The CDC’s New Opiate Prescription “Guidelines” Will Make The Problem Worse
Caveat Lector: I didn’t sleep great last night and this whole topic fills me with incoherent rage.
I’ve never written a story on Medium before. Okay; I’ve replied to a couple. This, it seems, has been enough to attract a few followers. I can’t say I understand it. Anyway, I’m writing here instead of my usual blog because I’m under the impression Medium has a wider reach in general, and this is something I want for this particular post.
Yesterday the United States Center for Disease Control released a new set of guidelines for prescribing opiates, proving beyond a shadow of a doubt that government agencies understand neither addiction nor chronic pain, and probably don’t care to. Since a large number of my friends and contacts are chronic pain sufferers, my Twitter feed blew up with people telling the CDC how far their collective heads are up their collective asses. (See a sample here.) Over on the CDC Facebook page, the relevant post was also swamped.
I don’t suffer chronic pain, myself. I have migraine disorder, which is bad enough. It renders me non-functional anywhere from a couple of days to a couple of weeks a month, with pain levels ranging from “I can cope if I take it slow” to “please shoot me now.” It’s nothing like the daily experience of people with fibromyalgia, lupus, rheumatoid arthritis, and other autoimmune and degenerative disorders. It does, however, give me a window into how seriously these guidelines will affect those who depend on pain medication in order to live their lives.
You know what, CDC, I get it. People in this country do abuse prescription painkillers. People in this country are taking heroin like never before. You see a connection. Probably there is one, of some kind. So you’ve come to the conclusion that restricting access to prescription opiates will curtail abuse. It’s an admirable goal. You’re going about it the wrong way.
A lot of people have responded to the outrage by saying, “It’s just guidelines! This doesn’t mean doctors are going to cut off people in real pain! Don’t get your knickers in a twist!” What they don’t understand is this: extreme attitudes toward opiates ALREADY impact people in real pain in damaging ways. Part of this has to do with the attitudes people in this country have toward pain. I honestly don’t know where people live, that they can walk into any old doctor’s office complaining of back pain and walk out with a month’s supply of Vicodin; certainly not anyplace I’ve ever lived. It’s more likely that when you try to get pain treatment, you get side-eye and the third degree. Where’s your pain? Why do you have it? Is it visible on a scan? What level is it? And remember, nurses often automatically assume if you complain of pain at level 7 or higher, you are LYING TO GET DRUGS. If you have had success for this pain with a particular treatment and you ask for that treatment, you are LYING TO GET DRUGS.
When my migraine pain gets bad, when it’s lasted more than three days, I call the local clinic and get a shot for relief. I live in a rural area with a small clinic I’ve been going to for the last twenty years. The doctors there know me. They know I have migraines. They know I maybe call for the shot three times a year. The shot used to be Demerol and Phenergran. It worked. It also used to be the case that if I really, really needed pain relief on a weekend, I could contact the doctor on call and they’d meet me at the clinic and give me the shot. That changed around seven years ago, when the clinic hired an out of town answering service. Now, when you call on a weekend, if it’s not urgent they tell you to call back and make an appointment during office hours. If it’s urgent, they tell you “Go to the ER.” Like, why bother having a doctor on call at all?
Anyway, I hate going to the ER for migraine. For one thing, it’s thirty miles away. For another, migraine isn’t an Emergency. It’s awful and unpleasant, but I’ve had them all my life and at this point I’m relatively sure they’re not going to kill me. But the worst part of it is the way they treat you when you go in wanting pain relief. You had better not say anything like “My doctor usually gives me a shot of 100 mg Demerol and 50 mg Phenergran,” because knowing what you get and in what amounts is a SURE SIGN you’re actually a drug addict. I’ve had nurses tell me, “Oh, opiates don’t actually work for migraine!” (a contradiction of my direct experience), and I’ve had doctors refuse to tell me what they’re giving me for fear it will lead me to seek out more of the same. More than once, I’ve gone home after three hours in the ER in just as much or worse pain than when I arrived, because doctors would rather prescribe anything but the thing that actually works.
The upshot is that I no longer go to the ER for pain treatment. I rarely even go to the clinic, because they don’t keep Demerol on hand anymore. The standard migraine shot now is Toradol, Phenergran, and Benadryl, and honestly, why bother? If I’m actually throwing up, the Phenergran helps, but otherwise I can take four Motrin and two Benadryl at home and get about as much relief. Which isn’t much.
And that’s just a sample of what others face. Migraine is chronic and episodic, i.e., yeah, you have it for life, but it doesn’t affect you every day. Some people are in brutal pain every day of their lives. They don’t take opiates to get high. They take them to function. They ration the pills they’re granted and arrange their lives around those few hours when the pain is manageable. These are the ones who are already suffering.
I have this one friend who’s virtually bedridden with chronic back pain. Norco works for her. Her doctor will only prescribe enough for two weeks of function out of every month: 30 pills at 2 a day. Last time she went to get her script filled, the pharmacist refused to do it unless she gave access to all her medical records, including her scans.
These are the people the new guidelines will hurt, are hurting right now. It’s literally easier to buy street drugs to manage chronic pain than it is to get a doctor to prescribe them. So, great job curbing the heroin problem there. way to go.
As for suggesting “alternate pain remedies” like Tylenol, Ibuprofen, meditation, acupuncture, and whatnot… I mean, really? That’s just fucking insulting. When people in pain ask for medical help, it’s because they’ve already tried all the “alternate” therapies and THEY DON’T WORK. Last fall, my BFF had a migraine that went on for days, getting worse and worse all the time. She was at the doctor and the ER repeatedly, trying to get relief. Their best advice was “Take Ibuprofen and don’t use too much caffeine!” No one even investigated her pain for two weeks, when she finally demanded a lumbar puncture. She had meningitis. Another friend was recently in severe pain from a burst ovarian cyst. She went to the ER. Guess what they told her? “Take Ibuprofen!” How condescending can you get? Like, “Gee, you’re right! I FORGOT OTC MEDICATION WAS AN OPTION!”
I’ve also heard stories of pain clinics steering people toward “alternate therapies” which they incidentally provide right on premises at a significantly higher cost than just writing a fucking prescription. If you’re lucky enough to have insurance — and I know in these days of the ACA everyone is supposed to, but many still don’t — often the insurance won’t cover these “alternate treatments” anyway. Big help, there.
Here’s the thing: Maybe there is an epidemic of painkiller abuse going on. I think it’s SO interesting that it’s getting press now that white people are dying more, but that’s another rant, and not one I’m really able to address. But people in power, and the general public, are too busy making moral judgments about how people manage pain to address the underlying causes of addiction and drug abuse. Dependence on a drug does not equal abuse. Lots of people are dependent on drugs to improve their quality of life and simply survive. Diabetics are dependent on insulin. I’m dependent on my antidepressant. People in chronic pain are dependent on their pain medication. But in a culture that preaches overcoming all obstacles and worships the rugged individual, needing help to cope with physical pain — even the admission of physical pain — is seen as a moral failing. Like, “If you were worthy, either this wouldn’t happen to you or you’d push on through!”
In spite of dependence, most people with chronic pain issues don’t become drug abusers because you get moral credit for not needing or turning away help. Part of you feels stronger and more virtuous if you can manage without. It proves something to the world — that you can’t be laid low by physical pain, that you can bite a strip of leather through your unanesthetized field surgery and return to leading your troops fifteen minutes later, whatever. I can’t articulate it, and I’ve DONE it. I’ve had my doctor tell me after surgery “Don’t be a hero! Use your pain meds! You don’t heal when you’re in pain!”
Where the problem lies, in my experience, is when people with an underlying predisposition and/or an undiagnosed mental health issue are prescribed opiates for an episode of acute pain, like after a surgery or accident. I actually have to watch out for this myself, because of my depression and because opiate abuse runs in my family. When I’ve been prescribed opiates, it’s like… It’s like I’ve been surrounded all my life by this dark cloud of smog, and the cloud finally lifts and I can breathe. All the darkness, all the weight that’s on me so constantly I’m not even aware of it, is gone, and it’s such an amazing thing. I feel like a regular human being. The things that get my way and prevent me from living my life just vanish. I want that to be the case ALL THE TIME. I’ve been working on my mental health for forty years, so I recognize this and I have other coping skills. I have actually moved across the country so as NOT to learn the identity of the heroin dealer in town.
Other people don’t have my experience with managing mental illness or my coping skills. In fact, among the white working class, where a lot of the problem lies, there is also a huge amount of mental illness stigma. On top of that, the “rugged individual/real men don’t need no help/quit your pansy-ass bellyaching” mentality is often stronger than usual. So it’s likely that in that population, when opiates life the black cloud and they feel like they can breathe, it’s a revelation. And lacking mental health resources, as well as, in all likelihood, being discouraged from seeking them out, this population will do whatever they can to keep that black cloud from coming back.
Limiting access to opiates isn’t a workable solution to the current “public health crisis.” It wrongly penalizes people with chronic pain and doesn’t address the real needs of those most likely to become addicted. The CDC needs to stop with the policy of prohibition and demonizing all opiate users and focus on making better solutions available to the ones who needs them most.
Read a more concise argument here.