By Anne-Marie Vidal, MPA ©
When Rush Limbaugh went public with his addiction to pain medication, I was not alone in holding my breath and wondering if his problem was about to become my problem. As a pain patient and a bi-racial, African American-Latina woman, I fought for years to get adequate pain medication; by the time doctors did give it to me, my blood pressure was at stroke levels and I had heart damage. My experience as a pain patient is not unique, while much is written about OxyContin and opioid abuse, make no mistake, pain medications are not easily obtained for the legitimate pain patient going through lawful medical channels. That minority and women pain patients have difficulty obtaining sufficient pain relief has been documented many times.
The circumstances of Mr. Limbaugh’s addiction, as they have been publicized, are not entirely clear nor do they seem to tell the whole story. It has been reported that his addiction began after back surgery several years ago and that the lingering pain caused a need for more and more medication. After my own back surgery, I was released from the hospital with exactly a 5 day supply of Vicodin and a list of exercises to do, so how exactly did the conservative strongly opinionated talk show host manage to obtain enough pills to lead to an addiction? Did a physician cave in to his celebrity or his bombastic style or is it simply that white males are more favorably heard by physicians when they wish to obtain pain medication?
Some combination of all three factors probably was in play. But the over riding point is that Rush’s problem will most likely become the problem of American pain patients if we let it. OxyContin has been under attack for the past two years. Headlines have blared its dangers. Many of these stories have been filled with half truths and outright twists of the facts. At the same time, doctors who are thought to “too freely” prescribe the drug are under scrutiny. Several have been arrested for their patients’ misdeeds and Dr. James Graves of Florida was found guilty of manslaughter due to a patient’s overdose with OxyContin. It is interesting that when it comes to OxyContin, law enforcement and conservatives are not about to apply the same logic that makes them say “Guns don’t kill people, People kill people.” If this logic applied to OxyContin, we could say, that “Oxycontin doesn’t create addicts, illegal drug use creates addicts.” To prosecute doctors for their patients’ transgressions is equivalent to prosecuting gun manufacturers for all shooting deaths in the U.S.
The Conservative talk show host’s addiction intensified the limelight on the already controversial drug that has been central to media invented misconceptions for quite sometime. For the past two years, there has been heightened media fanfare on Oxycontin focusing on “Oxy deaths” and “Hill-Billy Heroin”. At the same time a few dedicated doctors and enlightened reporters have tried to tell the truth that Oxycontin is not 4 times more potent than heroin, and that in almost 96% of the 500+ alleged “Oxy-deaths,” other drugs were found to have been ingested by the victims. Interestingly, the media does not turn any dramatic attention to the 16,500 deaths annually that stem from the use Non Steroidal Anti-Inflammatory Drugs, commonly called NSAIDS. NSAIDS are often prescribed for a variety of pain conditions such as osteoarthritis, muscle injuries, menstrual cramps, and tendonitis.
Used properly, chronic pain patients taking OxyContin are able to function, continue working, and be productive. Consider the alternative—a life of paralyzing pain where one is unable to work, or think clearly because the over riding factor of waking life is pain. That kind of life is reality for 50 million Americans, 15 million of whom are maintained on some type of opioid pain medication. And yet, there are probably many people in need of adequate pain medication who are not receiving it.
With Limbaugh’s announcement of his personal battle with drug addiction, a problem that he asserts he resulted from treatment with opioid medication for pain, it is likely that many more pain patients will be inadequately treated.
There was a time when the Drug Enforcement Agency focused its efforts on trying to stop the flood of illegal drugs into the country. These days it seems the DEA’s attention has turned to doctors who treat pain patients. Dr. Joel Hochman, director of the National Foundation for the Treatment of Pain released the following chilling statistics in a Nov. 2, 2003 article : The DEA investigated 622 physicians in 2002, brought charges against 586 and in 426 cases medical licenses were revoked “for cause.” His outlook for the future of pain patients is bleak if the DEA’s actions are not checked or reviewed. “If the DEA continues as at present there won’t be any doctors writing opioid prescriptions in two more years.”
Physicians like Roanoke Cecil Knox, whose trial ended recently, and William Hurwitz, who is also an attorney, hardly fit the image of drug dealers. Yet Federal prosecutors have compared Dr. Hurwitz to a street corner crack dealer, saying he uses his “white coat and with the power of a pen" distributes drugs, said Mark Lytle. Despite the prosecutor’s, hyperbole neither Dr. Knox nor Dr. Hurwitz fit the image of the sleazy “Dr. Feel Good” willing to give a patient anything that they want. It may be that these physicians erred on the side of compassion in caring for pain patients whose history may have included drug abuse or it may be that their patients did not make a full disclosure of their medical history including and previous problems with drugs or alcohol. However, a recent article in a Nursing journal recommended erring on the side of compassion when treating pain patients with a history of addiction. In the abstract it was noted that
…”Although clinicians are often reluctant to medicate with opioids, it is always best to err on the side of adequate pain relief. Withholding opioids from chronic pain patients in order to avoid the onset or relapse of addiction is contrary to the growing body of evidence and results only in unnecessary pain for the patient. Chronic pain in patients with a history of addictive disease can be treated successfully with opiate analgesia; it just requires caution and careful monitoring of medication use.
Indeed, it is implicitly part of the patient’s bargain with any doctor who will to treat our pain, if we act honestly and reliably. From published accounts both physicians have kept detailed patient records and their patients are for the most part functional and doing well. Both of them are being held responsible for the abuse of trust committed by patients. At this writing neither of these cases has been decided. Much has been made of prescription data bases that were designed to check doctors who prescribe opioid medications for patients frequently. Although these databases might reveal frequency, they will not reveal whether a physician prescribed medication appropriately, only a patient’s records can do that.
Another view of Mr. Limbaugh’s problem has been offered by attorney David Brushwood, R.PH, J.D., who is also a Professor of Pharmacy at University of Florida at Gainesville, offered the detailed view that addiction was not the problem, but neglect of his pain was. The article, “Is Rush Limbaugh a Neglected Pain Patient?” was published at the prestigious Pain and the Law website and cites a number of substantial and valid reasons for this view. One of them being that Mr. Limbaugh never engaged in poly-drug use, but just the use of pain medication. Another is that Mr. Limbaugh’s home area is increasingly hostile turf for pain patients and that many doctors will not treat pain adequately. Additionally, Professor Brushwood states that Mr. Limbaugh remarks that “you just keep needing more of the stuff” are consistent with developing a tolerance with opioid pain management. Brushwood’s view is seconded by Dr. Ronald Myers, president of the American Pain Institute and a Baptist minister who feels that Mr. Limbaugh did not have a lawful recourse to have his pain adequately treated.
Most lay people and many physicians are woefully ignorant regarding the use of opioid analgesics. They have no idea that these medications can be safe and effective. They are equally ill-educated to the dangers of NSAIDS, which as previously mentioned kill over 16,000 people in this country annually, or Tylenol which is responsible for over 500 deaths every year. If people are denied the appropriate, effective medication, they will search for inappropriate alternatives; some people will turn to illegal drugs. Others will overuse over the counter medications and harm their kidneys and their livers as a result, not to mention causing themselves untold gastric problems. We will see an increase in alcohol consumption in pain patients as people try desperately to do something about their pain.
Many people hear someone in law enforcement who should be an authority on opioid medications say something like “The number of people abusing their pain medication has quadrupled.” And think, ‘Oh my, the opioid medications lead to addiction’, in the 1990s and through the year 2000, the National Institutes of Health maintained that less than. .1% of pain patients became addicted. Now the DEA has the statistic at 3%, just how it is calculated is not explained. And given the inaccuracy of their data on OxyContin, I am unwilling to trust it. Additionally, the average person may perceive use of opioid pain medication as a weakness, or as ‘giving in.’ Instead of realizing that the pain patient takes medication so that he or she can function, people equate use of pain medication with illicit drug use. Use of illicit drugs is designed to escape reality and responsibility; pain patients want very much to be a functioning part of the world and the medication is simply a tool to be able to do that. Our life is not built around obtaining our medication, yet an addict’s life is centered on getting his next fix. Our lives are very different from an addict, we don’t steal, and we don’t neglect our responsibilities. If we find we are not getting relief from our medication it may be we have come to tolerate it and at that point with the help of the physician we should decide on the next step. Tolerance may not necessarily mean more medication but it may mean an addition of other therapies to our pain management regime.
I know quite a few chronic pain patients who have not had their dose of medication adjusted in years. We seem to be doing fine on the same dose for three years or more and we continue at that level. On some level we are lucky, on another we are realistic. Most of us never expected that one pill was going to take all the pain away and knew that to control our pain we would have to engage in physical therapy, positive imagery, biofeedback, distraction techniques, or heat applications.
Even if medication is only a part of controlling your pain, it is an important part. With the current climate of anti opioid pain medication and Mr. Limbaugh’s announcement that pain medication caused his slide into addiction, many of us are worried. We are not sure that our medication will be there next month when we need our prescriptions renewed. We are not sure when we return to our next doctor appointment that our doctor will feel positive about our need for pain medication and if we are going to be left on our own. Not all of this is Mr. Limbaugh’s fault, for some time now it has been the case that OxyContin has been turned into a kind of Frankenstein monster of our era. There is more inaccurate information in the media about the drug then there is accurate information.
It is important that pain patients become proactive, not only do we have to educate ourselves, but we must educate our physicians, our elected officials, media outlets and our who ever stands in our way of having our pain treated. We must not go the way of suicide as many have said they will if their medications are stopped because doctors are frightened. Reportedly, there have been 17 suicides in Arkansas already, and this is a sad result in a war we have to fight.
There are excellent web sites to educate yourself on pain management addiction, some are mentioned in the endnotes, others I will mention here. This information is important, it will give you the facts which you need to write your Congressman and state legislators. The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine have published information that helps clarify the differences between chronic pain management and addiction. It can be found at http://www.asam.org/pain/pain_and_addiction_medicine.htm#2
Other recommended web sites: American Academy of Pain Management
http://www.aapainmanage.org/
The Pain Relief Network
http://www.painreliefnetwork.org/index.htm
Our Chronic Pain Mission
http://www.cpmission.com/
Chronic Pain Foundation
http://www.chronicpainfoundation.org/home/index.php
If we want to lead productive lives, we may very well have to advocate for that right. Education is the first step. Learn. Write. Advocate.
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[1] Todd K H, Deaton C, D'Adamo AP, Goe L., “Ethnicity and analgesic practice” Annals of Emergency Medicine, 1999 or Kirchheimer, Sid, “Health-Care Bias Not Just Black and White”, Web MD Oct. 2003
[1] Fraser, Ronald, “The DEA’s disastrous War Against Pain Treating Drugs”, Roanoke Times Nov 2, 2003
[1] Pain Relief Network, Opioids: Questions & Answers, http://www.painreliefnetwork.org/opiates.htm
[1] Fraser, R, “The DEA’s disastrous War Against Pain Treating Drugs”
[1] White, J. and Kaufman, M, U.S. Compares Va. Pain Doctor To 'Crack Dealer', Washington Post, Sept. 30, 2003
[1] Compton P, Athanasos P., “Chronic pain, substance abuse and addiction.” Nurs Clin North Am. 2003 September, Vol 38
[1] Brushwood, David, R.PH, J.D., “Is Rush Limbaugh a Neglected Pain Patient,” http://www.painandthelaw.org/mayday/brushwood_101503.php
[1] Owen, Frank, “The DEA’s War On Pain Doctors” Village Voice, Nov. 5 2003
[1] Owen, Frank , Village Voice