Wednesday, February 12, 2014

Addiction: Not About "Good Guys" vs. "Bad Guys"

I recently read an appeal by Dr. Kelly Erola, CMO for Hospice Savannah.  She wrote about halting the attack on pain pills and argued on behalf of legitimate uses for opioids – cancer patients undergoing chemotherapy, hospice patients, and patients with serious injuries and acute pain.

She makes an important point.  Opioids are an effective and powerful tool that bring immeasurable relief to individuals suffering severe pain.  Let’s be sure that those individuals always have a means of getting the care and the drugs that they need.

What struck me was the contrast she drew between “law-breaking addicts” and “law-abiding patients.”  In my view, this is a component of our societal struggle with opioids, but misses the most fundamental and dangerous aspect of the opioid crisis: the group that lies in the middle – “law-abiding addicts”. 

Yes, pill mills are a problem.  So is drug diversion.  So is the unintended consequence of illicit drug use.  But the group most in danger is, in fact, the law-abiding patient whose physician is prescribing high doses of opioids to treat conditions such as non-specific low back pain.  Millions of patients are losing out on the benefits of what contemporary medical evidence tells us is most appropriate for the treatment of chronic pain: get up, move, exercise, lose weight, sleep better.  Instead, physicians continue to write prescriptions for powerful pain relievers, leaving us with millions of “law-abiding addicts”. 

Any clinician will rightfully point out that I’m taking certain liberties with the word “addict” here.  Addiction is a real disease characterized by aberrant, drug-seeking behaviors – the very behaviors that often lead to illegal activity on the part of the patient.  The point I’m trying to make is that many of these “addicts” didn’t start out as criminals.  And there are millions of patients not technically addicted, but nonetheless entirely dependent on prescription opioids on a daily basis.  Dr. Erola highlights a single battle in the opioid crisis, but this is where we’re losing the war.

If the public policy distinction was as black and white as Dr. Erola suggests, the solutions would be simpler.  In reality, the problem of prescription drug misuse and abuse goes well beyond a simple matter of “good guys vs. bad guys”.  Any public health or regulatory discussion around opioids has to acknowledge that there are lots of “good guys” (i.e., law-abiding patients) being hurt, too. 

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