The Demerol Diet
Doctors who prescribe painkillers for people desperately in need put themselves in danger of losing their licenses and maybe even going to jail, and it's killing their patients. Per H.L Mencken's definition of Puritanism -- "The haunting fear that someone, somewhere might be having fun" -- we're so worried that somebody, somewhere, might get high, that we're needlessly forcing people to live in terrible chronic pain. Jacob Sullum chronicles this in a terrific article in a back issue of Reason:
A 28-year-old man who underwent lumbar disk surgery after an accident at work was left with persistent pain in one leg. His doctor refused to prescribe a strong painkiller, giving him an antidepressant instead. After seeking relief from alcohol and street drugs, the man hanged himself in his garage. A 37-year-old woman who suffered from severe migraines and muscle pain unsuccessfully sought Percocet, the only drug that seemed to work, from several physicians. At one point the pain was so bad that she put a gun to her head and pulled the trigger, unaware that her husband had recently removed the bullets. A 78-year-old woman with degenerative cervical disk disease suffered from chronic back pain after undergoing surgery. A series of physicians gave her small amounts of narcotics, but not enough to relieve her pain. She tried to kill herself four times--slashing her wrists, taking overdoses of Valium and heart medication, and getting into a bathtub with an electric mixer--before she became one of Rose's patients and started getting sufficient doses of painkiller.
I especially love the stories in Sullum's piece about people dying of cancer who are denied painkillers -- lest they become addicts! Get this, you've got six months to live, and somebody's worried that you're getting "addicted" to Oxycontin? Hello?
One doctor who, it seems, sacrificed his license to help serious pain sufferers, was rewarded for his efforts with an indictment by a federal grand jury yesterday. If William E. Hurwitz is convicted, he faces life in prison. Here's an ugly piece of slanted reporting about Hurwitz in the Washington Post (compare it to Sullum's exhaustive piece linked above) that dovetails quite nicely with the national paranoia about drugs:
Prosecutors allege that Hurwitz made large profits by charging an initiation fee of $1,000 for each patient and then $250 a month for maintenance. They said Hurwitz had about 470 patients in his clinic over the past five years, accounting for millions of dollars in profit.
So, he's supposed to give medical care for free? The Washington Post reporter never bothered to talk to any of the patients the guy has helped, and it sounds like there are legions of them.
Anybody whose life has been markedly improved by any Schedule II drug -- me, for example: I take Ritalin, which keeps me at the computer instead of bouncing off the ceiling -- should be very, very afraid.
UPDATE: Here's a related link from Reason's blog -- first, an essay by professor of pharmacy health care administration David Brushwood, on how prescribing practices that seem suspicious to regulators may actually be legitimate treatment of a patient's pain. Finally, there's this great quote from the comments section on Reason, by RC Dean (rcdean@samizdata.net):
"One can only hope that, when they fall sick, the drug warriors responsible for this are treated by doctors who they have cowed into undermedicating pain."
My wife has serious chronic pain (from crohn's disease among other things), and it has been a real struggle dealing with the whole situation. The main drug of choice for pain is Roxanol, liquid morphine. When she was first prescribed this medication several years ago, no one ever explained to me what a powerful narcotic it is, and that the person taking it should not be dosing it out for themselves. I was slow to catch on, and after a couple of near overdoses and lots of irrational and even dangerous behavior, I finally realized the seriousness of the situation. Now I keep the morphine on my person at all times. If I slip and leave it out, or try to hide it in some clever place, or even keep it in a lock box, she will get it and take a large dose, or at least put some in a syringe for later. The dangers with these drugs are real, but I don't think that people should be forced to live in constant pain either. Close monitoring of the patient is required, by both the doctor and the family.
joe g at September 27, 2003 7:10 AM
The question is, though, WHY your wife would abuse the drug (assuming "a large dose" is abuse -- rather than an underprescription for her pain)? We deal with addiction and abuse totally wrong in this country, because we think of it wrongly, as a disease -- something that HAPPENS to people -- rather than something they DO -- and for some reason or reasons. You should check out the work of Stanton Peele and Archie Brodsky -- "The Truth About Addiction And Recovery" is one book. Treating your wife like a child who's getting into the cookie jar can't be the answer. Sooner or later, she's going to get into the drug supply. If it's because she's in physical hell -- well, she should be getting more morphine. If it's an escape from reality, maybe she needs to see somebody about why she's so unhappy in real life -- and in my opinion, for best results, a therapist who thinks along the lines of Peele and Brodsky. It sounds like she has zero desire to change. That would be the first step in dealing with her problems instead of masking them with drugs -- but because you take away her drugs (meaning well, but infantilizing her) -- the cause of the drug problem remains even though the drugs aren't within arm's reach to abuse.
Quote from Peele and Brodsky: FROM CHAPTER 6 -- HOW WE EVADE MORAL RESPONSIBILITY ..."an addiction is not isolated from but an EXPRESSION of our personal and cultural values. Whether, to what, and how severely we become addicted is based on who we are and what we value, just as recovery is a matter of who we want to be and how we want to change our lives."
FROM CHAPTER ONE -- WHY THE DISEASE MODEL IS WRONG: They show how calling addiction a disease is wrong, for many reasons; such as, it takes responsibility away from the person. "The question is: 'If addiction isn't a disease, then what is it?' An addiction is a habitual response and a source of gratification or security. It is a way of coping with internal feelings and extrenal pressures that provides the addict with predictable gratifications, but that has concomitant costs. Eventually these costs may outweight the subjective benefits the addiction offers the individual. Nonetheless, people continue their addictions as long as they believe the addictions continue to do something for them. It is important to place addictive habits in their proper context, as part of people's lives, their personalities, their relationships, their environments, their perspectives. The effort to change an addiction will generally affect all these other facets of a person's life as well."
(Amy Alkon) at September 27, 2003 8:25 AM
That's a far different response than the one I was expecting, and for that, I thank you.
You wrote:
"If it's because she's in physical hell -- well, she should be getting more morphine. If it's an escape from reality, maybe she needs to see somebody about why she's so unhappy in real life..." I think it's a little of the former and a lot of the latter. And the roots of her unhappiness go way back into childhood. Just this week she did start seeing a therapist, and I'm pretty sure that she (the therapist) would agree with the views of the authors you mentioned. I'll ask about that.
And yes, I hate having our relationship set up as the parent-child type. Nevertheless, are you aware of people who are capable of self-administering a drug like morphine without any temptation to deviate from the prescribed amount? It's hard for me to imagine my wife getting to that point after all these years.
And one other question that's probably addressed in that book: We've all heard the term "addictive personality" -- any truth to it? Or is there always another cause?
Thanks, Joe
joe g at September 27, 2003 10:43 AM
BTW, I was a little apprehensive about posting all this on a public forum, but I figure we're not the only ones in this situation.
joe g at September 27, 2003 10:46 AM
It's actually very courageous of you to post here, as many deal with what you are, and I've written to Archie Brodsky, via e-mail, and asked him to post here on the topic. www.peele.net is Stanton Peele's Web site -- check there for more info. Not sure if Archie has his own. Don't be too sure that your therapist is aligned with Brodsky and Peele's point of view -- it's radical and many therapists learn what they learn in school and go no further, never challenged the conventional wisdom. You should check out their books and "Alternatives To Abstinence," by Heather Ogilvy. There are links to both on my book picks page -- don't feel obligated to buy through those links -- but do click through because there should be a list of "related books" on the pages selling those books, and you may find others of value.
(Amy Alkon) at September 27, 2003 11:13 AM
Sorry, I think that's Heather Ogilvie not Ogilvy.
(Amy Alkon) at September 27, 2003 11:13 AM
My uncle recently died of multiple sclerosis. This was years after the unrelenting pain caused him to quit caring about life. He was given quite a bit of pain medication, but it always stopped short of actually alleviating the suffering.
I know that there are serious side effects to this medication, but I know that he, his wife and children would have wanted him to have a shorter life due to the side effects if it meant that he could have been pain free and actually enjoyed their company for his last days.
My mother also suffered for many years from severe rheumatoid arthritis. What ends up happening is that these patients mix OTC drugs with their prescription meds, in a desperate attempt to find relief. Or, for some of us in Southern California, we end up getting medicine from across the border. I know others who've resorted to street drugs in attempts to numb themselves.
If they had had to listen to her moans and cries of anguish every time she tried to move, maybe they'd understand that we aren't out on the street pushing these drugs--we're trying to bring a measure of normalcy and relief to people who are truly suffering. Isn't that what quality of life is about?
It's ridiculous the games you have to play with the system to try to get appropriate treatment. And while her doctor was sympathetic, he was not willing to risk his license to 'over' medicate her.
Peggy C at September 27, 2003 1:18 PM
Dear Joe,
Is it possible for your wife to use a non-narcotic pain reliever? I don't know how much pain she suffers from, but is there a possibility that your doctor can change her prescription to something non-narcotic?
I hate narcotic pain relievers myself, actually. I don't like that feeling of impaired thinking and not being able to control myself. I was given Lodeine (spelling?) Codeine and one other narcotic type drug when I was in a car accident. I threw them all out and took Advil. Worked great for me.
Apart from this, I have to agree with Amy. Hiding the drugs from your wife is treating the symptoms, not the cause. What is she truly medicating in her life? It's not physical pain. Because hiding the drugs is not the solution. She will eventually figure out how to get more narcotic, and it doesn't matter what kind. You'd be amazed at the things they do. I recently helped a friend of mine out of desperate situation, living with an abusive drug addict, and it was truly amazing the things I learned. Narcotic abusers have their own little network of drug traders. They might be trading their sleeping pills for Xanax, or buying Oxycontin at 5 dollars a pill.
She needs to get at the heart of her problem, because deprivation is not the key. Your wife has already shown that she isn't balked by a strongbox, which should tell you something right there about the magnitude of her desperation. If her problems are not addressed, she will probably be dealing with other narcotic dependents, and some of these people can be real lowlifes. Your wife will not care about that, trust me. When the need for a fix is paramount, she'll deal with the Devil himself. Please take Amy's advice to heart. I do not overstate one iota when I tell you that you are in a potentially dangerous situation.
Patrick at September 27, 2003 2:09 PM
Patrick, from my limited understanding, people in great pain can only be helped by strong narcotics. Crohn's Disease is pretty debilitating. My friend Marnye (whose page is on my site) had it, and the little I accidentally overheard about what she went through (because she NEVER complained about her medical problems) made it clear that it's torture to live with. What's sad, I think, is how many people don't take drugs that would alleviate pain or other medical problems, simply because they've bought into the Puritannically-driven prejudice against chemically-induced relief. It would be just as weird for me to be embarrassed about taking Ritalin for ADHD (which, by the way, I don't consider a disorder -- merely a different way of thinking) as it would for me to be embarrassed about injecting insulin if I had diabetes.
Amy Alkon at September 27, 2003 4:04 PM
Patrick, Amy's right about the narcotic; we've tried just about everything. Her case of Crohn's is indeed a severe one, with a high level of associated chronic pain and depression. As far as her getting drugs from another source, well, to my knowledge that hasn't happened. I'm not saying it couldn't, but it seems like she would have done that by now if she thought it was a viable option. Right now I'm more concerned about just improving the day to day situation. It has become quite frustrating for both of us, to say the least.
And yes, there is definitely a stigma about the use of these kinds of drugs that I think would be better left in the dust bin. Shame shouldn't be part of the deal, but it all too often is. Can't say that I've been blameless here, I'm sorry to say.
Thanks Amy, for the reading suggestions, and I look forward to the input of Mr. Brodsky.
joe g at September 27, 2003 5:22 PM
I worked in physical therapy for several years, sometimes with patients who had very serious chronic pain syndromes. A particularly tough one to treat is called RSD -- for Reflex Dystrophy Syndrome, if I remember correctly. The pain might start because of something like a "pinched nerve" in the back, or neck, with pain radiating to the extremities. Then, for some reason, the central nervous system (brain and spinal cord) starts getting involved in the production of symptoms. Because drugs like vicodin are successful initially, doctors and patients go gung ho with them. Then patients build tolerance and need higher dosages. Meanwhile, the pain syndrome isn't resolving with physical therapy, because vicodin addicts aren't so great at following their exercise/stretching/first aid regimens. So you've got these cranky, drugged-up, people who are incredibly hard to work with. PTs refer them back to their doctors, the doctors give them the drugs they want. Finally, they end up in rehab programs.
I think a lot of this could be avoided with Joe's very astute opinion: "Close monitoring of the patient is required, by both the doctor and the family." I'd add "especially early on, when the probability of pain pill addiction is so high."
Joe -- I admire your approach to your wife's condition, and I wish you the best.
Lena Cuisina at September 27, 2003 5:32 PM
Paging Archie Brodsky, Paging Archie Brodsky...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Thanks for the encouragement Lena.
joe g at September 29, 2003 11:17 AM
I am in sever pain, and need relief
Patrick J. Coyne at December 31, 2004 2:38 AM