In her third guest post for Points, pain relief activist Siobhan Reynolds traces the unraveling of the doctor-(pain)patient relationship under drug prohibition.
Perhaps the most disturbing consequence of opium prohibition, and the one least talked about in polite company, is the steady degradation of the doctor/patient relationship that has occurred since prohibition’s inception. In poor countries, where opioids are not at all available, physicians speak truthfully to their patients when they tell them that they have nothing with which to relieve their pain. In countries like the United States, where opioid pain medications are ostensibly legal but where physicians have been intimidated into withholding pain treatment, the doctors feign their impotence. There is certainly a great deal of pain relief to be found in opioid medications, and they are stacked on the pharmacist’s shelves. But physicians in the US are jailed – often arrested by SWAT teams, de-licensed and destroyed financially – for treating pain in a manner inconsistent with the opinions of government lawyers and agents. If you ask the physician who refuses to treat pain with opioids if his fear of official attention is the cause of his failure to serve his patient, you will likely meet with something quite different than such a humble confession. Instead, you will hear about how addictive the opioids are, or the doctor will say that their use should be confined to the care of the terminally ill, when addiction is not a concern. And he will extol the virtues of the anti-inflammatory and of psychiatric drugs. He will talk about the miracle of biofeedback and the importance of a positive outlook on life in the treatment of pain.
All of these responses have their place in the treatment of pain after the pain has been medically controlled. But recommending these adjustments as if they replace the pain relief provided by opioids is like telling a woman whose house is burning that a simple glass of water will fix her problem or a diabetic that he must exercise to earn his insulin. To a person in suicidal levels of pain, this kind of dissembling amounts to psychological and physical abuse. And yet this conversation between doctor and patient is par for the course under drug prohibition. It is a refrain patients hear over and over, until they finally stop searching for relief and eventually give up on living all together.
The fundamental truth that confronts anyone concerned with the quality of the doctor/patient relationship under drug prohibition – namely, that doctors have in essence been turned against the interests of their patients – remains almost entirely unacknowledged by the profession as a whole. As a result, in the underworld of pain treatment–where there are a few idealistic doctors, and many who are looking to take advantage of what is perceived to be easy money–patients are essentially imprisoned by their doctors; their very ability to function and provide for their families is held hostage to the demands their physicians make on them in order to comply with what the physician believes is required by law enforcement. It matters not that the demands might be utterly unreasonable or entirely degrading to the patient. The patient has no choice but to submit to the doctor or go to the street for the medications – a prospect that brings with it even more onerous sanctions.
As physicians have been subjected to a campaign of official intimidation that began with the adoption of the Harrison Narcotics Act and continues to this day (nicely documented by Joe Spillane on this blog) an ethos of suspicion toward people in pain has found its way into the doctor/patient relationship around the world. Without so much as a peep from the academic circles of medical ethics, the profession has adopted wholesale the law enforcement imperatives foisted upon it. The few physicians willing to treat pain patients with opioids come to be more aptly likened to compliance officers at drug rehabilitation clinics. Having tacitly accepted the notion that only patients who don’t also smoke marijuana or procure pain medications through other means deserve pain treatment, physicians routinely require patients to perform random urine drug screens and to pay for them out of pocket in order to prove their worthiness to receive pain care. A significant number of patients don’t metabolize opioids as expected, but this fact isn’t widely known.
Moreover, it is not unheard of for a physician who suspects “abuse” to call a local cop or DEA agent to the home of a patient in order for the officer to perform a surprise pill count. If the patient proves to have too much or too little of the drug, the physician will summarily discharge the patient from care. If a patient’s family in any way objects to his or her use of the medication and the family suspects that the patient suffers from addiction, the doctor is obliged to terminate care immediately or incur the wrath of the criminal authorities as well as the medical licensing boards and the civil attorneys braying for a sizable pay day. If a patient loses a prescription or has his pills stolen he is likely out of luck. The vast majority of chronic pain patients are forced to sign what is euphemistically called a “pain contract” with their doctors in which they give their doctor permission to terminate opioid treatment should any one of a whole litany of events occur. Patients also “agree” to refrain from calling the physician on weekends and skip going to a local emergency room should they need more relief. Turning the notion of informed consent on its head, patients are required to act as silent recipients of abusive treatment. If the patient is unhappy with the care he receives, he can attempt to find another doctor. Branded as a difficult patient, the malcontent will be shut out of whatever practices prescribe opioids. With the standard of suspicion set firmly in place, the power relationship between doctor and the person in pain is tilted entirely on the side of the embattled doctor. As a result, all kinds of abuses of power flourish in the dark.
I became familiar with this dynamic when my husband, Sean Greenwood, now deceased, suffered systematized abuse at the hands of the doctors who treated his pain. As I developed the Pain Relief Network and came into contact with thousands of people similarly afflicted, I realized that the abusive relationship was not unique to Sean and his doctors but was ubiquitous in the world of chronic pain sufferers. In a surprising and under-cited article that appeared in Practical Pain Management in early 2005, the authors trace the negative interactions between people in pain and the doctors who treat them to the Milgram studies conducted at Yale in the 1960s and later repeated at Stanford, which demonstrated that people tend to yield to pressure exerted upon them by authority figures even when the activities they are pushed to perform clash with their ethics or are could result in another person’s death. The experiments showed the powerful negative impact that outside authority has on human behavior, specifically when it affects fragile relationships in which one person has total control over another.
When told to administer “lethal doses” of electrical shocks to subjects under their control, a full 100 percent of those empowered by an authority figure were more or less obedient to the will of that authority figure. Many of the situational torturers were willing to comply even to the point of administering shocks that they believed were killing those people under their control. In this ongoing series of experiments involving 1000 people chosen because they demonstrated no history of psychological problems, it was discovered that apparently normal people would become abusive when the balance of power was profoundly unequal and when someone respected as an authority applied pressure on them. The results of the study were so unexpected and shocking, that the study was terminated ahead of its planned ending. At the time, the findings were controversial but subsequent studies have born the results out.
When reflecting on the desperate situation faced by people in pain due to the unavailability of effective treatment (and the few doctors who treat them operating at the direction of medically untrained police agents) imagine, if you will, what the patients suffer. Think for a minute about the following: the normal people in the Milgram studies were willing to torture their subjects to death rather than merely disappoint an authority figure. Imagine if, as is the case with doctors who treat pain, their lives, liberty and careers were on the line should the person under their control behave in a manner inconsistent with the wishes of the DEA or other supervisory bodies. Would you trust such a doctor to behave in a manner consistent with the best interests of the patient? Or would you be more realistic in acknowledging that the situation is ripe for abuse and neglect?
The situation is so bad inside medical practice that I advise patients to take any and all measures to keep their pain treatment to themselves. While it is illegal to grow opium, many native peoples have done it for generations, using opium tea to soothe chronic pain. To subject oneself to the ravages of modern pain practice is to put oneself at the mercy of people who are well versed in denying meaningful relief. And because the system has developed in the dark for nearly one hundred years, every aspect of it functions to profit off the suffering of the patient. Whereas medical management of pain is often the least expensive and most humane approach to serious intractable pain, the widespread denial of care functions to push our most vulnerable citizens into numerous surgeries, expensive poly-pharmaceutical regimens, rounds of physical rehabilitation, repeated efforts at diagnosis, and interventional pain treatments that are exceedingly expensive and of little help to those suffering the neurological disease of severe chronic pain. The pain patients are indeed the slaves of the system, those purporting to serve them profit from their predictable decline.