EDITOR’S NOTE: This post is a follow-up to The Drug War Claims Another Victim
America’s prohibition regime of certain sorts of drugs has never been called for by a medical consensus. It has never been based on application of the principles of addiction medicine. It has always been political, yet the notion that a politician should come between a patient and his cardiologist would be intolerable for most people. Imagine Trump or Clinton between you and your doctor.
Drug prohibitions are a political approach to a scientific problem, and this logic model can hardly be expected to yield more satisfactory results than if Democrats were adjudicating religious taboos, or if the Republicans were in charge of the acceptance of the current innovations in particle physics. The realm of medicine is for Doctors. Politics is not medicine, one of these things is not like the other:
Writing about music is like dancing about architecture.” — Thelonious Monk
Our current heroin overdose epidemic is directly the result of suddenly disallowing addiction to legal forms of pain control, by politicians suddenly concluding that pain medication had become “overprescribed.” Whatever the merits of their concerns, no doctor specializing in addiction would agree it’s wise to suddenly close off legal access to the addict’s medication. It’s as predictable as night following day that addicts would turn to street drugs to manage their pain. Having prescription pain medication addicts suddenly have to go to the streets for illegal and dubious criminal powders is an outcome brought about by political logic. It’s dancing about architecture. The bedrock principal of medical logic is to first do no harm. To have avoided the inevitable overdose epidemic there should have been a robust rehabilitation system in place.
In saying that pain medication is “overprescribed,” there needs to be a reckoning of the question of whether these addicts “deserve” to be treated for pain. This is a small scale consideration that should happen between a doctor and their patient based on their intimate relationship of specific knowledge. Most doctors would say some patients “deserve” pain medicine, and some don’t. All clinicians would say that the ones that don’t deserve to be addicts should not be left with the alternative of the streets.
But how to know who is deserving? Wise clinicians are never so sure. Take it from me, it is often very hard to tell. The reason is that there are no objective physical exam findings or blood markers to indicate pain level, and all people vary greatly in their perception of pain. Just like Alzheimer’s is speculated and treated based on a cluster of symptoms and can never be definitively diagnosed without a post-mortem brain exam, real pain is only theorized based on the story of that particular patient. Until their insides are looked at. Like we see with Prince. The poor suffering man needed a hip replacement.
We have another celebrity pioneer to show us a different example of this same issue: Howard Hughes’ pain level was not appreciated until after his autopsy. He suffered horrific injuries as a test pilot. The expert the State called in to condemn his doctors’ aggressive pain management testified that, in fact, his long-term survival was a medical miracle, only made possible by brilliant doctors, willing to risk the censure of the subsequent trail, all made possible only by Howard Hughes’ extraordinary financial power. Any other patient would have succumbed to the load of pain years before, never surviving for an additional thirty years. The State’s gavel came down, the Howard Hughes doctors’ case dismissed. But there was never a chorus yelling: “Wait a minute! He survived because of his ability to circumvent everyone else’s system!? And that system continues on unchanged!?” Part of the reason there is no such chorus is because people with the types of pain who need this type of management cannot fight for long about anything. Few doctors will fill out the miles of paperwork needed to properly treat a patient like Howard Hughes with opioids. A mishap on any one of those thousands of controlled substance tracking forms can have him investigated by any number of agencies, his whole career tipping on the whimsies of a lawyer or judge, not another doctor, and not the loved-ones of the patient. And the clinician will have no objective way to “prove” his patient had any pain at all.
It is ironic that Prince also had seizures. He never had the slightest trouble obtaining his Dilantin (or whatever analog drug he had to take). Afflictions like seizures or high blood pressure, have no layers of taboo intricacy. We simply prescribe them their correct level of medicine. There are some people that abuse the medications to control seizures; the anti-convulsive families of medications are mostly “downers” in the Valium family, but I don’t know of any clinicians who would think this controlled abuse is not a great bargain in the risk/benefit ratio for their patient. Controlled in that there are no criminal underworld ramifications; controlled in that the medications are made in factories with modern quality control, with precisely measured doses, most of the factors missing in our latest version of the opioid overdose epidemic. Imagine the outrage, and indictments of our health care system had Prince succumbed to unbroken seizures caused by Dilantin he had to get illegally from the Mob. That Prince gets his epilepsy recognized as a treatable disease, a fair and square honest to God sickness, but the pain from his needing a hip replacement generates untold numbers of pages of media controversy tells us all we need to know about our prejudiced moralizing about pain management. It should be very painful to Americans, given our history, that another African American man is a stigmatized drug addict despite his upper-most tier of contributions to our culture. He was a Jehovah’s Witness. The man believed there is a religious prohibition against blood transfusions (and so, hip replacement surgery). It is American legal bedrock that no one can come between Prince and his religious conscience. So it’s bedrock that his religion cannot be superseded, but the price he pays for that is irresolvable pain? I would call this an undue burden on his freedom of religious practice. Besides, hip surgery is not minor. Who is culpable if Prince cannot legally manage his pain, is driven to surgery by the deficit, and there is a bad outcome? Certainly our whimsical law-man sitting in judgement of the doctor will not answer as a legal remedy. It’s dancing about architecture.
As a clinician who has administered more than my fair share of opioid pain medication I can testify that it is more fraught with danger to my career than using the drug Dopamine; an agent so powerful its doses are measure in micrograms, and a thimbleful, carelessly administered, would cause the patient’s heart to run amok. Dopamine is plutonium compared to morphine, one of the few medications in the West pharmacopeia that can simply be reversed (with Narcan) if it is causing harm to our patient. All hospitals in New York City have a patient’s Bill of Rights, and the right to proper pain control is one of them, but there is little real life in the “Right”. I had a patient suffering from a sickle cell crisis, in terrible pain. The nurse presented him with his Bill of Rights paperwork and he laughed derisively and threw it down on the floor, a veteran of what this empty promise means in the real world. People in burn units get mind-boggling amounts of morphine, but their incidents of addiction are vanishingly rare. Morphine and its derivative family are just about the most well-known and understood drugs in the world.
Relief of suffering is one of medicine’s most basic mandates. The silent testimonies of Howard Hughes’ and Prince’s bodies should point the way to a more merciful future where a person would not need to be gnawed to death by untreatable pain. Or where they would have to turn to predators of the illegal drug underworld for pain relief. Only in art and politics can separate realities exist.
Consider Prince’s legendary Super Bowl performance, in the driving rain no less. Marvel at his commitment to his art, through his pain. God rest, Noble sir, you will be missed.
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