I just encountered a disturbing phenomenon. Maybe I’m the last kid on the bus to notice this, but apparently there’s a sect of chronic pain patients who are opioid crisis deniers. They feel that the deaths of drugs users is inconvenient to their cause. I’m guessing there are tons of these bubbles across the internet, but the 12,000+ strong one I came across on Twitter was headed by a Stanford educated doctor named Thomas Kline.
The tweets these people sent were fairly rambling and incoherent, especially those by Dr. Kline himself, but from what I could gather, they think the lives and deaths of addicted people are inconsequential, and the cause of their own woes. The sad part is, chronic pain patients and people in addiction recovery (or active addiction) have a common enemy, and if we banded together instead of engaging in this petty insane bullshit, maybe we could crush it. The enemy, of course, being STIGMA. Unfortunately, as long as Dr. Kline keeps spewing his pseudoscience to the sycophantic followers that need to believe him with all their souls, that community will never happen.
I’m not bashing chronic pain patients. Many chronic pain patients are on the same page as me. For those that I’m referencing in this post, I don’t blame them. It’s intoxicating to be part of a highly stigmatized population and then to find someone who speaks loudly in your favor, says everything you need said, and is willing to stand up and fight for you. If that person then skews facts and figures in your favor, why wouldn’t you defend him? I don’t blame the patients. But I do blame the doctors.
Killing The Cause With Dogma
There are a lot of wonderful causes in this world. The best of them, in my opinion, have to do with alleviating pain. The pain of hunger. The pain of sickness. Inequality. Addiction. Or, literal physical pain. That is certainly a worthy cause. While I do not personally believe an opioid medication is the best drug for every type of chronic pain–I’ve heard and experienced wonderful results from CBD, or nerve-painkillers–it is also certainly true that for some, opiates are necessary.
It’s absolutely unfair that every doctor who specializes in opiate prescribing has come under scrutiny, and that legitimate chronic pain patients are being left with less and less options due to the disease of addiction, or the bad choices of certain doctors. Advocating for chronic pain patients is a good cause. But it doesn’t excuse blind dogma.
I’ve seen it with the cause of addiction as well. A different doctor wrote an email in response to my article about taking methadone during pregnancy, in which he said methadone did not cause sleepiness, a well-known side-effect. I’m guessing because he thought it made methadone look bad. Dr. Kline, the CPP advocate, tweets that in order to become addicted to opiates, a person must be opioid naive (never took any kind of opiate before), and that if a person takes opiates non-addictively for a week, he is forever safe from developing an addiction. That’s not just misinformation–It’s dangerous.
Having a good cause does not excuse blind dogma. When you spread lies, you hurt your cause. No matter what the cause. When your lies are exposed, people stop trusting you, and your whole cause flops. Plus, it leads people to defend your words in really ridiculous ways that reflect poorly on you.
Devaluing Others Doesn’t Raise Your Own Value
This feels like a lesson we all should have learned in kindergarten, but saying someone else is ugly doesn’t make you prettier! And, now that we’re adults, it kinda just drops a spotlight on your insecurity. If you’re putting some else down as a method of raising your social status, then ya aren’t confident about why your social status should be raised.
It’s as true in the bar as it is on Twitter as it is on real life–This doctor, and these communities of chronic pain patients, are devaluing the lives of people addicted to opioids as a means of raising their social value. The doctor repeatedly says, “there’s no opioid crisis,” and then when anyone disputes him says, “there’s no data, show me data,” and then when data is produced says, “that data doesn’t prove a crisis, that’s not many people.” But that’s just devaluing people affected by opioid addiction.
According to current data, just under 1% of the US population is addicted to opioids. About 1% of the US population is autistic, but you don’t hear anyone saying that autism doesn’t deserve research, isn’t a serious issue, or shouldn’t be in the media. The only reason we don’t say things like “autism crisis” is because certain very vocal members of the autism community find that terminology offensive. Of course, that doesn’t get to include all of the non-verbal members of the community…but I’m going on a tangent. Anyway, 1% of the population matters…except when they’re addicted to opiates, apparently.
But I see a crisis, because I’ve been there. Because of the former and current inmates I’ve been talking to who are being abused for having an addiction disorder. Because of the teenager in my peer support group who says he wanted to die when his family found out he relapsed. Because of the friends I’ve seen addicted. Because of the friends I’ve seen die. Because when I take my daughters to the park, I have to be on guard for dirty needles. Because my husband called an ambulance for a young woman who overdosed outside our window, and instead cops showed up and shook her awake only to watch her stumble away. Because millions of people matter. We matter. Those are millions of people with a treatable disorder who are being told to pray our way well. Who are being denied access to the best medications and treatments available because of ignorance. Who are considered to be lazy, selfish, and worthless. And that matters.
What Do The CDC Guidelines Actually Say About Prescription Opioids?
This sect of chronic pain patients (and I say “sect” because I do not want to lump all chronic pain patients into this category, by any means) believes that those of us who’ve suffered or suffer an addiction are the root cause of their problems. Our terrible behavior caused them to lose access to their medication. Not big pharma greed, nor the greed and selfishness of doctors. Just shitty addicts. I feel like I’ve heard this joke before?
It’s true: the Center for Disease Control did issue guidelines in response to the climb in opioid deaths, and reports of addiction. But what do they actually say?
It’s kind of a dense document, so I’ll break it down nice and easy. Essentially:
1-If someone is in pain, try something non-addicting first.
This can be frustrating for people who end up needing long-term opioid medication, but if we just put everyone on opiates right off the bat, we’re not just introducing more people to the possibility of addiction, we’re sentencing people to dependency. For some, opioid dependency is the lesser of two evils and a necessity. But if it can be avoided, why the hell not?! I’ll admit: if marijuana were FDA approved, this guideline would be far more ideal. I was not always a believer, but ever since using CBD for labor pains, I’ve been a convert. Marijuana is an amazing pain medication, and could probably be used as an awesome, non-addicting replacement for many chronic pain patients, if doctors were allowed to dispense it.
2-Before prescribing long-term opiates, establish treatment goals
This one’s a no-brainer. Of course we should establish treatment goals for any kind of long term treatment. We do it for psychiatric or psychological care. We do it for addiction recovery. We do it for cancer treatment…autism treatment…physical rehabilitation…academic function…it’s normal. It’s good medicine.
3-Discuss the risks associated with long-term opioid use
Again, this is just good medicine. Despite what Dr. Kline and his kind wish to say, opiates have side-effects and dangers. Long-term use will result in dependence, which means if someone is suddenly cut off, or decides to discontinue use, he will go through withdrawal. Patients should know that before starting treatment.
Opioid had abuse potential. About 20% of the population carries a specific genetic predisposition for opioid addiction (it’s also associated with alcoholism), and since no tests are readily available to detect this, you could carry that gene variant and not know it. Not everyone who is addicted necessarily has this gene. Some people self-medicate psychiatric disorders, for example. So if someone who begins chronic pain treatment does not have that gene but then develops Post-Traumatic Stress Disorder, she could develop a substance use disorder.
There’s also a potential risk for overdose. If taken properly that shouldn’t happen, but doctors are human and make mistakes. Patients are human and make mistakes too. Counseling on the subject will reduce the risk of these mistakes being fatal.
Part of this guideline also states that prescribing doctors should check in with patients to ensure they are doing well, and that the benefits of the medication continue to outweigh the risks.
What’s wrong with any of that?
4-CLINICIANS should use immediate-release drugs
There were some previous claims that extended-release opioids deterred the formation of addiction, but studies debunked that and apparently found that initiating pain patients with long-acting opioid led to increased risk of overdose deaths. Methadone and buprenorphine are long-acting opioids used to treat addiction; the difference is that people taking these already have a tolerance. Initiation on methadone still has to be carefully titrated or overdose can occur–which I have witnessed. It’s terrible.
Anyway, if you read the guidelines they note that these longer-acting opiates are appropriate for severe, debilitating, around-the-clock pain, but that for other patients, shorter-term opiates should be used, and anyone being prescribed longer-acting drugs should have already developed a dependence.
5-Clinicians should prescribe the lowest effective dosage
Note the word “effective.” This guidelines is not saying chronic pain patients should get less than they need. It’s saying doctors should not promote increased tolerance or heighten overdose risk by prescribing more than they need. It doesn’t bar clinicians from prescribing higher doses; it simply asks that clinicians ensure those doses are needed. Which should involve a pretty simple assessment of pain. If doctors are doing that differently, that’s on them.
6-Treatment of acute pain should be relatively short.
The majority of opiate prescriptions are given for acute pain. Post-op breakthrough, pulled teeth, broken limb. This guideline asks prescribers to stop giving doses in excess of what acute pain patients will likely need–when they are treating acute pain. It’s not telling doctors to cut off chronic pain patients after three days, or force them to come in for a new script and pain assessment weekly.
A lot of kids–myself included–get introduced to pharmaceuticals either from their own prescription, or another person’s. This is because we tend to get more meds prescribed than we need for that oral surgery or whatever. So there’s leftover. Even if it’s your own leftovers, a brain in pain is different than a brain not in pain, so if you pop one of those pills when you don’t really need it, it affects you differently. It makes sense to try to curb the phenomenon of leftover pills.
7-Patients should be re-evaluated every three months
I can see how this one can be annoying for chronic pain patients, but it’s also pretty standard for patients of any long term medication. I have to see the doctor who prescribes my buprenorphine once a month. It’s a little annoying and I often feel like I don’t have much to say, but he’s a nice guy. The evaluation is just a way to check that my dose is holding–do I need more, do I need less?–that I’m not having uncomfortable side-effects or other health concerns, and that I want to continue with the current treatment plan, or change it as the case may be.
For chronic pain patients, that evaluation may also include other things. I can’t speak to that. Maybe those are stressful or annoying things, I don’t know. I do, however, know that evaluation does not equate forced withdrawal. If it does, you’re seeing the wrong doctor.
8-Before and during therapy, clinicians should evaluate risk for associated problems
While it’s true that the majority of chronic pain patients do not develop a substance use disorder, some do. That merits evaluation of the possibility. But guess what? Substance use disorder is only one of the risks listed in this guideline. It also includes decreased breathing associated with sleep apnea, overdose, pregnancy, etc. And it doesn’t say doctors should abruptly discontinue use. It does, however, say that doctors should consider prescribing naloxone, which can reverse and overdose and save lives.
9-Make sure patients aren’t “doctor shopping”
Look, it happens. Some patients get addicted. Some patients abuse the system. Chronic pain patients have a legitimate worry that they could lose their doctors to FDA closure, and ensuring doctors aren’t accidentally being involved in a doctor-shopping situation could stop that from happening. This really just means monitoring someone’s medical and pharmacy records from the inside. Is there more to it?
10-Urine test chronic pain patients once a year
Urine tests can be a little demeaning, especially if they’re supervised. But if they’re not supervised, it’s pretty standard. Pregnant women have to do them constantly. So do people with other conditions. I have to do it regularly for my buprenorphine, even though I’ve been stable for a while. I can see how this could be annoying, but it’s ultimately for patient safety, and to protect doctors from closures, which benefits everyone.
11-Avoid co-prescribing opiates and benzodiazepines
Benzos, like diazepam (Valium), clonazepam (Klonopin), and alprazolam (Xanax) can interact very dangerously with opiates. Many overdoses occur due to a combination of a benzo and an opiate. Sometimes, obviously, a patient may need both, but it’s a combination that requires caution. This is a safety issue. A life-and-death issue.
12-Doctors should prescribe evidence-based treatment for those patients with an opioid use disorder
If a patient is or becomes addicted to opiates, she should be placed on methadone or buprenorphine for both pain and addiction management. Because opioid medications place genetically vulnerable populations at risk for developing an addiction, it makes sense that there be a guideline in place in case addiction occurs.
Are any of these crazy unreasonable? I don’t think so! Sometimes guidelines and protocols can be misconstrued. Doctors who take legitimate pain patients off their meds in response to these guidelines aren’t doing their job properly. They are placing personal bias over the duties of their position. But the only person to blame for that is the doctor himself.
Truth is, I think that decriminalization of all drugs is a good idea. There’s some evidence to support that claim. I really do think that the average person would not decide to start taking something like, say, hydrocodone for a condition like insomnia unless a doctor prescribed it (which they do). I believe inappropriate opiate use would go down, while those who need it would have uninterrupted access. But I’m also a realist. This country is so mired in Nixon and the Bushs’ “War on Drugs” mentality that total decriminalization is a far-off dream. Realistically, reasonable guidelines that do not interfere with adequate patient care are the next best thing.
Chronic Pain Patients And Addiction Patients Face The Same Enemy
That enemy is stigma. Which is fueled by misinformation and prejudice.
The misinformation that addiction and dependency are the same hurts both chronic pain patients and people in addiction recovery. It causes us both to lose access to medication, and jump through hoops for what we need.
The idea that anyone who takes an opioid is a “junkie” hurts both populations. The difficulty in accessing medication during a disaster affects both populations.
Pretty much every big issue related to opioid prescription affects both populations. We need to stop fighting each other, and band together against stigma. Wouldn’t that be awesome? What strides we could make, together.
I think–I hope–most chronic pain patients and addiction patients know this. I hope this war is a small segment of each population, one that I just happened to encounter on Twitter recently. if you’re a part of that population, will you consider switching? Can we be friends instead?