Pain and Prescription

In 2019 the CDC clarified a much debated section of their guideline recommendations for opioid prescribing. A lack of clarity regarding a seemingly arbitrary measure of 90 morphine milligram equivalency led doctors into blindly rapid tapers to get patients under the threshold or fire them outright. State actors and insurance companies used the measure as a means to make receiving required care exponentially more difficult. Pain care had been hemorrhaging for years under this regime, and the CDC’s admittance that all of this was in defiance of their guidelines halted the bleeding in its official capacity, but hearts and minds follow suit slowly. The entire medical, political, and journalistic establishments had brought their weight to bear on the chronic pain community at such a ferocious length that continual mistreatment had been baked in, despite the official justification no longer being available.

As a whole, our medical system is remarkably bad at treating chronic illness The chronic illness memoirs The Deep Places by Ross Douthat and the Invisible Kingdom by Meghan O’Rourke make this case masterfully and at length. Doctors would much prefer to treat symptoms, not patients. An illness doesn’t have to be debilitating to present with a complicated story. It takes time to piece everything together. An adversarial ten minutes spent with a specialist just isn’t enough time. It’s exceptionally hard to turn internal sensations into words and concepts that can be grasped by an individual removed from the experience at hand. Western medicine has little tradition when it comes to listening to patient testimonials like these. Even absent the time constraints that plague health care, testimonials are regarded as too subjective and lacking in the expertise of a trained physician, resulting in the patient’s experience being regarded as of lesser value and oftentimes even incidental to the care itself.

Unfortunately, the rational understanding of illness displayed by doctors has spread throughout the power structures of American society. Pain has no vocabulary; it is subjectively experiential. To put patients in a situation where they have to justify their pain to a medical provider in private while also defending themselves to society at large is deeply unfair.

We explain mundane headaches by assuming that everyone has some experience with such a thing. This breaks down catastrophically when we need to discuss the sort of pain that requires opioids. It’s common to see patients in this situation frantically looking for metaphors that allow them to find any sort of understanding from others.

An important aspect of pain missed by the broader discussion is that pain by itself isn’t traumatizing. When we look back on pain that exists in the long term, it is what it costs us that is most prominent. We lose a lot when we lose quality of life. It denies us participation in society. We get passed over for promotions, lose time with our children, and watch life prospects evaporate. It’s in this regard that pain and its true crisis should be understood. If it were possible to accomplish all the good things in life while bearing pain then we would do so. The value judgments that are made aren’t just asking those in unrecognizable pain to accept it. They are asking those patients to sacrifice things that are core to the meaning in their lives.

This is all in contrast to the narrative that took root when the opioid epidemic was reaching broad cultural understanding. The blame of the epidemic wasn’t just put on Big Pharma and pill mills. It was also placed directly at the feet of patients with chronic pain. It would be unusual to see this stated plainly, but the intent was there. All of a sudden there was a correct way to handle pain. To succumb to opioids was a depraved weakness of character. Instead, good patients were the ones who practiced disciplined meditation, conquered their symptoms through physical therapy and procedures, and accepted the sad state of their existence. The feasibility of these options didn’t matter. These were costs that were expected to be carried by the detestable others who inadvertently sparked the opioid deaths of thousands all because they couldn’t handle their pain in the right way.

When a person reaches a state of pain and illness that sees them shedding life experiences, there’s nothing they haven’t tried in an attempt to return to a state of grace. Everything from alternative medicine remedies to cognitive behavioral toolsets have already been deployed. Otherwise insignificant rituals become obsessive compulsions in the unconscious need to return to a sense of control. This desperation too-often goes unnoticed.

It’s here that critics do have a point. The ease and effectiveness of opioids may slow new understandings. Narcotics are easy to depend on, but more importantly, they’re scalable. One doesn’t have to form a brand new perspective on life for a Percocet to control pain. Things like acceptance and meditation, which are touted as miraculous, ask a lot out of a patient already under intense stress. Physical therapy and interventional pain procedures depend on the health care infrastructure being present and of sufficient quality. In other words, the alternatives necessitate a great deal of moving pieces being in the right place, which requires more effort than the United States is willing to put into solving the problem. The ease of using opioids to treat chronic pain is problematic, but they remain the only consistent answer available.

This makes the continued assault on opioid pain control all the more devastating to patients. Without knowing it, the intense focus on opioids prescriptions as the sole driver of the epidemic have laid out an assumption, normally voiced by anti-opioid radicals such as Physicians for Responsible Opioid Prescribing (PROP), that its better to subject the seriously ill to a boot-strap reality. Another facet is the profound disinterest we have in the lived experiences of our incredibly vulnerable disabled population.

The chaos this has brought into the lives of those under incredible physiological stress cannot be overstated. Every prescription has to be fought for. It’s unknown if this is the month that the pharmacy or insurance will want a prior authorization, which seem to occur at random, thus risking a detox if the pharmacy doesn’t allow you to pay in cash. At every turn the establishment has taken an adversarial posture. Treating chronic pain puts one in the position of always having to prove oneself. Don’t raise your voice or show up to the pharmacy early. To remain justified turns one into a dog with a tail between its leg. All will is denied.

The entrenchment of a radical anti-opioid philosophy has naturally extended to all other areas of pain care. It could never do otherwise. Once people had it in their minds that there was a correct way to handle chronic pain it was only a matter of time until it started to affect other types of care.

If a person undergoes cancer treatment it is likely that their oncologist will not handle the pain care of their own chemotherapy patients. Worrying about monitoring opioid prescriptions and DEA investigations is a distraction that they may as well off load on a pain management specialists. This phenomenon of doctors not prescribing for their own care exists across all specialties, and it’s alarming. It overloads the already overfull medication pain clinics, making it harder for chronic pain patients to be where they need to be, while removing crucial oversight and quality control from essential care.

It’s also not uncommon to see doctors refuse to order opioids immediately after a surgery, even hysterectomies—the sexism inherent in this should not be overlooked—and joint replacements. The mindset which expresses a proper holistic method of handling pain has taken root to such extent that it has even started to affect acute care, believed to be totally exempt from debates regarding addiction, at least under current paradigms.

The CDC is getting ready to release new opioid prescribing guidelines later this year, but it’s going to take a lot more than that to dislodge from the collective imagination the immediate post-overdose epidemic narrative. It was a narrative that placed an incredible burden on the sick and vulnerable, accelerating disinterest on the lived realities of those with a chronic illness, while spreading the worst of inadequate pain care to all types of opioid prescribing.