This is the second part of an article exploring the media's role in whipping up hysteria against opioid painkillers and that hysteria's impact on chronic pain patients. The first part of this article can be found here.
What is an "addict?" Over the past couple of decades, we have been told that people can be "addicted" to sex, to gambling, to porn, to shopping. The list goes on. But the term "addict" has been divorced from its definition, and it is clear that the media uses the term addiction -- to refer to many ways of consuming a product or a indulging a habit -- without a clear understanding of what the word implies.
"Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors."
In addition, addiction has an impact not only on the neurological search for reward, but encompasses the decision-making part of our brains--the frontal cortex--"When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex." In other words, addiction short-circuits the function of the frontal cortex in making decisions in such a way that the addict pursues the object of addiction even if that behaviour is injurious to the body. Addiction works against the addict's instinct for self-preservation.
The issues raised by the media's reporting on opioids is that most reporters and headline writers fail to distinguish between "addiction" and "physical dependence." Physical dependence is the body's reliance on certain drugs to remedy a physical issue, and there are real consequences to the body if that medication is stopped abruptly. Obvious medications needed by the body include insulin for diabetics, or heart medications that control an erratic heartbeat or other cardio issues. Other examples include asthma medications, and even antidepressants. For example, if you have ever switched the antidepressant or heart medication that you are using, the new prescription will often come with instructions on how to taper off the old med and to add the new med in order to avoid the complications of withdrawal from the previous medication. And while addiction is now considered to be a disease, physical dependence is not.
In the case of painkillers for chronic pain patients, the body becomes physically dependent on a certain dose of medication each day. And, the unfortunate truth about opioids is that the body becomes acclimated to a dosage so that it becomes ineffective; thus opioid dosages go up over time. A person who found their supply to opioids, for example, terminated without any warning would be thrown into withdrawal. Withdrawal is severely uncomfortable, and there is debate on whether its effects may be fatal. The range of symptoms include: elevated blood pressure; nausea and continuous vomiting; muscle aches and cramping; anxiety; skin crawls and goosebumps; and "the kicks," which is the involuntary muscle spasms in the legs that cause the legs to "kick" out. While withdrawal can be endured "cold turkey," the symptoms of withdrawal may make a person feel as if they are dying. Fear of withdrawal symptoms may prevent a person from trying to stop taking opioids. The best practice is tapering slowly, (that is, reducing the amount of drugs taken by a small amount each day over an extended period of time). When the physical dependence on the opioids has been dealt with by slow tapering, the desire to take the drug disappears. Thinking about taking the drug does not take on the sorts of obsessive-compulsive behaviors associated with addiction.
While we don't refer to insulin-dependent diabetics as "addicts," many people seem unable to distinguish between opioid addiction and physical dependence. A diabetic who quits insulin cold-turkey might find themselves in physical trouble very quickly. A chronic pain patient who quits opioids cold-turkey will not only be thrown into withdrawal (it takes an average of 24 hours for withdrawal symptoms to start) but they will also find that the pain, which the opioids are making more tolerable, will also return.
It is clear that opioids do not cure chronic pain. But despite some advances in treatments, at current, there is no cure for chronic pain. And chronic pain is not something that is "all in the head." Chronic pain is in itself a disease. Robert Caudle, a pain researcher at the University of Florida, explains that pain has three components when it is processed by the brain. While acute pain warns the body that there is an injury that requires attention, or a situation that the body needs to move away from as quickly as possible, chronic pain is pain that continues to demand attention from the brain regardless of whether the original tissue damage still exists, or may be pain signals the brain processes for reasons that medical science does not yet understand. (Fibromyalgia and migraine are examples of this. The pain is real, but as of yet, the explanations for the pain remain elusive.) This does not mean that the pain is not real. It means that the pain receptors in the brain have developed a glitch in their programming that results in the brain feeling that it is under constant attack.
Understanding pain requires us to remember that it's the brain that feels pain, not the affected part of the body. To give an example that may make this more tangible: remember the last time you stubbed your toe, or cut yourself in hot, soapy water while washing dishes, or burned yourself. One of the things that I have noticed is that there is a split-second delay between banging my toe on the object on the floor and feeling the pain. Sometimes, I even have time to think, "This is gonna hurt" before the pain arrives. With burning, it feels like the instinct to move away from the burn takes place before the pain of the burn is acknowledged. Now, imagine that your brain tells you that you've stubbed your toe when you haven't, or that an amputated limb hurts.
For reasons that are also not clear to scientists, the demographics of chronic pain differ from the demographics of the new spate of heroin abuse. In a study published in the Journal of the American Medical Association--Psychiatry (JAMA-P), the study's authors report that the new demographics of heroin abuse shows that those seeking treatment are 90 percent white, are more frequently male, and that they are more likely to be found in suburban and rural areas. Given that the stereotypical view of heroin junkies is that they are predominantly black and living in cities, this marks a substantial shift. But, chronic pain patients are predominantly female. In addition, a complicating factor in trying to determine the demographics of chronic pain is that in study after study, it has been documented that women, Hispanics, and African Americans are consistently undertreated for pain. In cancer treatments and in post-operative settings, for example, African Americans are less likely to be given sufficient pain relief for their symptoms.
Pain relies on self-reporting to be documented. When a patient claims to be in pain, they are asked to "rate their pain" on a scale that asks them to distinguish between "no pain" and "the worst pain I've ever experienced." When I've been asked to answer that question, I often joke, "Does that include labor?" But even the amount of pain in labor is related to a lot of different factors. A woman with a wide pelvis delivering a six-pound baby may experience less pain than a woman with a narrow pelvis delivering a nine-pound infant. You can't take your pain to a carnival midway and hit a bell with a hammer to have it measure your pain. There isn't an objective measure. The body responds to pain with elevated blood pressure, a change in heart rate, or a change in respiration. But unless a patient's doctor has a long history with the patient and recognizes what constitutes elevated blood pressure for that patient, even this is not a foolproof method for determining pain. It comes down to whether the doctor "believes" the patient when they say that their pain is a "9." If one factors the biases that may be present in a doctor, a black woman claiming to be in pain may be "less credible" than a white man. Add to that class biases, and it's not difficult to see how a poor Hispanic woman is going to be undertreated for reported pain than a wealthy white male--and these assumptions are borne out by the studies.
The media continues to portray the increase in heroin and opioid-overdose deaths as a result of the increase in prescriptions for pain medications. Politicians, conscious of the white, middle-class vote, have greatly restricted a doctor's ability to prescribe pain medications as a panacea for heroin overdoses. Some legislators and politicians, including West Virginia Senator Manchin and Hillary Clinton, think it's a great idea to tax opioids to pay for drug-treatment facilities. I cannot think of another drug where those obtaining the drug legally--through a prescription written by a doctor and filled at a pharmacy--are to be taxed in order to combat the illegal use of that drug. How is it the chronic pain patient's responsibility to pay for the treatment for addiction that results from buying street drugs?
The rate of genuine addiction among chronic pain patients is very low. The addiction to pain medications has come about because recreational users--who buy the medication on the street or steal it from medicine cabinets--become addicted to the "high" that opioids provide. In fact, ask a chronic pain patient whether they get "high" off opioids and do not be surprised if the answer is "no." When one is in chronic pain, opioids provide relief. That can also equal emotional relief from having a break from the physical and psychological reactions to grinding pain. Pain wears a body out.
When the majority of users of heroin were perceived to be black and urban, the answer to drug abuse was to throw addicts in jail, or, to quote Nancy Reagan, to "just say 'no'," as if withdrawal symptoms could be solved by shouting "no" when puking in the toilet. Our prisons are full of those convicted of drug offenses. And yet, now that the majority of heroin users are white, suddenly the answer is treatment and increasing the restrictions on prescriptions for opioids.
Heroin and opioid abuse have been medicalized, rather than criminalized, because it is having a significant impact in the white community, especially in the suburbs. As the New York Times reported:
"Because the demographic of people affected are more white, more middle class, these are parents who are empowered," said Michael Botticelli, director of the White House Office of National Drug Control Policy, better known as the nation's drug czar. "They know how to call a legislator, they know how to get angry with their insurance company, they know how to advocate. They have been so instrumental in changing the conversation."
One of the direct consequences of the crackdown on prescription opioids has been the increase in the use of heroin. This fact, which has been repeatedly documented, proves that the current restrictions on opioid prescriptions is working as a deterrent to recreational users. But the consequences have also had an impact on pain patients being able to get the legal treatment for their conditions. In the JAMA article cited above, heroin users said that the fact that heroin was cheaper, that they preferred the high of heroin to that of opioid medications, and the difficulty in securing opioid medications had made heroin their drug of choice. In the meantime, increasingly stringent prescription rules are harming chronic pain patients. Chronic pain sufferers have been known to commit suicide. This, however, is seen as less of a public health issue than the 28,000 opioid and heroin overdose deaths reported in 2014. Those 28,000 deaths have been prioritized over the tens of millions of Americans who are trying to combat chronic pain. But even the authors of the Center for Disease Control's (CDC) report acknowledge that it is impossible to distinguish an overdose that occurred as a result of a legitimate prescription for Fentanyl and one that occurred from buying Fentanyl on the street. A Fentanyl overdose will be reported as a "prescription opioid overdose" regardless of whether it was legally prescribed or not.
The answer to finding an answer to prevention of death from opioids is not to issue blanket bans on the drugs. Nor is it to tax them. It will require the media to dial back their "opioid epidemic" hysteria, and their propensity to write the click-bait, but inaccurate, headlines that do not convey the true meanings of the words "addict," "prescription opioid," and even "epidemic." It will require changes in health insurance practices that, for example, make insurance much more likely to pay for opioids, which are much cheaper than, say, triptans, which are used to treat migraines. For example, 100 mg of Imitrex, one of the first triptans developed for migraine treatment, costs $408.00 for 9 tablets. The cost for 20 mg of oxycodone, an opioid, is $38 for 30-20 mg. tablets. Guess which one I have to fight my insurance company for each month? The role of insurance companies in promoting the prescription of opioids over other pain relievers is not a topic that is covered by the media. Neither is the fact that of all the pain relievers available to those who are suffering from chronic pain, it is opioids that work most effectively in treating the components of pain as processed by the brain. And, because no one knows what pain feels like except the person directly experiencing that pain, there is no objective measure for determining its effects. You can see a clogged artery on a scan, but you can't see the hot iron poker in the eye that migraines can feel like.
Chronic pain studies are underfunded. Opioids are not a cure for chronic pain, but right now, they are the best treatment that many have for treating the symptoms of the disease. Making chronic pain patients responsible for others' decisions to use medication for recreational purposes is irresponsible, and yet another example of blaming the victims. Chronic pain patients--and heroin abusers--both deserve better treatment from the media and short-sighted legislators.