Pain is a philosophically strange phenomenon. It’s our constant companion, from the stubbed toe, to athletic injuries, to illness, to more mysterious chronic pain. And we tend to act like we understand it—communicating it to our doctors, asking for them to make it go away, and often believing that such a thing is possible. That seeming mundanity, however, hides a mystery: we can talk about pain with our doctors all we want, but we will never make them understand our pain. Pain is an essentially private and subjective experience.
Despite being a philosopher by training, and so having spent a career thinking about things like subjectivity, this simple truth had never occurred to me—not, that is, until I had my foot crushed in a motorcycle accident in 2015. The pain I experienced in the aftermath of that accident taught me many things, but among the most important is that the mysteriousness of pain is responsible for significant insult and injury. The subjectivity of pain means that its presence can never be confirmed—there is no “pain marker” to be found with a blood test, nor definitive evidence to be found with imaging—and so physicians need to determine how to respond to unverifiable reports of pain. Now add to this the reality that opioids are both one of our most potent treatments for pain and capable of causing euphoria, addiction, and eventually death. Clinicians are charged with fixing an ailment that they can’t confirm, and they’re given a tool that is both desired and dangerous. The situation is ripe for tension.
Historically, this tension has led to the American medical community’s opinion of opioids swinging violently back and forth between wholehearted embrace and near-complete prohibition.[i] With the advent of morphine, the hypodermic syringe, and heroin in the nineteenth century, the medical community embraced the aggressive use of opioid analgesics. But when that strategy led to the country’s first overdose epidemic, fear of opioids became dominant, slamming the pendulum back and lodging it firmly in prohibitionist views. This reticence stayed put for nearly a half-century, leading to significant suffering of pain patients. Americans eventually realized the callousness of withholding powerful analgesics, though, and over the latter half of the twentieth century, the pendulum slowly began to swing back toward permissive attitudes, picking up steam in the 1990s. But here again, as humane treatment of pain gave way to recklessly flooding the country with prescription opioids, this glut in supply helped to kickstart a raging drug overdose epidemic, and so—just as it did a hundred years before—fear of the medication has crept back into discussion.
We have been seemingly unable, for at least 150 years, to respond to pain with nuance, compassion, and care, opting instead for one or another ham-fisted approach. Which is preferable: prohibition or recklessness? These aren’t great options, and so we need to land somewhere in the middle. And that, basically, is the starting point of my new book, In Pain: A Bioethicist’s Personal Struggle with Opioids. Combining my experience as a pain and opioid therapy patient with my expertise as a bioethicist, In Pain attempts to articulate what responsible opioid use looks like, and what this has to do with today’s drug overdose epidemic.
Responsible Prescribing
My education on pain medicine began not in the academic literature, but in the hospital. After the fifth limb-salvage surgery following my motorcycle accident, I experienced both harms of a swinging pendulum firsthand. In the morning, when I begged for more pain medication, I was treated with suspicion by the ICU attending; she told me brusquely that she had “noted my request for more pain medication,” and that she would “discuss its appropriateness” with her team before leaving me still writhing in pain. This was an astonishingly callous response, given the fact that the bones of my foot had, just a month before, shattered with such force that they ripped an opening in the bottom of my foot. Indeed, it was a callous response regardless of my reason for asking; her tone and curtness made it clear that she didn’t believe my pain was as bad as I claimed, and such disbelief is an insidious form of disrespect.[ii]
Later that day, though, I would eventually get one of the surgical residents to organize a pain management consult, and the pain team that eventually made their way to my room prescribed lots of opioids, plus a non-opioid called gabapentin, and intravenous acetaminophen. Those pain docs worked magic, as far as I could tell, sending me into fairly comfortable oblivion.
Although at the time, it seemed that the latter treatment was the appropriate one—aggressively treating my pain when I asked—that wasn’t the end of the story. I only ever saw the pain doc one more time, on the following day, when he stopped by for 30 seconds to ask if my pain was under control. And neither he, nor anyone else on his team, ever discussed the risks of opioids with me. We didn’t talk about tolerance, dependence, withdrawal, addiction, or overdose. We talked about getting “ahead of the pain” and staying there. This team started a pain management protocol that they never intended to manage over the long term, and so my surgeon picked it up when I left the hospital, signing off on refills and escalating my dose as tolerance reduced the drug’s effectiveness. Worse yet, when my trauma surgeon finally advised me to get off the pills a month later, no one from any of my clinical teams offered guidance or could provide a competent taper.
In the book (and elsewhere) I describe in detail the devastating withdrawal that resulted from this mismanagement, so I won’t do that here. For present purposes, I will simply note the obvious, that this sort of reckless prescribing is irresponsible. In my case, it caused terrible suffering, and I was one of the lucky ones—I eventually succeeded in tapering off the medication. But as I would go on to discover over several years of talking to patients and doctors, this particular failure is not uncommon. Doctors know how to write a prescription, but not many of them know how to actually manage opioids, or when (and for how long) they are appropriate. My experience made clear that, at this moment in history, we are simultaneously erring on both sides of the opioid pendulum: doctors are both under-prescribing, and treating pain patients with suspicion, while also recklessly prescribing, and continuing to risk treatment-originated dependence and addiction.
Many people at this moment are calling for responsible prescribing in a narrow sense. They note our recent history of overprescribing and recognize the need not to write prescriptions when they’re not called for. We’re even getting better at recognizing a more complex version of this sense of responsibility—noting not only that we shouldn’t prescribe Percocet for tooth extractions or moderate injury pain, but that when opioids are called for, we shouldn’t prescribe more than are necessary.[iii] Without an evidence base, we’ve massively overprescribed even for truly serious pain, like that resulting from surgery. But now we’re starting to accumulate that evidence base and improve.
What my work adds to this discussion is the observation that appropriate initiation is not the only relevant aspect of responsible opioid prescribing. Prescribed opioids must also be appropriately managed over the long term, beginning with patient education and counseling and continuing through a humane taper off the medication. Responsible pain medicine, in other words, must be nuanced. No ham-fisted policy of the “one size fits all” variety will fix opioid prescribing, because responsible pain medicine isn’t about limiting access to opioids or, conversely, ensuring that every last pain patient has access to opioids. That way lies the swinging pendulum, and it cannot solve this problem.
Stopping the swing, however, will be hard. Responsible opioid prescribing will require that every clinician who treats pain knows when opioids are called for, how much and for how long they are called for, how to counsel and educate patients, how to manage the medication over the long term, and how to taper dependent patients off the medication. They also need to have the relationships (and willingness) to partner with experts in pain or addiction medicine when particular patients outstrip their expertise. Somewhere between none and very few of these expectations are currently in place for most clinicians, and endorsing them will require major changes to the healthcare system.
Fixing Pain Medicine Won’t Solve the Drug Overdose Crisis
Clinicians can get better at prescribing opioids. A seductive narrative suggests that if they do this, it will solve the opioid epidemic. Unfortunately, that’s not true. As a matter of fact, not only is it untrue, but the simplistic notion that there is “an opioid epidemic” that is synonymous with the prescription opioid problem is responsible for a lot of harm—both to people with opioid use disorder and to pain patients.
Prescription opioids almost certainly contributed to today’s drug overdose crisis. When careless overprescribing really kicked off, in the 1990s, it led to a striking uptick in overdose death. Between 1999 and 2010, prescriptions for opioids quadrupled, which was matched by a quadrupling of the prescription opioid overdose death rate. The trend lines are hard to ignore.
That was not, however, the end of the story. Singling out this drug supply as the problem led to a supply-focused response: restrict prescribing. After all, if loose prescribing kills people, then restrictive prescribing should prevent those deaths. Right?
That is not, however, what happened. Although restricting the supply of pharmaceutical opioids did bend the curve down on prescription opioid overdose death, it did not solve the opioid crisis; in fact, since 2012, when prescription opioid overdose deaths began to decline, increase in the overall opioid overdose death rate sped up. This is because as soon as access to prescription opioids was restricted, the death rate from heroin increased dramatically, followed soon after by an absolute skyrocketing of the death toll from synthetic opioids like fentanyl. What seems to have happened is that at least some of the people who were taking prescription opioids were willing to transition to heroin when their supply was cut off; and as heroin became more and more contaminated with fentanyl and its analogues, we’ve been brought to the catastrophic heights of America’s current overdose crisis.
This telling of the history suggests that trying to solve the opioid epidemic by focusing on the supply of prescription opioids harmed a particular population—those with opioid use disorder—by either forcing or incentivizing a switch from their safer supply of pharmaceutical grade opioids to an increasingly contaminated supply of heroin. But there is another group that has been harmed by this policy focus, and that group is made up of pain patients who don’t have an opioid use disorder. Some of these patients are harmed by simply being underprescribed (since opioids do have some proper indications), while others are harmed by being abandoned or forcibly tapered, both of which can precipitate terrible withdrawal.
This last group of patients, who are sometimes called “legacy patients” (as they are a legacy of past, aggressive prescribing) or “orphan patients” (if they are abandoned by their prescribing clinician and cannot find anyone to fill their prescriptions), can be on truly massive doses of opioids. Because clinicians have been aggressively prescribing opioids for decades, and opioids cause tolerance, some patients are on many hundreds of milligrams of morphine or its equivalent, and the prospect of withdrawal can be terrifying.[iv] As someone who has experienced withdrawal, I completely understand this. Withdrawal can range from uncomfortable to excruciating, and at its most severe can drive one to contemplate suicide. Forcing someone into that position because doctors have changed their minds on whether they endorse some therapy seems cruel in the extreme.
Perhaps the most controversial claim I make in my book, then, is that clinicians should not unilaterally taper legacy patients without their consent. There was real overprescribing in the past, and we should correct much of it. But reducing opioid supply by forcing patients into withdrawal is not an appropriate response to America’s drug overdose crisis. We eventually must stop compounding the harms of our past behavior.
Moving beyond Supply
The broad lesson of In Pain is that although American pain medicine is desperately broken, fixing it won’t solve the opioid epidemic. Acting as if it will is likely to lead to un-nuanced policy that hurts both pain patients and those suffering from addiction.
So what will solve the broader drug overdose crisis? Well, moving beyond supply-focused responses can help us to realize what sorts of interventions are absolutely required. America has a population of people already addicted to various drugs, including opioids, and our goal should be reducing the morbidity and mortality that goes along with that addiction. The above exploration of the failures of supply-focused interventions regarding prescription opioids helps to explain why America’s War on Drugs has been such an abject failure: when a person’s health condition is defined by compulsive behavior despite harmful consequences, introducing ever-more harmful consequences is a bad way to try to change behavior. Some people will continue to be willing to engage in the behavior, and so the primary result of the intervention is escalating harm.[v]
Rather than engage in policy that exacerbates the harms of drug use, then, we should look for interventions that reduce those harms. These include, at a minimum, interventions like syringe-exchange programs (an evidence-based strategy for reducing the disease burden among people who inject drugs) and distribution of the overdose-reversal medication naloxone; more ambitiously, I think moving beyond supply should lead us to open safe-injection sites (sometimes called overdose prevention sites), where people who use drugs can do so in the presence of healthcare practitioners, with sterile supplies and naloxone on hand. Most radically, perhaps it should lead us to consider a safe-supply policy, on which doctors would be allowed to prescribe pharmaceutical grade heroin or hydromorphone for people with opioid use disorder who don’t want to risk the contamination of street drugs, but aren’t ready to seek treatment.
This last point about safe supply makes clear the extent to which harm reduction is a theme in my views on drugs, both prescription and illicit. Whether a patient is on high-dose oxycodone and fearful of withdrawal, or using illicit heroin and living with active addiction, I don’t think taking away their supply is an ethical response. In either case, restricting supply can be devastatingly harmful, either through directly causing withdrawal and recurrence of whatever pain they were medicating, or by driving them to less safe options.
I don’t expect, in these few words, to have convinced anyone who is vehemently opposed to harm reduction. The arguments canvassed here—laid out in more detail in In Pain—are largely about responsible opioid prescribing against the backdrop of the drug overdose crisis. Pain medicine and the broader crisis are linked, however, through opioids, and it seems to me that the lessons learned from investigating how we should view prescription opioids can provide insight into how we view drugs and addiction writ large.
Notes
[i] This paragraph is a summary of Chapter 3 of In Pain: A Bioethicist’s Personal Struggle with Opioids. For detailed sources on the historical narrative told here, please consult that chapter.
[ii] And of course: it should be noted that I’m privileged to have experienced this sort of epistemic injustice only rarely in my life. As a white man, I am actually more likely to have my claims of pain taken seriously than many others. An important component of the harm of not being believed, then, is that it furthers various forms of injustice.
[iii] A leader in this area is the organization Michigan OPEN (the Opioid Prescribing Engagement Network), which is both generating an evidence base for how many pills given pains and procedures tend to need, as well as providing resources for clinicians and patients. More information on all of this can be found at their website, here: https://michigan-open.org.
[iv] For context: the CDC recommends caution when escalating patients past 50 morphine milligram equivalents (MME), and advises against escalating past 90 MME without careful justification. I was on a total of about 170 MME when I began my too-aggressive taper, and I was immediately cast into terrible, acute withdrawal. Legacy patients can be on many hundreds, or even 1000 or more MME due to years of tolerance.
[v] This is only one explanation of why the War on Drugs failed. It is also morally problematic for other reasons, like its racist implementation.