Just say no.
That slogan – used for decades to try to encourage young people to reject the temptation of drugs – has a new target audience.
Physicians.
The opioid epidemic can’t just be laid at the feet of doctors who overprescribe powerfully addictive painkillers, but research shows that a preponderance of the dependence on opioids, including in its illicit forms such as heroin, began with a physician’s liberal jotting on a prescription pad.
“The road from prescription narcotics to heroin addiction is now wide and well-traveled. Doctors need to do everything they can to keep their patients off it. The first step is to say no,” writes David Brown in the cover essay of the fall issue of The American Scholar.
His thoughtful essay on the opioid crisis combines a medical practitioner’s firsthand knowledge with a skilled journalist’s solid research and good writing.
Though fatal heroin overdoses are the most grim outcome of opioid dependence, what Brown makes clear is that even if the condition doesn’t get to the end stage, the explosion in painkiller use is having devastating consequences in this country. It’s creating a “pharmaceutically damaged underclass” while also “damaging the medical profession and its practitioners in ways that will take years to acknowledge and redress.”
The way to repair both of them, writes Brown, is for physicians to worry less about pleasing their patients who are seeking pain relief or a continuous supply of pills. Brown makes no pretense that those conversations will be easy.
For one, an unintended consequence of welfare reform from the 1990s has been the steep increase in the number of people – especially in the nation’s high-poverty regions of Appalachia and the Southeast – being certified as disabled and thus eligible for lifetime cash benefits.
“One way to affirm that a disease is disabling is to treat its symptom – pain – with the strongest drugs available,” Brown writes. “For musculoskeletal system and connective tissue diseases, that often means opioids. People getting disability checks therefore have a perverse incentive to take opioids forever.”
In Kentucky and West Virginia, two Appalachian states with large numbers of poor whites, the percentage of adults drawing disability checks is about double the national average. They also are among the states with the highest rates of opioid addiction.
An even more sweeping cause of the opioid epidemic, according to Brown, is the evolution of attitudes in this country, and within the medical profession itself, toward pain. For the longest time, doctors viewed pain either from a puritanical (“Suck it up”) or paternal (“I know what’s best for you”) eye. But about 30 years ago, writes Brown, thinking began to change. Patients’ experiences and wishes – not their physicians’ judgment – became paramount. Medical protocols were revised. Monitoring a patient’s subjective sense of pain became as important as checking objective vital signs such as heart rate and blood pressure.
At the same time, the line between acute and chronic pain became blurred. Although opioids might be precisely what’s needed to care for patients who’ve just had surgery, broken a bone or are in the end stages of cancer, the painkillers have become too commonplace for treating nagging medical conditions that are not going to get better, such as lower back pain and aching joints. And because of higher obesity rates, more sports injuries and longer life spans, there’s more chronic pain to go around.
Brown’s essay affirms that Mississippi is on the right track in moving toward imposing stricter guidelines on the medicinal use of opioids. A draft proposal from the state Board of Medical Licensure would cut down on how many of these pills doctors prescribe for acute pain and discourage their use for chronic pain.
Brown stresses that this much-needed weaning of Americans off opioids doesn’t have to be done callously. Non-addictive drugs and other non-pharmaceutical pain relievers can all help a little.
But the biggest remedy, he writes, is adopting a new paternalism in which doctors advise patients that living with a little pain is better than the narcotic-dependent alternative – and have the courage to withstand the anger from patients who don’t want to hear it.
“Getting there won’t be easy,” Brown concludes. “It will require that physicians weather their own version of withdrawal. But like their patients, they’ll feel better on the other side.”
