The FDA took two apparently contradictory actions in the past week that have provoked another battle in the war between pain patients and addicts. First they tightened regulations on hydrocodone, the most-prescribed drug in the U.S. and the opioid painkiller in Vicodin. Then, against the recommendation of their own advisors, they approved Zohydro, a long-acting hydrocodone whose formulation includes no mechanism to prevent abuse. So on the one hand patients will be able to buy another super-powered opioid that’s crushable, snortable, and shootable—let’s call it “OxyVicodin”; and on the other hand, they’ll have to jump through more hoops to get it.
Heading into Battle
Pain patients protest the new restrictions give them unfair burdens in obtaining medications. Addicts and those who know them fire back that these are dangerous drugs whose use ought to be curtailed. In the comments sections of news outlets across the country, the two sides in the Civil War on Drugs are flaming each other over who gets the drugs, when and how. I’m like Switzerland in this war because I straddle the Mason-Dixon Line: I’m a pain patient and an addict.
It’s another good old American drug fight. In any war, it’s easy to put a contested property in the middle and fight over it; it’s harder to do diplomacy, especially in 12 minutes inside an exam room. We don’t talk about addiction, so we’re always going to wind up bickering over the drugs.
Managing Pain or Fueling Addiction?
The FDA’s actions spotlight the increasingly insupportable situation for public health with regard to prescription painkillers: people need pain management, and more and more people are dying from painkiller availability. The Institute of Medicine estimates 100 million Americans have chronic pain. And the CDC reports prescription painkiller-related deaths have tripled since 1990, with more than 16,000 Americans now dying annually of prescription opioid overdoses.
Unless something changes in our approach, the painkiller trends show every sign of increasing. Only attitude changes, not regulations, will alter the ways these drugs make it into people’s medicine cabinets. There are those who fake pain conditions to sell their pills, and those who steal them; and there are those who, like me, seek pain treatment and become addicted. Most doctors who prescribe painkillers have no clue how to screen for or recognize the signs of The Big A, and they’re overcome with fear of DEA Suits when they suspect a patient might have crossed to the Dark Side.
Bearing the Brunt of Both
Before prescribing painkillers, the university specialists who treated me for two neurological disorders only wanted to know about my smoking, drinking, and “recreational” drug use. I posed none of these risks—but had they screened my family history, they would have turned up addicts galore. My mother died of lung cancer after 40 years of smoking; her father died of cancer after decades of alcoholism. My father died of cirrhosis and cancer after a lifetime of drinking; his mother, uncle, and several nephews and nieces were alcoholics and addicts. I myself considered this information irrelevant because, like most people—including doctors—I thought addiction was about making lousy choices.
Here’s what my pain physician missed in her initial history-taking: just as my chronic pain conditions run in my family, so does my addiction. They go hand-in-hand. Some people can chain-smoke and escape cancer, but others with a family history can’t escape. Some people can chip heroin or pop “borrowed” OxyContin and dodge addiction, but others, like me, cannot.
I had fears that I was an addict by the time I detoxed five years ago, and no doubt my pain specialist also suspected I “had a problem.” But we never talked about it. Pain patients avoid The A-Word for fear of being denied treatment. And most doctors never raise it with patients unless they’re ready to kick them out. Even after I hired another doctor to detox me—because my pain doctor was incapable of helping me quit the drugs she’d started me on—she never spoke the word “addiction” to my face. If doctors are trained to get people on these drugs, they need to learn how to get them off safely and compassionately.
This inability to tell a simple truth in a setting that should be safe is made all the more bizarre by the fact that so many Americans are addicted. Ours is the most over-fed, over-drugged, over-indebted, over-wired culture on the planet, and still The A-Word spoken in the exam room is tantamount to criminal charges. When my physician catches patients doctor-shopping or using other drugs, she kicks them out of her practice and into a psych ward, Do Not Pass Go, Do Not Collect Your 200-Count Refill. Jails and psych wards are punitive, unhelpful responses that make people with addiction—the “unclean”—into modern-day lepers.
Opiates Still the Go-to Band-Aid
To be sure, we pain patients need to have access to treatments that will improve our quality of life. But the jury is still out on whether opioid painkillers actually serve that function for those with chronic non-malignant pain. And it’s a sorry fact that, when we look for almost any “treatment,” our medical establishment—and the regulators, media, and comments-section flamethrowers—are so focused on drugs. It’s ironic: when I told my pain physician I’d started outpatient detox, I thought she’d be glad I’d gotten help. Instead she was incensed I’d quit her drugs without consulting her first, as though I’d denied her the perverse satisfaction of kicking me out. And when I returned for continued pain treatment, the nurses expressed surprise: I wasn’t taking painkillers anymore, so what was I even doing there?
This month, I’ve been five years drug-free. According to public perception, I’m a unicorn: addicts, especially opioid junkies, are supposed to be unable to recover. I manage my addiction with no chemicals. And I continue to negotiate my pain with a small dose of one daily non-addictive drug, as well as exercise, good sleep, and healthful food. A strong, loving community of friends and family is also a critical part of my solution. A simple, old-fashioned formula; it isn’t perfect, and I still have days when I gripe about my pain, but I’m not jonesing to try Zohydro, and I’m happier without having to jump through those regulatory hoops.
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