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The human brain is an amazing device. Each day our brain takes in massive amounts of information through our ears and eyes, our sense of smell and our sense of touch. But what about our sense of pain? Under normal circumstances people don't give much thought to pain but the sensation is very important. Without pain you might walk on sand hot enough to fry an egg without noticing. In this way it is a blessing to feel pain. Pain helps prevent injury. Also a blessing, it is difficult to remember pain. You may remember the event and that it was painful, such as spraining an ankle. But what happens if the pain never goes away? Some injuries and conditions leave permanent nerve or structural damage that causes pain that never subsides. Most people who experience pain even close to this severe find it is short lived and soon forgotten. Once a doctor tried unsuccessfully to reset a bone in my arm after an injury. I remember the bones scraping and crunching in his hands and how he kept giving me shots of Demerol but the pain was still more than I could stand and he had to stop. I can't imagine living with pain like that for more than 45 seconds and I really do thank god I can't even remember what that felt like. Societies collective lapse of the memory of pain helps to explain the epidemic of under treatment of pain. What epidemic? My best estimate is that there are more than 75 million Americans that suffer long term unrelenting pain. There are many million Americans suffering needlessly because of undertreatment of pain. Of all the epidemics I have studied the epidemic of under treatment of pain is the one that seems the most curable and the most senseless. Consider the report by Maia Szalavitz, 13 July 2005, New York Times; " EVEN as Afghanistan's immense opium harvest feeds lawlessness and instability, finances terrorism and fuels heroin addiction, the developing world is experiencing a severe shortage of opium-derived pain medications, according to the World Health Organization. Developing countries are home to 80 percent of the world's population, but they consume just 6 percent of the medical opioids. In those countries, most people with cancer, AIDS and other painful conditions live and die in agony. The United States wants Afghanistan to destroy its potentially merciful crop But why not bolster the country's stability and end both the pain and the trafficking problems by licensing Afghanistan with the International Narcotics Control Board to sell its opium legally? " But certainly we, in the USA, have good availability to pain medicine? Don't bet too much on that. Again Maia Szalavitz; " Here in the United States, only half of all dying patients receive adequate relief, and those suffering from chronic non-cancer pain are even more likely to be undermedicated. " There are many reasons why pain is under medicated in the USA. According to the 1996 report of the International Narcotics Control Board titled "availability of opiates for medical needs" the four main reasons for under management of pain is 1 -- "concerns about addiction" 2 -- "insufficient training of doctors" 3 -- over burdensome regulations and 4 -- "reluctance to prescribe or stock opiates because of concerns about legal sanctions". Number 2 is cured by educating doctors and both three and four are vanquished with a truce in the drug war so that leaves number one, fear of addiction. Consider what the World Health Organization says about addiction and pain treatment: " WHO recognizes that the medical use of opioids is rarely associated with the development of drug dependence ( addiction ) and further clarifies that a cancer patient who is physically dependent ( as manifested by withdrawal ) is not considered drug dependent ( i.e., addicted ) ". [appx. one percent] The medical community tries to stay as far away from the subject as they can get. And who can blame them? The DEA has targeted doctors for high profile prosecutions and even though the DEA claims the percentage of doctors they prosecute is small the actual number of doctors willing to prescribe strong pain medicine is tiny and shrinking in spasms coinciding with every additional doctor imprisoned. Recently in Montana the DEA had to face this issue head on when the patients displaced by one of their prosecutions found no safe harbor for their medicine despite comforting statements made by DEA to the contrary. One of the most insidious aspects of the war on drugs interference with medical practice has to do with a device called a "pain contract". When I asked the American Medical Association [AMA] about pain contracts they referred me to the American Academy of Pain Management [AAPM] . The AAPM promotes the use of a well thought out and fair document called a pain attestation. The trouble is that no-one uses the pain attestation and instead pain clinics use a patchwork quilt of the quasi legal "pain contracts" that call for outrageous and degrading accommodation by patients under duress of discontinuance of their needed medicine. The pain contract makes it clear that you aren't to be trusted like a regular patient. You must submit to routine urine drug testing for marijuana. One patient tells me that his doctor rolls dice to see who gets drug testing. I can't imagine submitting myself to a lab procedure based upon a dice game. You must never ask for additional office visits. You must never need more medicine. You must get better; failure to improve will result in removal from treatment. I asked a dozen or so doctors from across the country about the use of pain contracts. Those in favor of them said they were necessary to protect the doctor. Some see the contract as similar to a consent form that you sign before surgery. Doctors opposed to the contracts felt they negated the doctor patient relationship and replaced the Hippocratic oath with a law enforcement oath. Consider the words of Dr. Fisher from California: " By rejecting the essential elements of the standard of care, contracts, as they currently exist, guarantee that the therapeutic goal of optimal patient functioning will seldom be achieved. In the vast majority of cases they make this an impossibility." Or the words of Dr. Adams of the Texas Pain Society: " Contracts are supposed to prevent diversion, but there is no evidence that they actually do so. The pain contract is nothing more than ritualistic behavior in support of a myth fueled by an ideology" In his great work, Ceremonial Chemistry, Dr. Szasz writes about how doctors in the USSR were ordered to give up the Hippocratic oath since doctors in the USSR were communist agents of the state and not agents of the patient. In this situation, like in the USSR, doctors are being put in a position of working as an agent of the state and not of the patient. Contracts call for patients to be immediately cut off from opiates for a failed marijuana urine test despite bonafide medical science affirming the benefit of cannabis as an adjunct medication to opiates and despite state laws allowing for cannabis use as a medicine. Cannabis helps reduce the amount of opiates needed and is extremely useful for patients that cannot tolerate opiates side effects. Worst is the fact that some kicked out of pain clinics for medical marijuana find their only refuge from pain in methadone clinics where they help perpetuate the drug war myths by the requirement that they swear they are truly a drug addict before they can receive treatment. Forcing a patient to sign a contract under duress of withholding medicine violates a huge list of human and civil rights such as Constitutional rights, section 504 of the ADA, Universal Declaration of Human Rights ( 1948 ), the International Covenant on Civil and Political Rights (1966), and the International Covenant on Economic, Social and Cultural Rights (ICESCR, 1966). Bottom line is you have a basic human right to access the medicine you require. As a compassionate society proper treatment of pain should be one of our highest priorities. Michael Krawitz is a regular columnist for the Collegiate Times |
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