Pain Medication For Chronically Ill Patients
Are doctors overeager to give chronically ill patients pain medication?
I have a friend who has just been diagnosed with bone cancer and will begin radiation treatment on his hip shortly. He has been on a morphine drip for 9 days. When I voiced my concern about addiction since he is not terminal or in last stages, his wife blithely answered that the doctor said not to worry, that it takes six months to become addicted. I was rather shocked at that, plus his comment that vicodan was for PMS. Does the six month addiction process sound right to you? Thank you.
I agree that a six month cut off sounds glib. But that kind of glibness is preferable to the other kind—don’t provide adequate pain relief, because the person will become addicted. There have been a number of studies that have come to the same conclusion: remarkably few people exposed to pain medication become addicted in the hospital. Indeed, a 1982 editorial in the New England Journal of Medicine, entitled, “The quality of mercy,” by Marcia Angell, still applies: “The desire to protect patients from becoming insidiously drawn into a state of addiction distorts both our sense of priorities and our scientific judgment. . . . These attitudes and misconceptions have led to a rather ritualized and parsimonious use of narcotics for the relief of pain.”
A personal note: I had had a painful knee operation from a prominent New York surgeon, after which the doctor gave me a very mild analgesic. I was writhing in pain in the car ride home, so that my wife had to stop and call the doctor for a prescription for a powerful pain killer from a New Jersey pharmacy en route. Many years later, I had a hernia operation. I was discussing pain killers with the anesthesiologist, who told me he had had pharmacology at City University’s medical school under John Morgan, who had taught his students to avoid this persistent tendency to undermedicate. After my recuperation, I called John to thank him personally. Another patient, Cynthia Snyder, described this phenomenon over a longer recuperation, in a moving “Open letter to physicians who have patients with chronic nonmalignant pain” (Journal of Law, Medicine, and Ethics, 22: 204-205, 1994). Although this message has been repeated for decades, it continues to make front page news into the nineties (“Patients in pain find relief, not addiction, in narcotics,” by Elisabeth Rosenthal, New York Times, March 28, 1993), and will continue to do so into the future.
I actually strongly dislike relying on analgesic drugs, which are depressants, and as quickly as possible ween myself from these. Indeed, I am not that unusual in this regard. Studies (not generally in the U.S.) have found that patients responsible for the titration of their own medications following surgery use fewer drugs overall than when they are medicated by physicians, because they use them more selectively and tail off more rapidly.
The strange phenomenon that hospital patients take powerful narcotics for long periods without becoming addicted is, of course, a powerful indicator that addiction is not a direct result of pharmacological action itself—or that such action is even a major component in addiction, as I showed in The Meaning of Addiction. I also comment on the tendency of seminal theorists, like Alfred Lindesmith, to incorporate such findings into their theories of addiction—for Lindesmith, the failure to know you are suffering withdrawal from narcotics and that reinjection will cure this problem explains the absence of large scale addiction in this population. Of course, this explanation is also glib—does Lindesmith mean that if you told me that I underwent withdrawal from my painkiller that I would have become an addict?
Obviously, some people do become addicted to hospital and post-operative medications—we read about them shuttling into rehab regularly in the Hollywood Reporter. What is it about such people that seemingly makes them so susceptible to something which rarely is observed elsewhere in nature? In part, it seems to be the modish acceptance of the inevitability of addiction. So, it is not knowing that narcotics will addict you that is crucial, but being convinced that this will occur, either as a personal belief or due to a set of beliefs that are prevalent in those around you, that seems to be operating.
Now, as for medicating PMS on a regular basis, I have a different feeling. But that will wait for another time.