When Pain Becomes Criminal: All About Opiate Phobia

Opiate phobia affects pain management by interfering with the ability of chronic pain patients to receive adequate care. Opiate phobia is rampant in the United States. This fear has been stimulated more by demagoguery and demonization than the actual harms associated with opiate abuse. The U.S. history of opiate phobia stretches back to at least the early 1800s when it was referred to as “narco-phobia.” But most physicians viewed opiates very favorably. They worked not only for pain relief but also as a cough suppressant, anti-diarrhea medicine and sleep aid. This is why many physicians, when prescribing opiates, referred to them as “G.O.M.” or “God’s Own Medicine.”

Narco-phobia (now opiate phobia) really got started in earnest just before the end of the 19th century. Starting in the 1890s, legendary newspaper publisher William Randolph Hearst used his newspapers to campaign against the supposed dangers of opium. Movies and pulp fiction did a great job of terrorizing people using fiction in place of science to demonize opiates. Dr. Hamilton Wright (U.S. President William Howard Taft’s nephew-in-law) and Bishop Charles Brent had caught the strong anti-opium xenophobia wave and rode it for all it was worth to the Harrison Narcotics Tax Act of 1914. As a result, more and more physicians turned away from the medicinal use of opiates, viewing them as a pathway to addiction.

By the 1950s, both patients and doctors began to be afraid of “addiction.” Dole and Nyswanger’s efforts in the early ‘60s to return substance abuse treatment to the medical realm via Methadone maintenance, is remarkable because they were moving upstream against over 60-plus years of opiate phobia. Today in the current environment, opiate phobia is flourishing. Both physicians and patients are undereducated, erroneously educated, or uneducated about pain, adequate pain treatment and assessing risk-benefit vs. side-effect considerations with treatment of pain.

Costs – Human and Financial

The annual cost in the United States associated with untreated pain (missed work days, inability to work, time spent visiting medical professionals) is estimated to be in the range of $85 billion to $90 billion.

The impact of chronic pain on a patient’s life may include the following:

• Sleep disturbance

• Effects on mood

• Restriction of the ability to do household chores

• Restriction of social activities

• Job change due to pain

• Job loss due to pain

One of the most common reasons patients consult physicians is to seek relief from pain. Due to opiate phobia, pain is all too often inadequately treated in the United States. Medical jouralist Maia Szalavitz writes in a February 24, 2010 Time Magazine article, “even in modern times, the process is fraught with moral judgment, stemming largely from the nature of available pain treatments and an incomplete understanding of how to use them. Patients who ask for more pain drugs are eyed as potential addicts; doctors who prescribe pain medications too frequently fear being arrested for it.”

Inadequate, inappropriate pain management has led to enormous social costs, including lost productivity, needless suffering and excessive health care expenditures. Conventional wisdom has created many barriers to the therapeutic use of opiates. These include concerns about addiction, fear of respiratory depression and other side effects, concern about tolerance and medication diversion and fear of regulatory action. These fears are free floating in our culture and are shared by many patients and physicians.

This problem hampers access to our best weapon against pain: opioids. Some physicians are even reluctant to treat the ravages of cancer pain with opiates because of cultural and regulatory fears. They will endure the pain, “just don’t make me a drug addict, a junkie.” Oncology nurse specialist Carol Blecher, RN, MS, AOCN, laments, “But every day patients and families come to me filled with fear about taking opioids.” The fear of natural and synthetic opiate pain killers like Methadone, morphine and OxyContin stands in the way of pain relief for many patients.

In today’s environment opiate phobia is flourishing because both physicians and patients are under-educated, erroneously educated, or uneducated about pain, adequate pain treatment and assessing risk benefit vs. side effect in treatment considerations.

This fear-of-opiates phenomenon is more pronounced in the United States than most other industrialized nations. Sadly, in the United States, as opposed to Europe, treatment of chronic pain, even in the very ill, is a very controversial issue. In the United Kingdom, the terminally ill have access to heroin, cocaine and LSD. This is a far cry from America where it is difficult to get adequate pain treatment in far too many normal circumstances.

The United States is one of the few countries not to allow the use of heroin for medical purposes, even though in some situations, such as treatment of pain for post-abdominal surgery and cancer, it is superior to morphine.

In the 1990s and again in the first decade of the 21st century, the American Medical Association (AMA) published an editorial naming inadequate treatment of both acute and chronic pain as one of the most important issues in contemporary American medicine. As Figure 19-1 illustrates, pain is an all too common problem and accompanies many chronic and end-of-life conditions. In a 1997 press release, the AMA called inadequate pain management a crisis in American medicine. According to an October 2008 Pain Management Journal article, the situation has not improved in the intervening years.

The high-profile case of the late Playboy model Anna Nicole Smith brought out many of the conflicting and confounding issues related to pain management.

Did she have pain? How much pain? Did the doctor prescribe in good faith? Was Smith an addict? What is an addict? How much is too much pain medication? In Smith’s case it appears, from a distance anyway, she was prescribed too much and without regard for adequate follow-up, but that’s based on newspaper articles, not the facts. Whatever the truth of the matter, sadly the real fallout is likely to be just feeding our opiate phobia.

Opiate phobia has decreased the availability of appropriate pain medication for patients suffering from pain. This is true even though over the past decade there has been an increasing recognition by physicians and the general public of the deleterious effects pain can have on the quality-of-life and healing.

The conflict between providing adequate pain treatment and concerns about diversion of prescription medication into the illicit market has put doctors in the crosshairs. Doctors must do a delicate balancing act between conflicting demands. Pain management presents challenges for clinicians in terms of balancing the legitimate benefits of prescription pain therapy with the potential for misuse of the drugs. This is compounded by misinformed and misguided government agencies.

Jeffrey Coben, M.D., professor of emergency medicine and director of the Injury Control Prevention Center at West Virginia University in Morgantown, notes, “We’re in a bit of a conundrum when it comes to this issue. Ten years ago, doctors were criticized for not providing adequate pain management and there’s still concern in that regard. We’re trying to respond, but at the same time, we’ve seen an increase in abuse, misuse and other sequellae.”

Opiate phobia, stimulated by demagoguery and demonization, confounds reasonable medically based pain management. At every conference of professional organizations where members deal with opiate and/or pain management—such as the California Society of Addiction Medicine (CSAM), American Society of Addiction Medicine (ASAM) or to American Pain Management Association (APMA)—there are presentations discussing strategies for dealing with the legal pitfalls awaiting physicians who are providing their patients with adequate pain relief medication.

Implications of Opiate Phobia for Pain Management

Opioid phobia has negative implications for patients. The late Dr. Joel Hochman, former executive director of the National Foundation for the Treatment of Pain, wrote the use of opiates for pain management is viewed by the general medical community with “fear, discomfort and anxiety.” Hochman charged, “fears related to addiction, tolerance, abuse and diversion doggedly remain part of the opiophobic mythology that persists in American medicine.” This is in the face of major medical organizations and professional associations all coming to the opposite conclusion: “addiction, tolerance, abuse and diversion are statistically insignificant complications of the treatment of legitimate pain, both acute and chronic.”

Hochman argued the media and politicians completely “disregard the statistical insignificance of overdose or addiction in the legitimate use of opiods.” He continues, “Media exploitation, self-perpetuating drug enforcement propaganda and political opportunism have all combined to promote and sustain opiophobia. Even highly intelligent and intensively trained physicians are susceptible to this cynical hysteria. The consequence is the crisis in pain care.”

The Medical Case Against Drug Testing in Workplaces

The ability to detect a drug depends on many variables, among which are: dosage, absorption rate, route of administration, drug purity, type of filler used, tablet compression, individual metabolism, frequency of use and whether drugs are consumed singly or in combination. A urine toxicology screening does not test for the presence or absence of the drug, but for a critical quantity of it. If the concentration drops below a certain level, the test will not usually detect it. Knowing how long it takes for abstinence to reduce concentrations below these critical thresholds – 2-4 days for cocaine, heroin and amphetamines; 3-10 days for occasional use of marijuana; 5-13 hours for alcohol – allows chronic users to feign illness and postpone their test long enough to free their bodies of the drug and its metabolites.

Abstinence is not the only way to pass the tests. Employees have been known to smuggle in clean urine (and to keep it at body temperature to fool the medical attendant), to drink large quantities of water to dilute their samples, even to obtain prescriptions for legal drugs known to test positive in order to provide themselves with a “legitimate” explanation of their own more genuine positives. Marijuana users can add salt, sweat or Drano to increase the pH of their urine samples. This has fueled a game in which patients try to get around detection of illicit drugs by using various methods. Then laboratories institute counter measures to detect adulteration, substitution or dilation.

There is also a chance that positive tests will be false. Even if the test is accurate, the mere indication of the drug does not tell us whether the employee has used the drug once or a hundred times – or at all. There is a 5% to 10% chance illicit drug users will falsely test negative despite the drugs in their bodies.

Most laboratories screen for illegal drugs with the so-called EMIT method, which is hardly foolproof. A number of harmless—or in any case legal—substances have molecular and electrochemical patterns similar to the hard drugs EMIT was designed to identify. Over-the-counter cough and cold preparations may test positive for amphetamines. The opiate-like drugs and alcohol found in other legal medications may also confound test findings. Poppy seeds eaten in quantity may produce an opiates indication.

Regular urine testing does little to stop the diversion of prescription medicine into the illicit market. The urine toxicology at least is “good for the economy.” A urine test can cost over $200.

Throw the Pain Sufferers in Jail?

Given the long history of freedom in the United States, it is hard to fathom why the use of pain medication became a crime. From 1492 until 1918, this was not the case. Furthermore, the best way to decrease opiate abuse is the legalization of cannabis—and we did just the opposite over the objections of the AMA. By rescheduling cannabis as the AMA suggested in 2009, or legalizing it as many drug reformers advocate, we would make cannabis more readily available to the ill and infirm. Here is a painkiller that is effective and with no addictive potential. It does not cause decreased respiration and has a therapeutic index of somewhere between 4000:1 and 40,000:1. (Therapeutic index is the ratio of the lethal dose to the therapeutic dose.)

Prescription drugs and substance abuse, like most illnesses, knows few boundaries of race, religion or class. However our attitude toward celebrity substance abuse is often more forgiving than it is for the average person. When people like Cindy McCain (wife of 2008 Republican presidential candidate, John McCain) and radio personality Rush Limbaugh were treated with sympathy and understanding over their excessive reliance on pain medication, one has to take note of the disparity. Cindy McCain has a long history of migraine headaches. She is one of 30 million Americans who get migraines. In the late ‘90s, she had been placed on opiates for back pain. This led to excessive and inappropriate use of pain pills. She continued to use Percocet and Vicodin excessively. She went to rehab not jail.

Which situation seems appropriate and makes the most sense?

This is an excerpt from my book Drugs Are Not the Devil’s Tools. The first edition is available now on Amazon and the second edition will be released in the Spring of 2017.