The War On Chronic Illness Drugs

Over the last generation, an unconscionable amount of chronically ill patients have been faced with substance abuse disorders and overdose deaths. A lot has been written about the failures of big pharmaceutical companies, our government’s response, and short sightedness from within the health care establishment. In our panicked response, however, we’ve lost sight of the victims, and at every turn we’ve made the situation worse for those who carry the unimaginable burden of a chronic illness.

The geographic make up of the first wave of the opioid epidemic is instructive. Much attention was paid to how excessive opioid prescriptions were ravaging rural America. At its ugliest it was implied at a distance by writers from New York and Washington, D.C. that was due to some fundamental lack of character in rural communities. At its best, blame was placed on companies like Perdue and the Pain As A Fifth Vital Sign health care philosophy. Both of these approaches, and the official response from the Obama administration, missed two crucial details: the profound regional inequities of health care access and and the scant interest in the realities of chronic illness.

Managing a chronic illness is extremely difficult. Treating one is even harder. We mythologize the state of medical advancement, which has accomplished amazing things, but has fallen well short in the management of long-term pathologies. This is a painful fact in places with top-notch health care infrastructure. The best doctors in the world simply don’t have the time to adequately understand their patients and direct treatments are far more limited than the broader public realizes. This is frustrating in urban America where clinics, hospitals, and medical schools are common. It’s apocalyptic where population density is at the lower end of the spectrum.
There’s a common assumption that patients and rural doctors are choosing to ignore interventions like physical therapy (PT), but there are places in this country where the closest PT clinic is hours away, requiring marathon round trips in order to meet the frequent appointments one needs to make progress in this sort of treatment method. PT practices run the gamut when it comes to quality, so all that driving may only get the patient to something that produces no benefits.

Nor is medical knowledge evenly spread throughout the provider community. In a rural community, a specialist is going to be a city over, at beast. At worst a visit to a top tier specialist could require a plane trip to Seattle, New York, or Washington, D.C. Even an excellent local general practitioner is going to face a Herculean task to overcome limitations since the tools at their disposal are far less than those available to a doctor or an ARNP in a large community.

So why did so many opioids end up in small towns? It was the only realistic care offered. Narcotic pain medication provides a sedation of all kinds of symptoms with incredible ease. In 2017, I waited a year for my insurance to approve artificial disk replacement surgery. During that agonizing wait I was struck by the realization that insurance would much rather pay for cheap opioids than shell out 50k for decisive surgery. It was much easier to help me ignore my symptoms than to treat them, and this same phenomenon was happening en masse across the United States.

If we are looking to solve this epidemic of overdose deaths then this matters a lot. It is impossible to remove one thing and expect the rest of the system to move with it because in many communities there is nothing to compensate. By solely removing opioid pain medication, as the Obama administration did, all we did was remove the last option for care. A community in desperate struggle does desperate things. The health care industry shut their doors and the black market answered. We obliterated access to prescription opioids only to see deaths go even higher.

This isn’t to say that reform wasn’t needed. Too often we fall into binaries where we follow course or do nothing. It’s common to see chronic pain advocates insist on not changing anything at all, but that’s delusional. Something had to give. A system without integrity can’t do the hard work of treating patients; it would lack the required public support. However, this works both ways. A medical system that cares too much about public opinion loses the faith of the people it’s supposed to treat and an underground starts to take shape. To my mind the correct way to take things would’ve been to address the underlying regional inequities, but that would’ve required a passionate commitment, as the resources necessitated would be substantial. The problem is that we don’t give a damn about people who suffer from chronic illness.

To be chronically ill is to lack power. It’s a denial of access, that is participation. Your ability to work and earn money is reduced, which reduces your power as consumer. It also is a lack of representation. The incredible misunderstanding of the toll of chronic illness and the nature of the pain it produces means that government programs are at best ill targeted. The behavioral expectations are not in line with the possible, so instead of integration, there’s a sidelining and a cascade of unmet needs.

To hold integrity in oneself is to overcome the invisible levers that always seek to chip away at it. We expect so much from the sick and give nothing in return. We create endless hoops to jump through, but are fine being too sick with the cold to get out of bed. When we reacted to the opioid epidemic we only saw levers to pull. We didn’t see the lives at the other end of the equation. Content with blindness, we were uninterested in the realities facing patients as long as our morality regarding opioids was sated.