction. Scott Fishman, direction of pain medicine at the University of California, Davis School of Medicine defines addiction as, “a chronic disease that’s typically defined by causing the compulsive use of a drug that produces harm or dysfunction, and the continued use despite that dysfunction,” (Hitti). This means that physical dependence on a drug is not what causes addiction. Addiction is when a person continues to take a drug even after it is affecting their life and body in a negative way. They cannot mentally handle the idea of no longer taking a drug. This is not the case for patients that take opioids for pain relief from chronic illness. A reason for concern within this country should be the fact that many physicians are not properly trained to handle pain management. Within the United States, the number of pain specialists has dramatically decreased to just over 3,000 physicians (Sifferlin). With this small number of qualified pain specialists, primary physicians are now the ones left to handle their patients’ chronic pain. This also creates a dilemma because primary physicians are not properly trained to deal with the issue of chronic pain and its treatment. It is estimated that in medical school, only a few hours of instruction is spent on the education of pain treatment (Sifferlin). This situation
has left many primary care physicians in a dire situation where they can never win. These doctors can be charged for prescribing too much pain medication, yet they can also be charged for prescribing too little. Primary care physician Edward Pullen regarded this fact by saying, “Treatment of chronic pain is the scenario that puts me and every practicing primary care physician in a no-win situation regularly in the office,” (Pullen). The fear that doctors experience when prescribing pain medication is well-grounded. In 2006 alone, the D.E.A. opened 735 different investigations of doctors that prescribe opioid drugs (Rosenburg). There are official guidelines regarding how doctors should prescribe medication. They state, “subjective reports by the patient should be supported by objective observations by the physician,” (Pullen). The fact that pain is so subjective has left physicians with no concrete rules on how to treat patients. Bill Newkirk, a doctor that treats patients that experience chronic pain said, “Deciding who to start on narcotics is sometimes easy- a terminal patient with widespread breast cancer metastases- and sometimes hard- a patients with chronic back pain and a host of emotional issues.” The prescription of pain medication is clearly not back and white. In order for this crisis on pain management to be dealt with, doctors need to be more informed on pain relief. Most doctors hold the same misconceptions as the public about the risks of opioid use for pain relief. In reality, doctors need to take on each patient as an individual case and leave the stigma that opioid drugs have behind. Each patient is different, therefore each patient needs different doses of medication and different types of treatment. Doctors should spend time with the patients and learn all their symptoms and level of pain, and then start a medication regiment accordingly. The amount of medication and the progress of the patient should be monitored frequently to see whether the medication working. This practice is called ‘titration to effect’ (Rosenberg). In cases where opioid drugs are helping, the dosage should be gradually in-
creased and monitored until the pain is acceptably controlled or the side effects begin to outweigh the pain relief benefits. Completely individualized treatment and monitoring of opioid use for pain relief would help eliminate many of the country’s problems concerning chronic pain. In the opening of the Institute of Medicine’s new report on pain it states, “Pain is part of the human condition; at some point, for short or long periods of time, we all experience pain and suffer its consequences. While pain can serve as a warning to protect us from further harm, it also can contribute to severe and even relentless suffering, surpassing its underlying cause to become a disease in its own domain and dimensions” (IOM ix). This controversial subject is clearly something that should be at the forefront of America’s attention. Treatment of patients for whom pain medication is appropriate is negatively impacted by illegal abuse of opioid drugs, limited physician training on pain management, and inadequate public education around prescription pain medication. This has escalated to a point where even the most qualified pain sufferers are met with suspicious eyes at doctors’ offices, leaving those with chronic illness to suffer in silence.
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